1. Neonatal emergencies
Dr. Miada Mahmoud Rady

2. Definitions
Newborn : A recently born infant, usually during the first few hours of life.
Neonate : Baby during the first 28 days of life.
Preterm : less than 37 completed weeks.
Term : 38 to 42 completed weeks.
Post-term : more than 42 weeks.

3. Transition from fetal to neonatal circulation
With the first breath, circulation changes.
Larger amount of blood is sent to the lungs
Ductus arteriosus begins to wither and close off
Circulation to the lungs increases left atrium flow, increased pressure causes the foremen ovale to close and blood circulates normally

4. Transition from fetal to neonatal circulation
Respiratory system must suddenly initiate and maintain oxygen:
Change from maternal circulation (placenta) to neonatel circulation.
Chest expands, fluid is forced from lungs and oxygen exchange begins.

5. Stimulant for the first breath:
First breath triggered by mild hypoxia and hypercapnia from partial occlusion of the umbilical cord during delivery.
Also Tactile stimulation and cold stress promote early breathing.
During the first breath , pulmonary vascular resistance drops .

6. Delay in drop pulmonary pressure leads to:
a. Delayed transition
b. Hypoxia
c. Brain injury
d. Death

7. Epidemiology of fetal distress
Incidence
Approximately 6% of deliveries require life support
Incidence of complications increases as Birth Weight Decreases
Morbidity / mortality
Neonatal mortality risk can be determined based on birth weight and gestational age

8. Risk factors Antepartum factors Multiple gestation
Inadequate prenatal care
Mother’s age <16 or >35
Post-term gestation
Drugs / medications
Toxemia, hypertension, diabetes

9. Risk factors Intrapartum factors Meconium-stained amniotic fluid
Rupture of membranes greater than 24 hours prior to delivery
Abnormal presentation
Prolonged labor or precipitous delivery
Prolapsed cord
Sever bleeding

10. Neonatal resuscitation
Initial steps of neonatal resuscitation include:
Airway (position and clear)
Breathing (stimulate to breathe)
Circulation (assess heart rate and oxygenation)
Additional resuscitation steps :
They are used based on need and include →

11. supplemental oxygen.
positive pressure ventilation.
Intubation.
chest compressions.
medications.

12. Initial steps of stabilizing a newborn
Warming the newborn to prevent hypothermia.
Positioning the newborn
Clearing the airway if necessary
Drying and stimulating breathing

13. Warming the newborn to prevent hypothermia:
Place on prewarmed towels or blankets and dry.
Replace wet towels with dry, prewarmed ones.
When resuscitation is complete, place the newborn on the mother’s chest or abdomen, another heat source, or under a radiant warmer.

14. Positioning the newborn:
Position on the back or side with the neck in the sniffing position.
Use a small shoulder roll to keep the head in this position.
Clearing the airway :
Use a bulb syringe or suction catheter.
Turn the head to the side.
Suction the mouth before the nose to prevent aspiration.
Return the head to the sniffing position.

15. Drying and stimulating breathing
Dry the head and body with towels to provide stimulation.
Additional tactile stimulation methods include:
Slapping/flicking soles of the feet
Rubbing gently on the back or trunk
Keep appropriate position of the head throughout stimulation.

16. Basic requirement of neonatal delivery
Warm, dry blankets
Bulb syringe
Two small clamps or ties
A pair of clean scissors

17. Equipment for Neonatal Resuscitation
Manual resuscitator (infant)
Masks (2 sizes, term and premature)
Dry towels/blankets
Suction equipment
ET tubes (sizes 2.5, 3.0, 3.5)
Laryngoscope and blades (sizes 0, 1)

18. Apgar score

20. APGAR test Definition :
A quick test performed on a baby at 1 and 5 minutes after birth.
The 1-minute score determines how well the baby tolerated the birthing process.
The 5-minute score determines how well the baby is doing outside the mother's womb.

21. How the test is done?
You will examine the baby's:
Breathing effort
Heart rate
Muscle tone
Reflexes
Skin color
Each category is scored with 0, 1, or 2, depending on the observed condition

22. This test is done to determine whether a newborn needs help breathing or is having heart trouble.
Normal Results
The APGAR rating is based on a total score of 1 to 10.
 The higher the score, the better the baby is doing after birth.
A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health.

23. APGAR score

24. A for appearance Appearance (Skin color):
If the skin color is pale blue, the infant scores 0 for color.
If the body is pink and the extremities are blue, the infant scores 1 for color.
If the entire body is pink, the infant scores 2 for color

25. P for pulse Pulse (Heart rate) :
is evaluated by stethoscope ,this is the most important assessment:
If there is no heartbeat, the infant scores 0 for heart rate.
If heart rate is less than 100 beats per minute, the infant scores 1 for heart rate.
If heart rate is greater than 100 beats per minute, the infant scores 2 for heart rate.

26. G for grimace
Grimace response ( reflex irritability ):
It is a term describing response to stimulation such as a mild pinch :
If there is no reaction, the infant scores 0 for reflex irritability.
If there is grimacing, the infant scores 1 for reflex irritability.
If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for reflex irritability.

