Newborn resuscitation lessons in the delivery room
Respiratory movements that occur shortly after birth are currently not fully understood. There is controversy over the role of hypoxia, on blood acidosis
All obstetricians and pediatricians, as well as all midwives can see the fact that a baby having difficulty delivering can have serious consequences and can come at a cost. its life or the mental and intellectual consequences of the child.
Everyone working in the delivery room must know all the techniques and operations of newborn resuscitation thoroughly and thoroughly.
A newborn's adaptation to ectopic life
From the very first seconds of birth, many physiological mechanisms interfere with the infant being able to adapt to life outside the uterus.
Indeed in the womb, the fetus lives completely on the external circulation of the uterus, which is the uterine circulation to ensure cardiac flow, oxygen saturation, body temperature balance, water exchange, and electricity. and his essential nutrients.
Within a few minutes immediately after delivery the child must accept a life of complete physiological independence.
The infant's respiratory and cardiac adaptive mechanisms will occur earliest and most importantly.
All abnormalities of the respiratory and circulatory systems that are not detected before childbirth or abnormality in respiratory and circulatory adaptation that are not taken care of may be the cause of organizational hypoxia and there is a risk of serious consequences due to brain damage.
The mechanism of adaptation at birth.
There are three main adaptations that allow for the transition from water life in the uterus to normal life outside the uterus.
The initiation of respiratory movements
It happens about 20 seconds after the birth of the baby, usually after it comes out of the chest.
Respiratory movements that occur shortly after birth are currently not fully understood. There is controversy about the role of hypoxia, about blood acidification, about the cold and about the departure from life in water.
The infant's first respiratory movements (manifested by the first cries) create in their lungs a pressure varying from -40 to + 80 Cm of water.
The baby's first cries
It induces dilation (dilation) of the lung alveoli. This dilation is accompanied by a push of the lung's Surfactant mass into the respiratory tract. As a result it creates a functional residual capacity of about 30ml / 1kg of infant weight by the end of the first day of life.
Excretion of pulmonary fluids
The pulmonary fluid present in the respiratory tract of the fetus is excreted out by 2 mechanisms:
One is the compression in the child's chest as it travels through the mother's genital tract.
The second is their absorption through blood vessels and lymph in the first 4-6 hours after birth and this mechanism works much stronger than the other.
The excretion of pulmonary fluid is difficult in some of the following cases.
The baby was suffocated during birth
Children whose initial respiratory movements are not as strong as preterm infants, infants with respiratory failure due to lack of oxygen or use of certain drugs to the mother or anesthesia.
In order to correct the relative lack of oxygen, it is necessary to ventilate the child quickly with pure oxygen.
In cases of severe hypoxia and severe metabolic acidosis, it is necessary to effectively ventilate with pure oxygen and use bicarbonate buffers.
There are 2 anatomical catheters between the right and left halves of the circulation:
The oval hole is also known as the Botal hole.
From the loaf to the right atrium, the oxygen-rich blood must pass through: the umbilical vein, the Arantius tube and finally the inferior vena cava. In the right atrium the oxygen-rich blood is mixed with the used blood of brain cells through the superior vena cava.
From the right atrium 60% of the oxygen-rich blood flow passes through the oval hole (the Botal hole) to the left atrium then the left ventricle, through the loops of the aorta it travels to the coronary artery, into the trunk of the first arm artery, and into the left carotid artery before it reaches the descending aorta after receiving blood from the ductus arteriosus. On the other hand, the used (oxygenated) blood goes from the lower aorta to the right atrium, then the right ventricle, then the pulmonary artery stem.
It seems that the entire blood flow (90%) of the pulmonary artery follows the artery and is mixed with oxygen-rich blood that is circulating in the aorta.
Eventually the 2 umbilical arteries carry oxygen-depleted blood to the vegetable cake and receive 60% of the fetal cardiac flow.
The catheters that connect the right and left half of the heart have the same pressure, the ventricles function equally.
Mechanism of cyclic adaptation after birth.
After birth, there are two main factors that are created as follows.
