NEONATAL RESUSCITATION

dr. Irman Permana, Sp.A , M.Kes

dr. Tatan Tandubela, Sp.A, M.Kes
Ressa Novita Afandi

ASPHYXIA
Asphyxia neonatorum is defined as a reduction of oxygen
delivery and an accumulation of carbon dioxide owing to
cessation of blood supply to the fetus around the time of birth.

Asphyxia is reserved to describe a neonate with

all the following conditions:
1.Profound metabolic / mixed acidosis
< 7.0)
2.APGAR score 5 minutes : 0-3
3.Neonatal neurologic manifestations
4.Multi-system organ dysfunction

(pH

APGAR SCORES
Give informations about condition of the
baby and rescucitative efforts

not

It is
to determine whether the
baby needs rescucitation

APGAR
Scores
Sign
Score = 0
Score = 1
Score = 2
---------------------------------------------------------------------------------------------------APPEARANCE
Blue all over,
Acrocyanosis
Pink all over
(color)
or pale
PULSE
(heart rate)

Absent

Below 100

Above 100

GRIMACE
No response
(reflex irritability)

Grimace or
weak cry

Good cry

ACTIVITY

Some flexion of

Well flexed, or active

extremities

movements of

Flaccid

(muscle tone)
extremities
RESPIRATIONS

Absent

Weak, irregular,
or gasping

Good crying

==========================================
==
The APGAR score should be assigned at one minute and five minutes, finding
the total score (0-10) at each time by adding up points from the table
above. Continue to assign scores every five minutes thereafter as long as
the APGAR score is less than 7.

EtiologyHigh Risk Factors

Maternal factor:
hypoxia, anemia, diabetes, hypertension, smoking,
nephritis, heart disease, too old or too young,etc

Delivery condition:
Abruption of placenta, placenta previa, prolapsed
cord, premature rupture of membranes,etc

Fetal factor:
Multiple birth, congenital or malformed fetus,etc

Pathophysiology
When fetal asphyxia happens, the
body will show a self-defended
mechanism which redistribute blood flow
to different organs called inter-organs
shunt in order to prevent some important
organs including brain, heart and adrenal
from hypoxic damage.

What normally happens at birth to allow a

baby to get oxygen from the lungs ?
RESPIRATORY SYSTEM TRANSITION

Fluid replaced by air in alveoli

Fetal
lung
fluid

Air

First
breath

Second
breath

Subseque
nt breaths

The physiology of asphyxia

Primary
apnea

Secondary
apnea

Heart Rate

Blood pressure

Degree of asphyxia:
Apgar score 8~10: no asphyxia
Apgar score 4~8: mild/cyanosis asphyxia
Apgar score 0~3: severe/pale asphyxia

PREPARATION
Endotracheal tube

The appropiated-sized tube

Tube size
(mm)
(Inside
diameter)

Weight
(g)

Gestational
age
(wks)

2,5

< 1000

< 28

3,0

1000 - 2000

28 - 34

3,5

2000 3000

34 38

3,5 4,0

> 3000

> 38

Non Re-breathing bag valve

Re-breathing bag valve

Oxygen Reservoir

Reservoar

Ujung tertutup
Ujung terbuka

Characteristics of resuscitation
bag used to ventilate newborns:

Size of bag: 750 mL

Capable delivering 90%-100% oxygen

Newborn require : 15-25 mL tiap ventilasi (58 mL/kg)

Without reservoar O2 concentration to baby:
40%
With reservoar O2 concentration to baby: 90%100%

Appropriate-sized masks

Cover the chin, mouth and nose but not eyes

MASK

Size
Rims
Shaped

Giving Oxygen
1

Giving Oxygen
3

Which babies require

resuscitation
Always
needed
by
newborns

Assess babys response to birth

Initial Steps in resuscitation
Resuscitation Bag and mask

Needed
less
frequentl
y

Chest
compressions +
Bag and mask
Medications

Rarely
needed

THE RESUSCITATION FLOW DIAGRAM

ASSESSMENT (IN FEW SECONDS)

assessed for these questions
Birth

1. Term gestation?
2. Breathing or crying?
3. Good muscle tone?

Routine care
Yes

Provide warmth
Clear air way
Dry
Evaluation

Determine if a baby needs

rescucitation in few seconds:
1.

Term gestation?

