Neonatal Resuscitation - Steps Involved

Introduction

In many life-threatening situations, newborns fight for their last breath with weak vitals. In such emergencies, neonatal resuscitation skills are one of the best options available to save a life. According to the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), “approximately 10 % of newborns require some assistance to begin breathing at birth. Less than 1 % require extensive resuscitative measures.” There are a few cases that increase the chance of the need for resuscitation like twins delivery, premature delivery, mothers with uncontrollable bleeding, and long labor.

In the transition from intrauterine to extrauterine environment, sometimes a newborn feels difficulties in breathing on their own, and in conditions like asphyxia (condition due to insufficient oxygen supply), resuscitation re-establish normal breathing. Before initiating the resuscitation, the healthcare workers must be properly trained and certified for this. Updated guidelines for neonatal resuscitation are issued by the American Heart Association and the American Academy of Pediatrics, and it is necessary to follow these guidelines for the safety of newborns.

How to Prepare for Resuscitation?

To commence with, being prepared for resuscitation is the first step in delivering successful resuscitation. Every hospital should have trained and designated personnel to deliver successful resuscitation; during childbirth, they should be present there. The person should have the required skills to evaluate the newborn, and if necessary, he should initiate the resuscitation procedures like chest compression and positive pressure ventilation. In case of emergency, they should know to carry out a complete resuscitation protocol that includes endotracheal intubation and medication administration.

In order to carry out successful resuscitation, there are a few things that are required, such as:

• Suction Equipment:

  • Bulb syringe.

  • Mechanical suction and tubing.

  • Suction catheter.

  • 8F feeding tube and 20 ml syringe.

  • Meconium aspirator.

• Bag And Mask Equipment:

  • Positive pressure ventilation delivery device.

  • Face Masks.

  • Flowmeter with an oxygen source.

• Intubation Equipment:

  • Laryngoscope with straight blades.

  • Extra bulb and batteries for laryngoscope.

  • Endotracheal tubes.

  • Scissors.

  • Tape.

  • Alcohol sponges.

  • CO2 detector.

  • Laryngeal mask airway.

  • Stylet.

• Medication:

  • Epinephrine.

  • Sodium bicarbonate.

  • Dextrose 10% -250 ml, normal saline for flushes.

  • Sterile gloves, scalpel or scissors, antiseptic solution, umbilical tape, umbilical catheter.

  • Isotonic crystalloids for volume expansion of -100 or 250 ml.

  • Puncture device for a needleless system.

• Miscellaneous:

  • Gloves and personal protection.

  • Radiant warmer.

  • Firm padded resuscitation surface.

  • Warmed linens.

  • Stethoscope.

  • Cardiac monitor. Heart rate monitors are available online nowadays.

  • Oropharyngeal airway.

  • Timer.

• For Preterm Babies:

  • Compressed air source.

  • Pulse oximeter and probe.

  • Chemically activated warming pad.

  • Transport incubator to maintain temperature.

  • Oxygen blender.

What Are the Special Situations Where Resuscitation Is Immediately Needed?

• Pharyngeal Airway Obstruction: Obstruction of airflow due to pharyngeal collapse.

• Pneumothorax: It is a condition where air leaks between the lung and chest wall.

• Pleural Effusion: When there is excess water buildup in the lungs.

• Choanal Atresia: Congenital defect, where the back of the nasal cavity wall is narrowed.

• Diaphragmatic Hernia: It is a congenital disability, where there is a hole in the diaphragm.

What Are the Steps for Resuscitation?

Initial Steps:

• Provide warmth by placing the newborn under the radiant heat source.

• Position head in sniffing position to clear airway and avoid flexion or hyperextension of the neck.

• Clean and clear the airway with a suction catheter or syringe gently and quickly.

• Dry the baby to evoke tactile stimulation.

• Rub the back and soles of the feet for at least 5 seconds.

• Clamp and cut the umbilical cord.

• Initiate bag-mask ventilation by fitting the mask over the mouth firmly to prevent air leakage. Hold it with one hand, and with the other hand, squeeze the bag at the rate of 30 to 60 breaths per minute. It works when the chest rises and falls with breathing movement.

• Check the vitals and skin color every 30 seconds.

• If a newborn is showing vitals like decreased heart rate (<100 bpm) or low muscle tone, tracheal suctioning is required.

  • For tracheal suctioning, with direct vision, insert the laryngoscope using a catheter to clear the mouth and pharynx.

  • Insert the endotracheal tube into the trachea and attach the suction device and with suction, slowly retract the tube. Repeat until vitals are normal.

  • Right after this, stimulation is given without any delay by rubbing the back slowly and gently.

• If the heart rate is low, positive pressure ventilation should be provided without suctioning.

• If the newborn is not breathing with blue skin and a heart rate less than 100 bpm, positive pressure ventilation is provided along with supplemental oxygen for 30 seconds, and then evacuation is done until the newborn appears pink with normal breathing.

• If the heart rate is more than 60, then check compression with positive pressure ventilation is done until the heart rate reaches >100 bpm.

• If the heart rate is less than 60 bpm, the chest compression and positive pressure ventilation are done for 30 seconds along with evaluation.

• In the case of bradycardia (low blood pressure), epinephrine administration intravenously is required, along with chest compression and positive pressure ventilation.

• In the case of blood loss from the umbilical cord due to placenta abruption, the vitals of the baby may not improve, and there are chances of hypovolemic shock. In a condition like this, volume support is the only option.

The above guidelines are mandatory for any caregivers to follow in order to achieve good results. For every newborn baby, there should be one designated person allotted in the labor room. However, conditions like choanal atresia, pharyngeal airway malformations, pleural effusion, pneumothorax, and laryngeal web quick resuscitation are essential for airway management.

Withholding Resuscitation:

• In cases of congenital anomalies like premature birth and chromosomal abnormalities where the morbidity rate is high, resuscitation is not suggested.

• In conditions with borderline survival and high morbidity, resuscitation is withheld with the permission of parents.

How to Do Post-Resuscitation Care?

If the vitals of the children in resuscitation return back to normal, then it should be discontinued under observation because there are chances of deteriorating health. If required, they should be kept under anticipatory care and a controlled environment for a few more days to observe if their vitals are stable.

Conclusion:

Neonatal resuscitation training is part of successful childbirth and can be a life-altering treatment for newborns fighting for their last breath. Lastly, with constantly evolving medical treatments, It is mandatory for doctors to have knowledge of updated guidelines and training. It is a team-based effort of doctors to save the life of a newborn.