Activation of pulmonary artery circulation is a major, kinetic and secondary factor for alveolar ventilation.
The umbilical cord pair, within a few minutes of the birth, permanently divides the child from the cake.
These two factors have consistent effects in the fetal heart.
Reduces pressure in the right heart chamber (right atrium and right ventricle).
Increased pressure in the left heart chamber (left atrium and left ventricle) and in the aorta create two systems: one is low pressure, the other is high pressure it closes automatically and physiologically then. is the surgery of two catheters connecting the right half to the left half (oval hole, artery catheter) and from now on put the two ventricles not working the same.
Regulating body temperature in the fetus
Fetal temperature regulation is made through vegetable cake, it acts as a temperature exchange place.
The temperature of the fetus is 0.3-0.8 degrees C higher than the mother's temperature.
Mechanism of postpartum body temperature adaptation.
Reduction in heat release
The vasoconstriction of the skin's blood vessels allows to reduce heat loss due to heat dissipation and heat conduction.
In contrast, the heat loss due to vapors and respiration is a forced heat loss that cannot be limited by the infant.
Increased heat generation
To produce heat, an infant has only one system that is chemically heat-generating, it is not able to generate heat through muscle movement (such as stretching or doing exercise ...). Thermogenesis is done through the liver's Glycogen stores but primarily from fat burning.
The neutral temperature of term infants is 32 ° C and preterm infants are 35 ° C.
Newborns are particularly sensitive to cold (the temperature of an undressed infant at 24 0 C will drop to 0.25 degrees C / 1 minute). Hypothermia happens quickly and is very worrying for a child. It can lead to hypoglycemia, constriction of the blood vessels of the lungs, decreased surfactant synthesis, and bleeding around or within the ventricles.
Increase the temperature in the delivery room.
Place your baby next to a heat source (heated table).
Dry the baby quickly after birth.
Place the child in a place with a blanket to warm.
Place the baby on the mother's body if conditions permit.
Causes of neonatal asphyxia
The reasons are related to the mother
Mother suffers from a number of medical diseases that affect respiratory and circulatory function such as heart disease, lung disease, anemia, high blood pressure ...
Mother has blood loss that reduces circulating volume during labor such as bleeding from amaranth or young vegetables ...
Preterm or old pregnancy.
Fetal malnutrition. Chronic pregnancy failure.
Abnormal cling of vegetables, fibrous vegetables.
Little amniotic fluid.
Causes related to labor
Difficult pregnancy book.
Intervention procedures for infertile pregnancy are not prescribed or not qualified.
Recognize neonatal asphyxia
Assessment of asphyxiation in a newborn.
Characteristics of clear or green amniotic fluid: There is excretion of meconium into the amniotic fluid chamber.
With certainty of acute pregnancy failure: Abnormalities of fetal heartbeat.
Use of some maternal inhibitors: Pain relievers, psychotropic drugs, anesthetics, Beta blockers. During a period of 4 hours there is a risk of respiratory distress in the infant.
There is bleeding in labor: Vegetable striker.
Labor with high risks for the newborn: preterm or old birth, multiple births, maternal and fetal infections (fever, dirty amniotic fluid, premature rupture of the amniotic fluid, urogenital infection of the mother), childbirth mechanical difficulty (pelvic mismatch, abnormal fetal position). Prolonged labor, prolonged pregnancy loss, umbilical cord pathology (short umbilical cord, ligament loops, vegetable cord prolapse, cord rupture, ruptured umbilical cord), delivery method (cesarean section, forceps)
A child's adaptation to ectopic life can be assessed in the first few minutes using the Apgar index.
<100 beats / minute
> 100 beats / minute
Weak, slightly folded head limbs
Pink body, purple limbs
Among these factors are 3 main factors: breathing movement, condition of fetal heart rate and skin color.
The Apgar index is not used to make an indication of when it is necessary to do the resuscitation movements or to make the right decisions during resuscitation.
The Apgar index is, however, still an objective means of assessing the child at the first minute and 5 minutes thereafter, perhaps 10, 15 and 20 minutes later and as such is itself an effective means of assessment. Efficacy of neonatal resuscitation.
