According to statistics, every tenth newborn child receives medical care in the delivery room, and 1% of all those born need a full range of resuscitation. A high level of training of medical personnel can increase the chances of life and reduce the possible development of complications. Adequate and timely resuscitation of newborns is the first step towards reducing the number of deaths and the development of diseases.
Basic concepts
What is neonatal resuscitation? This is a series of activities that are aimed at revitalizing the child's body and restoring the work of lost functions. It includes:
- cardiopulmonary resuscitation;
- intensive care;
- application of mechanical ventilation;
- installation of a pacemaker, etc.
Term babies do not require resuscitation. They are born active, scream loudly, pulse and heart rate are within normal limits, the skin has a pink color, the child responds well to external stimuli. Such children are immediately placed on the mother's stomach.and cover with a dry warm diaper. Mucous contents are aspirated from the respiratory tract to restore their patency.
Carrying out cardiopulmonary resuscitation is considered an emergency. It is performed in case of respiratory and cardiac arrest. After such an intervention, in case of a favorable result, the basics of intensive care are applied. Such treatment is aimed at eliminating possible complications of stopping the work of important organs.
If the patient cannot maintain homeostasis on their own, resuscitation of the newborn includes mechanical ventilation (ALV) or pacemaker placement.
What do you need for resuscitation in the delivery room?
If the need for such events is small, then one person will be required to carry them out. In the event of a severe pregnancy and waiting for a full range of resuscitation, there are two specialists in the maternity.
Resuscitation of a newborn in the delivery room requires careful preparation. Before the birth process, you should check that you have everything you need and make sure that the equipment is in working order.
- It is necessary to connect a heat source so that the resuscitation table and diapers are warmed up, roll one diaper into a roller.
- Check if the oxygen supply is properly installed. There must be sufficient oxygen, properly adjusted pressure and delivery rate.
- You should check the readiness of the equipment thatrequired to aspirate airway contents.
- Prepare instruments to eliminate gastric contents in case of aspiration (tube, syringe, scissors, fixing material), meconium aspirator.
- Prepare and check the integrity of the resuscitation bag and mask, as well as the intubation kit.
The intubation kit consists of endotracheal tubes with wires, a laryngoscope with different blades and spare batteries, scissors and gloves.
What makes events successful?
Newborn resuscitation in the delivery room is based on the following success principles:
- availability of the resuscitation team - resuscitators must be present at all births;
- coordinated work - the team must work smoothly, complementing each other as one big mechanism;
- qualified staff - every resuscitator should have a high level of knowledge and practical skills;
- work taking into account the reaction of the patient - resuscitation actions should begin immediately when they become necessary, further measures are carried out depending on the reaction of the patient's body;
- equipment serviceability - resuscitation equipment must be serviceable and available at all times.
Reasons for events
The etiological factors of oppression of the heart, lungs and other vital organs of the newborn include the development of asphyxia, birth trauma, the development of congenital pathology, toxicosis of an infectious genesis and other cases of unexplainedetiology.
Children's resuscitation of newborns and its need can be predicted even during the period of bearing a child. In such cases, the resuscitation team should be ready to immediately help the baby.
The need for such events may appear under the following conditions:
- high or low water;
- overwearing;
- maternal diabetes;
- hypertension;
- infectious diseases;
- fetal hypotrophy.
There are also a number of factors that already arise during childbirth. If they appear, you can expect the need for resuscitation. These factors include bradycardia in a child, caesarean section, premature and rapid delivery, placenta previa or abruption, uterine hypertonicity.
Nonborn asphyxia
The development of respiratory disorders with hypoxia of the body causes disorders in the circulatory system, metabolic processes and microcirculation. Then there is a disorder in the work of the kidneys, heart, adrenal glands, brain.
Asphyxia requires immediate intervention to reduce the possibility of complications. Causes of respiratory disorders:
- hypoxia;
- impaired airway patency (aspiration of blood, mucus, meconium);
- organic brain damage and CNS function;
- malformations;
- not enough surfactant.
Diagnosis of the need for resuscitation is carried out after assessing the child's condition on the Apgar scale.
| What is assessed | 0 points | 1 point | 2 points |
| Breathing state | Missing | Pathological, irregular | Loud cry, rhythmic |
| HR | Missing | Less than 100 bpm | More than 100 beats per minute |
| Skin color | Cyanosis | Pink skin, bluish limbs | Pink |
| Muscle tone condition | Missing | Limbs slightly bent, tone weak | Active movements, good tone |
| Reaction to stimuli | Missing | Mild | Well defined |
Evaluation of the condition up to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia of moderate severity. Resuscitation of a newborn with asphyxia is carried out immediately after assessing his general condition.