2. Breathing or crying ?

Assass whether the baby breathing

spontaneously

No efforts

Gasping

intervension
intervension

3. Muscle tone ?
Good muscle tone :flexed extremities and be
active

Variable assesment
No

i. Provide warmth
ii. Position;clear
airway (as
necessary)
iii. Dry, stimulate,
reposition

30
seconds

i. PROVIDE WARMTH

The baby should be placed under a radiant

warmer

ii.POSITION;
CLEAR AIRWAY AS NECESSARY

Position by slightly extending the neck

Positioned on the back or side

The neck slightly extended in the sniffing
position
Placed rolled blanket under the shoulders

Clear airway

1. If no meconeum is present dan

meconium is present but the baby
vigorous

Clear secretion

Mouth and nose : wiping-suction

Copious secretions

Turn the head to the side secretions

to collect
=>removed easily

Mechanic suction

The negative pressure < 100 mmHg

If no meconeum is
present

Mouth before nose

Be careful not to suction vigorously

or deeply

Vagal reflex bradycardia / apnea

Gentle suctioning

Adequate to remove secretions

Clear airway

(if no meconeum is present)

Giving Free Flow Oxygen

Options:
1. with a self-inflating bag
2. oxygen pipe
3. Oxygen mask

Oxygen concentration
: 100%
Oxygen flow
: minimal 5 L / minute
The baby become pink
stopped gradually
If cyanosis persistent:
possitive pressure ventilation

.Clear airway
2. If meconeum is present

If meconeum is present and the

baby is not vigorous
depressed respirations

depressed muscle tone

heart rate < 100 bpm

direct suctioning of the

trachea soon before respirations
have occurred

iii. DRY_STIMULATION_REPOSITION

Position & suctioning stimulate

spontaneous breathing

Tactile stimulation :
1. Flicking of the soles of the feet
2. Rubbing the
back/chest/abdomen/extremity

Tactile Stimulation

Giving Free Flow Oxygen

Options:
1. with a self-inflating bag
2. oxygen pipe
3. Oxygen mask

Oxygen concentration
: 100%
Oxygen flow
: minimal 5 L / minute
The baby become pink
stopped gradually
If cyanosis persistent:
possitive pressure ventilation

Assess for these questions:

1. Breathing .... Apnea / Breathing
2. Heart rate .. > 100 beats/minutes ?
(in 6 seconds,multiply by 10)

Evaluate respirations,
Heart rate

breathing

Observational care
HR> 100
& PINK

Apneic
Or
HR < 100

PINK

Effective ventilation

Provide positive pressure

ventilation

HR > 100
& PINK

Post- resuscitation
care

Illustrative Pressures

Initial breath after delivery :

30 cmH2O

>

Normal lungs:
15 - 20 cmH2

Diseased or immature lungs : 20

40 cmH2O

How often should you squeeze the bag?

40-60 breaths per

minute

Breathe
(squeeze)

Two.Three
(release..)

Breathe
(squeeze)

Two..Three
(release.)

If the chest is not rising?

MR. SOPA
Mask

adjustmet
Reposition
Swab
Open mouth
Pressure
Alternative -- ETT

If you must continue bag and mask

ventilation for more than several
minute:

Insert orogastric tube

Gas forced into stomach disturbing

ventilation

Gas in the stomach regurgitation of

gastric contents aspiration

30 sec
Effective ventilation

Provide positivePressure ventilation

HR < 60

HR > 60

Provide positive-pressure ventilation

Administer chest compressions

HR > 100
& Pink

Post resuscitation
care

Indications for beginning

chest compressions:
the heart rate remains <60 bpm
despite 30 seconds of effectivepressure ventilation

How do you position your hands

on the chest to begin chest
compressions?
Two techniques:
1)

Thumb technique

2)

Two-finger
technique

The thumb technique

Two thumbs are used to depress the sternum
The hands encircle the torso and the fingers
support the spine

The two-finger technique

The middle finger and either the index finger or ring
finger of one hand are used to compress the sternum
The Other hand is used to support the babys back

The thumb
technique
advantage

Ussually less tiring

disadvantage

More convinient if the baby is

large or your hands are small
It also make access to the
umbilical core more difficult
when medications become
neccessary

Frequency

Ratio 3 : 1

1 cycle (2 second)

11/2 second : 3 compression

/2 second : 1 ventilation----- 90

compression + 30 ventilation on 1 minutes

one
breathe

and

two

and

Three

and

After 30 second chest

compression + ventilation
check heart rate

Heart rate > 60 x/minutes

Discontinue chest compression, continue
ventilation

Heart rate > 100 x/minutes

Discontinue chest compression and the baby
begins to breathe spontaneously, you should
slowly withdraw positive-pressure ventilation.

Heart rate < 60 x/minutes

Have Intubation (you most likely ) then you
should give epinephrine

Provide positive-pressure ventilation

Administer chest compressions

HR < 60

Administer epinephrine

Indication to give epinephrine

Heart rate remains < 60 bpm after
given 30 seconds of assisted
ventilation and another 30 seconds of
coordinated chest compressions and
ventilation

How should epinephrine be

given?
The umbilical vein (recommended)
The endotracheal tube

Give epinephrine

Preparation : 1:10.000 solution in 1 ml

syringe
Dose IV : 0,1-0,3 ml/kg larutan 1:10.000
ET
: 0,3-1,0 ml/kg larutan 1:10.000
Rate of administration : rapidly

If this does not happen

you can repeat the dose every 3 to 5
minutes

Stopped Resuscitation

Current data support that resuscitation of

newborn after 10 minutes of asystole is very
unlikely to result in survival or survival without
severe disability.

Parents clearly should have major role in

determining the care delivered to their newborn.