There is no natural ventilation.
Ventilation movements are mild, rare and completely absent.
Heart rate below 60 beats / min.
Signs of bad peripheral perfusion.
The extremities are cold, pale, or purple with white, purple spots.
Time to re-pink skin lasts more than 5-10 seconds.
Cardiac arrest, apnea.
Decreased systemic muscle tone.
Reduced blood sugar.
Conditioning your body temperature
Quickly lead to hypothermia.
This is the most severe condition, giving birth to severe asphyxiation, and the Apgar score below 3 points in the first minute.
Treatment of neonatal asphyxia or resuscitation methods for the newborn
The expected outcome after neonatal resuscitation is that the baby is alive and completely neurologically normal
The quality of a child's neurological rehabilitation depends on the flow of oxygen-rich blood to the brain. Therefore, the goals of treating newborn asphyxia have two:
Ensures effective alveolar ventilation.
Ensures effective hemodynamics.
The newborn was born with no signs of cardiac arrest, respiratory arrest, but had difficulty initiating effective natural ventilation.
Children are in a low head position.
It is a movement made quickly with quick and decisive pressure on the child's back as we dry the child with a towel. As well as some definitive light presses on the soles of the child's feet, these stimuli should not injure the child and do not last longer than 15-30 seconds.
All other methods of stimulation on the child are not effective or even dangerous for the child.
Criteria for evaluating its effectiveness
The child inhales or initiates the first inhalation with regular breathing movements.
Smoking upper respiratory tract
Absorption of all secretions as well as mucus in the upper respiratory tract of the child must be done before doing any ventilation exercises.
All newborns soon after birth.
Lie on your back, head slightly inclined, but in an intermediate position.
Sonde sucks 8 or 10 Fr and with a pressure of about 100-200 mbar.
The worker's left hand is on the child's face to keep it in position, instead hold the catheter in the direction of the catheter as desired (or opposite to a left-handed person).
The first is oral suction: 3-5 times of 3 to 5 cm insertion of a 3 to 5 cm sex tube from the child's lips with an 8 or 10 Fr catheter ensures release of the oropharynx.
The second is the nose: Once in each nostril, insert the catheter 3 to 5 cm with an 8 or 10 Fr catheter to ensure release of the oropharynx.
Third is the stomach: One 8 or 10 Fr catheter inserted deep into the distance from the mouth to the navel ensures the release of the lower part of the throat and also to check the esophageal clearness and also to empty the stomach . To check whether the sonde is in the stomach or not requires a syringe test: hear in the epigastric region and we notice gas noise as we pump 3-5 ml of air into the stomach. and this air will be drawn out after gastric aspiration.
Gastroesophageal aspiration could be the cause of the slowed heart rate if it is done before the fifth minute of the baby's birth. It is important to hear the fetal heartbeat while smoking and the suction should not last more than 10 seconds
Performance evaluation criteria
Streaking is not heard in regular respiration.
Young or older ruddy.
Aspiration of lower respiratory tract
When the child inhales the amniotic fluid mixed with meconium, they are basic actions to avoid causing the child to inhale more. It is necessary at the same time to remove all feces from the child's respiratory tract
It is important to suck before all ventilation movements.
Thick amniotic fluid separates the meconium or forms small lumps.
Lie on your back with your head slightly tilted in an intermediate position.
Probe 10 Fr.
Aspiration is done by placing the catheter into the child's airway using an endotracheal tube. The catheter is inserted 2-3 cm deep through the laryngeal opening.
Aspirate inside the trachea with simultaneous withdrawal of the sonde. Must suck with 200 mbar pressure continuously for 3-5 seconds and repeat this movement if it is still not clean.
Draw carefully around the oropharynx, while the larynx is drawn last.
Smoking is not necessary if we see no fecal matter around most of the larynx. Laryngeal aspiration in pregnancy is very important and should be done when possible.
Criteria for performance evaluation
No poop was found in the sonde after the last smoking.
Children can breathe on their own.