Sequence of condition assessment
- The child is placed under a heat source, his skin is dried with a warm diaper. The contents are aspirated from the nasal cavity and mouth. Tactile stimulation is provided.
- Respiration is assessed. In the case of a normal rhythm and the presence of a loud cry, proceed to the next stage. With irregular breathing, mechanical ventilation is carried out with oxygen for 15-20min.
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Heart rate is being assessed. If the pulse is above 100 beats per minute, go to the next stage of the examination. If the heart rate is less than 100 beats, IVL is performed. Then the effectiveness of the measures is evaluated.
- Pulse below 60 - chest compressions+IVL.
- Pulse from 60 to 100 - IVL.
- Pulse above 100 - IVL in case of irregular breathing.
- After 30 seconds, if indirect massage with mechanical ventilation is ineffective, drug therapy should be carried out.
- Skin color is being examined. Pink color indicates the normal condition of the child. In case of cyanosis or acrocyanosis, it is necessary to give oxygen and monitor the condition of the baby.
How is primary resuscitation done?
Be sure to wash and treat hands with an antiseptic, put on sterile gloves. The time of birth of the child is recorded, after the necessary measures are taken, it is documented. The newborn is placed under a heat source, wrapped in a dry warm diaper.
To restore airway patency, you can lower the head end and put the child on his left side. This will stop the aspiration process and allow the contents of the mouth and nose to be removed. Gently aspirate the contents without resorting to deep insertion of the aspirator.
If these measures do not help, resuscitation of the newborn continues by sanitizing the trachea using a laryngoscope. After the appearance of breathing, but the absence of its rhythm, the child is transferred to a ventilator.
The neonatal intensive care unit receives a childafter initial resuscitation for further assistance and maintenance of vital functions.
Ventilation
The stages of neonatal resuscitation include artificial ventilation. Indication for ventilation:
- lack of breathing or the appearance of convulsive respiratory movements;
- pulse less than 100 times per minute, regardless of breathing status;
- persistent cyanosis with normal functioning of the respiratory and cardiovascular systems.
This set of activities is carried out using a mask or bag. The head of the newborn is thrown back a little and a mask is applied to the face. It is held with index and thumb fingers. The rest take out the child's jaw.
The mask should be on the area of the chin, nose and mouth. It is enough to ventilate the lungs with a frequency of 30 to 50 times in 1 minute. Bag ventilation can cause air to enter the stomach cavity. You can remove it from there with a gastric tube.
To control the effectiveness of the conduction, it is necessary to pay attention to the rise of the chest and the change in heart rate. The child continues to be monitored until the respiratory rhythm and heart rate are fully restored.
Why and how is intubation performed?
Primary resuscitation of newborns also includes tracheal intubation, in case of ineffective mechanical ventilation for 1 minute. The correct choice of the tube for intubation is one of the important points. It is made independing on the baby's body weight and gestational age.
Intubation is also performed in the following cases:
- need to remove meconium aspiration from trachea;
- prolonged ventilation;
- facilitating the management of resuscitation;
- administration of adrenaline;
- profound prematurity.
On the laryngoscope, the lighting is turned on and taken in the left hand. The head of the newborn is held with the right hand. The blade is inserted into the mouth and held to the base of the tongue. Raising the blade towards the handle of the laryngoscope, the resuscitator sees the glottis. The intubation tube is inserted from the right side into the oral cavity and passed through the vocal cords at the moment of their opening. It happens on the inhale. The tube is held to the planned mark.
Remove the laryngoscope, then the conductor. The correct insertion of the tube is checked by squeezing the breathing bag. Air enters the lungs and causes chest expansion. Next, the oxygen supply system is connected.
Card Compression
Resuscitation of a newborn in the delivery room includes chest compressions, which are indicated when the heart rate is less than 80 beats per minute.
There are two ways to perform an indirect massage. When using the first, pressure on the chest is carried out using the index and middle fingers of one hand. In another version, the massage is carried out with the thumbs of both hands, and the remaining fingers are involved in supporting the back. Resuscitator-neonatologist conductspressure on the border of the middle and lower thirds of the sternum, so that the chest caves in by 1.5 cm. The frequency of pressing is 90 per minute.
It is imperative to ensure that inhalation and chest compressions are not carried out at the same time. In a pause between pressures, you can not remove your hands from the surface of the sternum. Pressing on the bag is done after every three pressures. Every 2 seconds you need to perform 3 pushes and 1 ventilation.