27. A for activity Activity ( Muscle tone):
If muscles are loose and floppy, the infant scores 0 for muscle tone.
If there is some muscle tone, the infant scores 1.
If there is active motion, the infant scores 2 for muscle tone.

28. R for respiration Respiration ( Breathing )effort:
If the infant is not breathing, the respiratory score is 0.
If the respirations are slow or irregular, the infant scores 1 for respiratory effort.
If the infant cries well, the respiratory score is 2.

32. Neonatal resuscitation algorithm

33. Neonatal Resuscitation Guidelines:
Dry the baby with a clean cloth
Check for:
Breathing or crying
Pink central color
Good tone
If all present, continue routine care
If baby does not have good respiratory effort, pink central color AND good tone:
Position infant in neutral position
Clear airway
Stimulate
Give oxygen if available

34. Neonatal Resuscitation Guidelines:
If baby responds to positioning and stimulation by turning pink and breathing, return to routine care
If baby does not respond to these measures within 30 seconds:
Apply mask and ventilation bag to infant
Give 5 slow breaths
If baby responds and begins breathing, continue to observe closely, return to giving routine care
If baby is not breathing after 5 slow breaths:
Check position of infant
Continue bag and mask ventilation
Check to see if chest is rising: if there is no chest movement, suction airway, reposition infant, then resume bag and mask ventilation

35. Neonatal Resuscitation Guidelines:
If not breathing after 30 seconds:
Check heart rate
If heart rate is > 60 beats per minute:
Continue to ventilate at 40 breaths per minute
Use oxygen to ventilate if available
Watch for chest rise
Monitor position of infant
Stop ventilation every 1-2 mins to see if HR is greater than 60 beats per minute
Stop compressions if HR is > 100 beats per minute
Stop ventilations when breathing is > 30 breaths per minute
Continue oxygen therapy until infant is pink and has good tone

36. Neonatal Resuscitation Guidelines:
If not breathing after 30 seconds:
Check heart rate
If heart rate is > 60 beats per minute:
Continue to ventilate at 40 breaths per minute
Use oxygen to ventilate if available
Watch for chest rise
Monitor position of infant
Stop ventilation every 1-2 mins to see if HR is greater than 60 beats per minute
Stop compressions if HR is > 100 beats per minute
Stop ventilations when breathing is > 30 breaths per minute
Continue oxygen therapy until infant is pink and has good tone

37. If heart rate is < 60 beats per minute:
Continue effective Positive Pressure Ventilation and begin chest compressions at a rate of 90 compressions/minute
Continue chest compressions until HR>60 beats per minute
Continue to ventilate at 40 breaths per minute
Use oxygen to ventilate if available

38. Watch for chest rise
Monitor position of infant – should be neutral head position
Stop ventilation every 1-2 mins to see if HR is greater than 60 beats per minute
Stop compressions if HR is > 100 beats per minute
Stop ventilations when breathing is > 30 breaths per minute
Continue oxygen therapy until infant is pink and has good tone

39. Neonatal Resuscitation Guidelines:
Cessation of resuscitation
If after 20 minutes the baby is not breathing and there is no pulse, the recommendation is to stop resuscitation efforts

40. Thank you

41. Arrival of the newborn

42. History taking Woman’s age Length of pregnancy
Presence and frequency of contractions
Presence or absence of fetal movement
Any pregnancy complications
If membranes have ruptured ( Timing , color of fluid ).
Medications being taken

43. Resuscitation oriented history

44. If delivered in the ambulance………….
Cover the foot of the stretcher with clean, warm blankets for the initial stabilization.
After confirming adequate airway, breathing, and pulse rate, place the newborn on the mother’s chest.
If more extensive resuscitation is necessary, transition newborn to a second ambulance with a neonatal transport incubator

45. Suction the mouth, then the nose with a bulb syringe once the head is delivered.
Keep the newborn at the level of the mother after delivery, with head slightly lower than the body.
►►► If the cord comes out ahead of the newborn, the blood supply to the fetus may be cut off (prolapsed cord) , ►►►so relieve pressure on the cord by gently moving the newborn’s body off the cord and pushing the cord back.

46. Do an initial rapid assessment simultaneous with treatment interventions.
Note time of delivery.
Monitor ABCs.
Assess airway patency, respiratory rate and effort, tone, pulse rate, and color.
Position the newborn in the sniffing position to ensure a patent airway, clear secretions, and assess the respiratory effort.