Ventilate through the mask
Bradycardia less than 100 beats / min.
Invest in an intermediate position.
The ball expands itself with oxygen storage bag.
The oxygen flow should be 4-6 l / min.
Size 0 mask for children under 2000 g.
Mask size 1 for children over 2000g.
Oral or mouth-to-mouth method in the absence of tools.
Technique of ventilation with the mask:
Apply the mask so that it covers the child's nose and mouth to avoid gaps, the size of the mask should be appropriate.
Raise the lower jaw during ventilation.
The resuscitation person's left hand should keep the mask close to the child's face while lifting the lower jaw. Thumbs and index fingers on each side of the mask. The middle finger holds the child's jaw at the position of the chin to press the mask against the child's face. The ring and little finger are placed under the jaw to keep the lower jaw lifted.
Pressure to press the ball with two fingers.
Squeeze frequency 40-60 times / minute.
Some special features:
The first 4-5 squeezes are critical to achieving good alveolar ventilation has a real effect on enlarging the lungs in the first few seconds by extending the first squeeze for 3-5 seconds.
For infants under 32 weeks or with a fetal weight below 1500g should not hesitate to apply a strong pressure during the first 2-3 squeezes.
In the event of ventilating failure with a respirator:
Reposition the resuscitation hand and position of the mask.
Use a different mask that is more suitable.
If ventilation is still ineffective during the first 30 seconds, the decision is made to endotracheal intubation.
Performance evaluation criteria:
The thoracic expansion is regular and uniform.
Hear alveolar whispering on both sides of the lung.
Increased fetal heart rate.
The fetus becomes ruddy.
Discontinue the mask ventilation when the child is able to re-breathe effectively with a breathing frequency of 40-60 beats / min, all efficiency indicators are good.
The ventilation through the mask will create tension in the gastrointestinal tract due to gas, if necessary, aspiration every 3 minutes to relieve pressure in the abdomen (sonde 6 Fr), every 2 minutes other times open the sonde's free head.
Mask ventilation is contraindicated in case of diaphragmatic herniation
While manipulating this technique, it is necessary to have 3 people: one person to do, one person to hold the position for the child and an assistant to put the tools and suck.
Mask ventilation is ineffective after 30-60 seconds.
It is necessary to prolong the supportive ventilation: infants born before 28 weeks and babies weighing less than 1000g.
The child lies on his back intermediate head, his face parallel to the table surface, the purpose of making the pharynx of the larynx and trachea become a straight line, we can keep the posture of the medial head by using a small pillows below the neck (not under shoulders).
The endotracheal tube is suitable for the child's weight.
Endotracheal lamp with straight light.
Tape fixing the endotracheal tube (duct tape).
The left hand holds the baby's head and opens the child's mouth.
The right hand holds the endotracheal lamp.
Insert the endotracheal lamp into the mouth (slightly to the left) while pushing the child's tongue to the left.
Reveal the oropharynx by pulling upward and forward in the direction of the handle (do not move the seesaw).
Throat aspiration using sonde number 10 Fr.
Insert the endotracheal tube when the opening of the larynx is clearly visible.
Withdraw the endotracheal lamp to keep the endotracheal tube intact.
Connect the endotracheal tube to the balloon and begin to work through the endotracheal tube.
Listen to the lungs to check the position of the endotracheal tube and see if ventilation is even. Check the position of the endotracheal tube by seeing if its mold is appropriate (on the edge of the child)
Fix the endotracheal tube
Criteria for performance evaluation.
Appropriate endotracheal intubation and endotracheal ventilation are assessed using the following criteria.
Increased heart rate.
A ruddy child.
When there are no signs of effective ventilation, check under the endotracheal lamp to see if the position of the endotracheal tube is good (the endotracheal tube has fallen out or placed into the esophagus).
Good endotracheal intubation has not shown improvement in the child's condition requiring some haematodynamic assistance.
Failure may be due to poor exposure to the oropharynx or lack of a clear view of the oropharynx. After 20 seconds of intubation test without the need to continue ventilating the child through the mask.