Actions in case of meconium contamination of waters
Newborn resuscitation features include assistance with meconium staining of amniotic fluid and an Apgar score of less than 6.
- During labor, after the head emerges from the birth canal, immediately aspirate the contents of the nasal cavity and mouth.
- After birth and placement of the baby under a heat source, before the first breath, it is advisable to intubate the tube of the largest possible size in order to extract the contents of the bronchi and trachea.
- If it is possible to extract the contents and it has an admixture of meconium, then it is necessary to reintubate the newborn with another tube.
- Ventilation is adjusted only after all contents have been extracted.
Drug Therapy
Children's resuscitation of newborns is based not only on manual or hardware interventions, but also on the use of medications. In the case of mechanical ventilation and indirect massage, when the activities are ineffective for more than 30 seconds,use drugs.
Newborn resuscitation involves the use of adrenaline, volume resuscitators, sodium bicarbonate, naloxone, dopamine.
Adrenaline is injected through an endotracheal tube into the trachea or into a vein by jet. The concentration of the drug is 1:10,000. The drug is used to increase the force of contraction of the heart and accelerate the heart rate. After endotracheal administration, mechanical ventilation is continued so that the drug can be evenly distributed. If necessary, the agent is administered after 5 minutes.
Calculate the dose of the drug depending on the weight of the child:
- 1kg - 0.1-0.3ml;
- 2kg - 0.2-0.6ml;
- 3kg - 0.3-0.9ml;
- 4 kg - 0.4-1.2 ml.
When blood loss or the need to replenish the volume of circulating blood, albumin, saline sodium chloride solution or Ringer's solution are used. The drugs are injected into the vein of the umbilical cord in a jet (10 ml per 1 kg of the child's body weight) slowly over 10 minutes. The introduction of BCC supplements can increase blood pressure, reduce the level of acidosis, normalize the pulse rate and improve tissue metabolism.
Resuscitation of newborns, accompanied by effective ventilation of the lungs, requires the introduction of sodium bicarbonate into the umbilical vein to reduce signs of acidosis. The drug should not be used until the child is adequately ventilated.
Dopamine is used to increase cardiac index and glomerular filtration. The drug dilates the vessels of the kidneys and increases clearancesodium when using infusion therapy. It is administered intravenously by microfluidic under constant monitoring of blood pressure and heart rate.
Naloxone is administered intravenously at the rate of 0.1 ml of the drug per 1 kg of the child's body weight. The remedy is used when the skin color and pulse are normal, but there are signs of respiratory depression. The newborn should not be given naloxone while the mother is using narcotic drugs or is being treated with narcotic analgesics.
When to stop resuscitation?
VL continues until the child scores 6 Apgar points. This assessment is carried out every 5 minutes and lasts up to half an hour. If after this time the newborn has a score of less than 6, then he is transferred to the ICU of the maternity hospital, where further resuscitation and intensive care of newborns are carried out.
If the effectiveness of resuscitation measures is completely absent and asystole and cyanosis are observed, then the measures last up to 20 minutes. When even the slightest signs of effectiveness appear, their duration increases for as long as the measures give a positive result.
Newborn Intensive Care Unit
After the successful recovery of the lungs and heart, the newborn is transferred to the intensive care unit. There, the work of doctors is aimed at preventing possible complications.
A newborn after resuscitation needs to prevent the occurrence of swelling of the brain or other disorders of the central nervous system, to restore workkidneys and excretory function of the body, normalization of blood circulation.
A child may develop metabolic disorders in the form of acidosis, lactic acidosis, which is due to violations of peripheral microcirculation. On the part of the brain, convulsive seizures, hemorrhage, cerebral infarction, edema, and the development of a coma are possible. Also, ventricular dysfunction, acute kidney failure, atony of the bladder, insufficiency of the adrenal glands and other endocrine organs may appear.
Depending on the condition of the baby, he is placed in an incubator or an oxygen tent. Specialists monitor the work of all organs and systems. The child is allowed to feed only after 12 hours, in most cases - through a nasogastric tube.
Mistakes not allowed
It is strictly forbidden to carry out activities whose safety has not been proven:
- splash baby with water;
- compress his chest;
- strike buttocks;
- to direct an oxygen jet in the face and the like.
Albumin solution should not be used to increase initial CBV as this increases the risk of neonatal death.
Carrying out resuscitation does not mean that the baby will have any abnormalities or complications. Many parents expect pathological manifestations after the newborn was in intensive care. Reviews of such cases show that in the future, children have the same development as their peers.