47. Opening the Airway "Sniffing" position Right positioning
The newborn should be placed on his or her back, with the neck slightly extended.
Care should be taken to prevent hyperextension or flexion of the neck, since either may decrease air entry.
To help maintain correct position, you may place a rolled blanket or towel under the shoulders, elevating them three fourths of an inch to 1 inch off the mattress. This roll may be particularly useful if the newborn has a large occiput.
Correct positioning allows an open airway to be maintained. In addition, the newborn will be in the optimal position if assisted ventilation becomes necessary.
Wrong positioning:

48. Newborn is at risk for hyperthermia , so ensure thermoregulation by:
Placing the newborn on prewarmed towels or radiant warmer
Drying the head and body thoroughly
Discarding wet towels and covering with a dry towel
Covering the head with a cap

49. Finally ……………………….
All babies are cyanotic right after birth , If the newborn stays vigorous and begins to turn pink in the first 5 minutes:
Maintain ongoing observation.
Continue thermoregulation with direct skin-to-skin contact with mother while en route.

50. Additional resuscitation steps…..

51. Airway management Free-flow oxygen:
If a newborn is cyanotic or pale, provide supplemental oxygen , until a pulse oximetry reading can give an accurate reading.
Oxygen flow rate should be 5 L/min.
oxygen can initially be delivered through:
PPV (first choice unless not indicated)
Oxygen mask
Oxygen tubing cupped and held close to the newborn’s nose and mouth.

52. Oral airways :
Rarely used on newborns , but it can be life saving in Bilateral Choanal Atresia .
Bilateral Choanal Atresia : Bony or membranous obstruction of the back of the nose.
Management :
Surgical correction is definitive treatment.
First aid measure : keeping newborn mouth open either by oral air way or gloved finger .

55. Other Conditions that may require oral airways:
Pierre Robin sequence
Macroglossia (large tongue)
Craniofacial defects that affect the airway

56. Breathing

57. If a newborn baby fails to breathe after bulb suctioning, then Positive Pressure Ventilation With A Bag-and-mask is the single most important step in neonatal resuscitation.

58. Bag-mask ventilation Indicated when a newborn: apneic
Has inadequate respiratory effort
Has a pulse rate of less than 100 beats/min after:
Airway is cleared of secretions.
Tongue obstruction is relieved.
Newborn is dried and stimulated.

59. Signs of respiratory distress suggesting need for bag-mask ventilation include:
Periodic breathing
Grunting on expiration
Nasal flaring
Intercostal retractions
The correct ventilation time (40 to 60 breaths/min) is important because a higher rate can cause:
Hypocapnia
Air trapping
Pneumothorax

60. Causes of ineffective bag-mask ventilation:
Continue PPV as long as the pulse rate is less than 100 beats/min or the respiratory effort is ineffective.
If more than 1 minute of PPV is needed, hook the system to a pressure manometer.
Causes of ineffective bag-mask ventilation:
Inadequate mask seal on the face
Incorrect head position
Copious secretions
Pneumothorax
Equipment malfunction

61. Gently pull infant’s jaw forward to mask
Use a “C-grip” to hold mask to infant’s face, using the 3rd finger to hold jaw up to mask

62. Correct positioning : Watching for chest-rise- if chest is rising and falling you are performing adequate ventilation

63. Intubation Indications : Meconium aspiration . Diaphragmatic hernia .
No response to bag-mask ventilation and chest compressions, necessitating ET administration of epinephrine
Prolonged PPV needed.
Craniofacial defects impede an adequate airway.

64. Complications of ET tube placement include:
Oropharyngeal or tracheal perforation
Esophageal intubation with subsequent persistent hypoxia
Right main stem intubation
Risks can be minimized by:
Ensuring optimal placement of laryngoscope blade
Noting how far the ET tube is advanced

65. Circulation

66. Chest compression
Chest compression is indicated if pulse rate remains at less than 60 beats/min despite of :
Positioning.
Clearing airway.
Drying and stimulations.
30 seconds of effective PPV.

67. Criteria of chest compression in newborn
Two people are needed for effective chest compressions while ventilating.
Two different techniques:
Thumb technique . (preferred one)
Two finger technique .
The compression depth is one third of the anteroposterior diameter of the chest.

68. Chest compressions and artificial ventilation should not be delivered simultaneously.
{ Coordinate 90 compressions and 30 breaths/min , equaling 120 events per minute (1/2 second each) }.
Pulse rate should not be assessed for at least 45 to 60 seconds after ventilation and chest compressions are established.
{ Interruption of chest compressions to assess the pulse may decrease perfusion of coronary arteries }.

69. Stopping chest compression
If pulse rate is above 60 beats/min:
Chest compressions can be stopped.
Effective ventilation should continue at 40 to 60 breaths/min.
Recheck pulse rate after 30 seconds.
If the pulse rate goes above 100 beats/min:
gradually slow the rate and decrease PPV pressure.

70. Hypovolemia In Newborn

71. Etiology Placenta abruption Twin-to-twin transfusion Placenta previa
Septic shock

72. Signs Pallor Persistently low pulse rate Weak pulses
No improvement in circulatory status after adequate resuscitation efforts.

73. Treatment Place a low umbilical vein line in a newborn.
If more than a few days old, place a peripheral IV or IO line.
Fluid bolus in a newborn is 10 mL/kg given IV every 5 to 10 minutes of:
Saline
Lactated Ringer’s
O Rh-negative blood
Multiple boluses may be given if needed.