The role of the woman
Before doing: Prepare and test tools.
Keep the head of the fetus in place.
Give tools to workers.
Helps with laryngeal suction.
Track your child's heart rate, respiratory movements and skin color.
Calculate the time from the start to the alarm time for the operator when it reaches 20-30 seconds.
In the event of failure, ventilate the infant through the mask and shade to allow to do it again.
Check the location of the sonde.
Record sonde's milestone.
Ventilate the child through the sonde.
Oxygen through the sonde versus free flow
Indications: Babies born with normal heartbeat, normal ventilation, no signs of resistance but slight purple signs around the lips.
Posture: Similar to the posture of the masking ventilation
Instrument: Oxygen source (oxygen tank or central oxygen system) with flow rate of 5 l / min. The oxygen pipes must be connected through the meter
Method: Insert the oxygen tube near the child's nose and let the child breathe
The criteria for evaluating the effectiveness: The baby returns and continues to ruddy after stopping oxygen.
It is important to look for signs of support in infants carefully: bulging nasal wings, tugging of the intercostal cavity or groans, which may be essential in determining supportive ventilation. support. If the cyanosis continues to persist despite being given oxygen, it is necessary to clarify two possibilities:
Congenital Heart Disease: If this is the case, the baby needs to be intubated and ventilated
Left diaphragmatic hernia: With signs of flat stomach, no left alveolar groin, heart sound being pushed to the right, children must be intubated and provided with artificial ventilation.
Heart massage outside the chest
Heart rate below 60 beats / minute, after 15-30 seconds, do artificial ventilation fully and effectively.
Place the child on his or her back on a hard background.
The worker only uses his or her own hands
There are two techniques that allow for extra-thoracic cardiac massage in infants. In both techniques the press is in the center, located in the lower 1/3 of the sternum about 1 cm below the inter-nipple line.
2-finger technique: The person implants the two index fingers and the middle finger of one hand perpendicular to the child's chest wall, at the lower third of the sternum. You can use the other hand placed under the child's back to ensure the assessment of pressure pressure of two fingers.
2-handed technique: The practitioner's hands embrace the child's chest on either side, the thumbs meet at the lower third of the sternum, pressure is applied to the ends of the two fingers. the. In preterm infants, the hand of the person making it much larger than the child's chest in which case the thumbs should cross each other at the lower third of the sternum.
In both cases the pressure must be applied to a level that causes the child's sternum to sink 1.5-2 cm. The frequency of pressing on the sternum should reach 120 times / min
Some special cases
Extra-thoracic stimulation and massage of the heart can be done even in intubated infants. If the child is ventilated through the mask, sometimes the downward pressure of the massage will counteract the inflow of the balloon, in which case it is necessary to alternate between balloon ventilation and external heart massage. chest: 2 compressions-8 external compressions and so on ...
Performance evaluation criteria
Catching the thigh artery, umbilical artery.
Young pink back.
The fetal skin return time on the right forehead should be less than 5 seconds.
The effectiveness of the cardiac massage outside the chest gradually decreases over time, if more than 25 minutes, continuing to massage the heart outside the chest does not increase the chances of survival.
Severe bradycardia with heart rate below 60 beats / min.
Road of use:
The endotracheal tract is the fastest, and when injecting drugs into the endotracheal intubation it is necessary to stop the cardiac massaging outside the chest for at least 10 seconds.
100 micrograms / kg of the child's weight or in the case of intubation, the dose would be 1 ml / kg of weight with a dilution of 1/10 000: 1 1 ml of adrenaline 1 ml, adding enough to 10 ml and Thus 1 ml of this solution contains 100 micrograms.
Performance evaluation criteria:
Increased heart rate.
Catch the pulse.
Reduces skin rejuvenation time.
Young children are back.
If no signs of effectiveness are found after 1-2 minutes of first intubation, it may be repeated again or even twice.
Neonatal respiratory distress where mothers take morphine before delivery (within 4 hours of delivery)
Route of use:
Injected intramuscularly, under the skin, through the endotracheal tube.
