Jenny Brewster NEWBORN RESUSCITATION

University of West London

What is the main cause of collapse in adults …… and what is it in children? University of West London

Adults have cardiac arrests Children have respiratory arrests University of West London

Birth Asphyxia - Causes Drugs given to Mother Obstruction of airway Antepartum haemorrhage Stressful delivery (shoulder dystocia, malpresentation) Pre-term Severe infection Non-patent airway Cardiovascular or central nervous system abnormalities Intracranial haemorrhage University of West London

Physiology AEROBIC METABOLISM: – Carbohydrate is converted to glucose – Stored in muscles as glycogen – Broken down to pyruvic acid – In presence of oxygen, pyruvic acid is converted into CO2, H2O and energy. ANAEROBIC METABOLISM – If no O2, pyruvic acid is converted into lactic acid – Lactic acid builds up in tissues to create a metabolic acidosis – pH>7.25 = normal – pH = mild acidosis – pH <7.20 = severe acidosis University of West London

Physiology PRIMARY APNOEA – Brief period rapid ‘ breathing ’ – Stops breathing – HR unchanged, then decreases to about half normal rate – Anaerobic metabolism – less fuel-efficient – Circulation to non-vital organs reduced – Lactic acid build up SECONDARY APNOEA – Deep, shuddering gasps initiated by primitive spinal centres – Stops breathing – Lactic acid build up effects cardiac function – Heart failure University of West London

Anticipated Outcomes A baby in primary apnoea will generally respond well to stimulation and supplementary oxygen A baby in secondary apnoea will need assisted ventilation University of West London

Newborn Life Support It ’ s as easy as A,B,C – Airway – Breathing – Circulation University of West London

Anticipate Call for paediatrician and resuscitaire? Towels Warmth – close windows/doors Bag and Mask Stethoscope Resuscitaire: – Pre-heat – Clock – Tom thumb/neopuff – Check Oxygen – Suction University of West London

More Physiology! What happens as the baby takes it’s first breath? Fluid is pushed form the alveoli to establish the resting lung volume University of West London

Newborn Life Support University of West London

CC D Newborn Life Support Airway & Breathing A B C D cover Dry & University of West London

Initial Actions Start the clock Dry the baby Assess Do you need help ? University of West London

Initial assessment Colour Tone Breathing Heart rate University of West London

Blue Pink Good tone Breathing regularly Fast heart rate University of West London

Dry and cover Give to Mum University of West London

When should the cord be cut? If baby is in good condition, it can be left for at least a minute before clamping and cutting (resus council 2010) If baby Is in need of resuscitation, then this should be a priority, and the cord clamped and cut so that baby can be moved to an appropriate surface. University of West London

What if baby isn’t breathing? Place the head in the neutral position University of West London

Always think…………… DO I NEED HELP and call for the appropriate help In hospital? At home? University of West London

If this doesn’t work…………. Consider inflation breaths What is an inflation breath? Using bag and mask, or ‘T’ piece ventilation, give breaths lasting 2-3 seconds at 30cms water pressure. For premature babies, this should be reduced to 20-25cms water pressure University of West London

Reassess………. What? Colour Tone Breathing Heart Rate University of West London

What are you looking for? If the heart rate was slow and has increased, you have successfully inflated the lungs If the heart rate remains slow, either you have not inflated the lungs, or the heart needs help to respond. How will you know if the lungs have been inflated? Look for chest movement. University of West London

If the chest is not moving? Then the airway is not open. Reposition using a single handed jaw thrust if alone……….. University of West London

OR A two handed jaw thrust if you have help University of West London

Mask inflation is nearly always effective Only about 1 in 500 appear to need intubation University of West London

When you have chest inflation…. If the heart rate is still slow, consider chest compressions. Why is it not beneficial to do chest compressions until the lungs have been inflated? There will not be any oxygen available in the lungs for the blood to ‘pick up’ and take back to the heart. University of West London

Chest compressions You want to move oxygenated blood from the lungs to the coronary arteries Its not that far and won’t take long University of West London

Chest Compressions Do not start until you are sure the lungs have been aerated Place 2 thumbs on lower third of sternum, just below an imaginary line joining the nipples Compress chest quickly (about 100/min) and firmly, reducing the anterio-posterior diameter by about a third Ratio of compressions to breaths in newborn resus is 3:1. Re-assess every 30 seconds – check position and keep looking for chest movement when breath given Stop and continue maintenance breaths once HR>60 University of West London

Copyright ©1999 BMJ Publishing Group Ltd. Hamilton, P. BMJ 1999;318: Two Methods of External Chest Compression University of West London

Airway In the unconscious baby airway obstruction is usually due to loss of pharyngeal tone not foreign material in the airway i.e. Position not suction University of West London

Meconium Stress leads to passage in utero Triggered more easily near term Aspiration requires gasping University of West London

Meconium Screaming babies have an open airway: leave them alone Floppy babies :- HAVE A LOOK University of West London

Thick meconium CALL FOR HELP Suck out any visible thick meconium No need to clear thin meconium Proceed to face mask ventilation If heart rate not improving and chest not moving, have another look and consider suction between the cords University of West London

You will need help When to ask? How to ask? Who to ask? What to ask for? How long will help take to arrive? University of West London

A Reminder of the Mechanisms of Heat Loss Conduction: heat passed to what is in contact with the patient Convection: air currents over the body Radiation: heat passed from the body to the environment Evaporation: evaporative heat loss from exposed viscera or wet surfaces University of West London

What happens to a Hypothermic Infant? Oxygen consumption: –36% in premature & 23% full-term neonates Cardiac function Lactate production and metabolic acidosis Peripheral vasoconstriction Shift of O 2 -hemoglobin dissociation curve to the left Glomerular filtration rate University of West London

What can you do to Reduce heat loss ConductionWarm surface – TURN ON resuscitaire (Thermal mattress) ConvectionClose doors/windows ?Turn off air-conditioning RadiationWarm room EvaporationDry and wrap Hat (Plastic wrap) University of West London

Ambient Temperature At birth –A naked baby exposed to an ambient temperature of 23 o C at birth suffers the same heat loss as a naked adult at 0 o C WHO 1997 –Infant temperature can drop by 0.1 o C /minute –Mean rectal admission temperature decreases 0.21°C with each 100-g decrease in birth weight Vohra 2004 University of West London

How warm? Recommended delivery room temperature o C WHO 1999 An adult should not determine the delivery room temperature according to their own comfort WHO 1997 University of West London

Skin to Skin warming Very effective if done correctly For well term infants –Warm room –Dry infant –Naked between breasts –Nappy and hat –Cover parent and infant with blanket –Regular checks to ensure improvement University of West London

Summary of thermal care Newborns don’t like being cold Keep the room warm Turn on resuscitaire heater Dry and wrap Bag and hat (and thermal mattress) for premature infants Regular/continuous monitoring University of West London