10 micrograms / kg of infant weight or 0.1 ml of the following solution: 1/2 ampoule 1 ml (0.2 mg) naloxone (NARCAN) add 1.5 ml of such physiological saline 0.1 ml of solution This translation contains 10 miccrogam naloxone.
The efficiency evaluation criteria:
Activate the child's respiratory movements.
Children need to be closely monitored in the following hours because this drug lasts for 20-30 minutes.
Business cycle of emergency asphyxiation management
Dry -> Stimulate -> Put the right posture -> Smoking -> Assessment: Breathing, Heart rate, Skin color.
The risk of infection in infants is very high and it is even higher in preterm infants. To avoid infection:
The resuscitation worker must be clean.
Wash your hands before the procedure.
Wear clean clothes, hats and masks.
Wear gloves when resuscitating.
Tools must be clean
Carefully wash and disinfect after each use: recovery table, ventilator, stethoscope ...
Small tools must be clean
Single-use aspirated, endotracheal catheters ..
Care after resuscitation
Favorable cases evolve
Quick and complete recovery. Newborns who are intubated from the first few minutes after delivery can be intubated in the delivery room when assessing the infant's condition as well:
Natural and effective breathing movements.
Stable heart rate over 100 beats / min.
Normal skin color after oxygen apnea.
Endotracheal withdrawal is performed concurrently with aspiration.
Some minimal movements must be done even in the most favorable progression:
Perform first and complete physical exam to find for malformations.
Eye drops to prevent infection of the eye.
Vitamine K1: By intramuscular injection 1-2mg / kg body weight right from the first hours after birth. Orally with the first breastfeeding or the first bottle
Monitoring the following hours is primarily the child's breathing rate, skin color, awakening, alertness and activity, and measurement of body temperature and blood sugar.
Let the baby lie with the mother and breastfeed the baby
Cases unfavorable developments
Children endured a heavy resuscitation (clinical death).
Children in which recovery is not complete: Difficulty breathing, cyanosis, decreased muscle tone. All of these cases require referral to a special neonatal unit for evaluation and follow-up. It is necessary to find the cause of the child's initial difficulties, especially the malformations of the child, when these causes are not clarified, it is necessary to find the cause of the maternal and fetal infection, microbiological tests. It has to be done both on the mother's side as well as on the child's side.
Some special cases
Some medical conditions can lead to early difficulties in newborns, but the diagnosis is not made during pregnancy and it is necessary to do immediately after birth for appropriate care. Simplicity can also help your child recover in a good way.
Stenosis of the posterior nostril
It can be one side or both sides.
Sometimes it is the result of edema caused by trauma.
Diagnosis: The child has difficulty breathing in, but when crying, the condition improves, unable to pass the nasal catheter to suction. Bilateral stenosis leads to postpartum respiratory failure, which is rapidly improved by Guedel canul insertion.
Pierre Robin syndrome
3 main signs
There is a division of the curtain.
Jaws small and receding back.
Place the child on his or her stomach.
Order canul Guedel.
Keep track of your child's heart rate.
It is characterized by intra-thoracic migration of organs during the fetal period due to a hole in the diaphragm. This migration leads to bilateral pulmonary dysplasia and as a result severe respiratory failure.
The triad allows for diagnosis
Loss of alveolar fencing of the left half of the chest.
The heart is heard clearly on the right side.
Need to treat
Put the sonde to the stomach.
Endotracheal intubation of artificial ventilation.
Place your baby in a slightly upright position (head high).
Transfer to a pediatric surgery center for surgical treatment.
Congenital oesophagal atrophy
This type of deformity is characterized by the communication of the esophagus with the trachea, there are many forms, the diagnosis must be made immediately without delay, otherwise when feeding the baby food will go into the lungs.
Poly amniotic fluid during pregnancy.
There is a picture of a soap bubble in the child's mouth.
Negative syringe test (no gas movement heard when the stethoscope was placed on the epigastric region while pumping air through the gastric tube)
Set sonde to smoke continuously.
Endotracheal intubation for supportive respiration.
Place the child on his normal side slightly on his side.