Any birth, including planned ones, must take place under the supervision of a resuscitator. There are cases when emergency resuscitation of a newborn is required. There are special indications for its implementation.
During childbirth, serious changes occur in the baby's body: the cardiac and pulmonary systems, as well as the central nervous system, begin to work differently. Therefore, one wrong move by the obstetricians and the mother in labor can cost the baby her health and even her life. IN emergency situations The baby may need resuscitation to restore his vital functions. The indications for it are:
- asphyxia (observed by the number of inhalations and exhalations). U healthy newborn the number of inhalations ranges from 30-60 times per minute;
- low heart rate. In babies born at term, the frequency of contractions of the heart muscle is 120-160 times; if the baby is not full-term or has congenital cardiac pathology, the pulse drops to 100 units or less;
- unhealthy skin color. Ideally, a child is born with a pink tint to the skin; the blueness of the hands and feet persists for the first 90 years of life. If general cyanosis is observed, this is an indicator to carry out primary resuscitation;
- lack of muscle tone. In healthy babies, it persists from birth to 1-2 months, but if there is no tone immediately after birth, doctors regard this as an intrauterine lesion of the central nervous system and resort to the stages of resuscitation;
- absence innate reflexes. If the baby is born at term without pathologies, he actively reacts to stimulation (wrinkles and cries when pulling mucus out of the nose or getting dressed), and when the baby reacts poorly, this is another indicator for intubating the child.
Note! The Apgar scale provides a complete assessment of the newborn's condition. How to do it rightconduct an assessment and what characteristics differ this technique, .
Resuscitation of a newborn in the delivery room: what it represents, stages
The Ministry of Health issued an order to resuscitate infants after birth. This is a set of activities aimed at returning vital functions the fetus is removed prematurely from the uterus, as well as if difficulties arise during childbirth.
If the Apgar score is low and cardiopulmonary activity is impaired, it is imperative to nurse the baby with intensive care.
Children say! A child after watching a cartoon about three heroes:
- Mom, you’re still not going to the store to pick up your brother, but maybe we’ll at least get a talking horse?First, the first stage of resuscitation is carried out: this includes a full assessment of the child’s condition. Meconium aspiration and diaphragmatic hernia are considered an indisputable indicator for measures to save the life of a newborn.
This stage involves resuscitators, an anesthesiologist, a neonatologist and two pediatric nurses. Everyone performs strictly assigned tasks. If the baby does not breathe on its own, they switch to artificial lung ventilation (ALV) until the skin turns pink. If the child's condition remains the same or worsens, proceed to tracheal intubation.
Note! In the event that the baby within 15-20 minutes resuscitation measures does not take an independent breath, the manipulations are stopped and the death of the newborn is recorded. If the dynamics are positive, they move on to the second stage of resuscitation.
After the respiratory and cardiac functions have been established, the baby is transferred to the intensive care unit and placed in an incubator with oxygen supply. It controls kidney function, heart rate, blood clotting and intestinal function. The presence of protein, calcium and magnesium in the blood is analyzed. The first feeding of a resuscitated newborn is allowed 12 hours after birth with expressed milk. Nutrition is supplied from a bottle or through a tube, depending on the severity of the baby’s condition.
Similar measures to save the life of a newborn are carried out during home births or at the birth of a baby in depressed state. We recommend watching the training video, which shows the algorithm for carrying out all the actions.
Neonatal resuscitation kit: equipment and medications
When important vital functions of the baby’s body are restored, he is placed in an incubator so that the head is below the level of the lungs. This prevents fluid from entering the lungs and aspiration of gastric contents, which can lead to inflammatory process and, as a consequence, the development of pneumonia.
Pulse monitoring is mandatory; for this purpose, a special sensor is attached to the newborn’s wrist or foot, which can quickly determine the state of heart contractions.
A blood test is carried out regularly, which is taken through an installed umbilical catheter; if necessary, an infusion and the necessary medications are administered into it.
Artificial pulmonary ventilation (ALV) in newborns is controlled by equipment. Proper oxygen supply is important to prevent the breathing valves from sticking. Respiratory support should be no more than 150 breaths per minute with adequate gas flow.
Children say! The son looked at himself in the mirror for a long time, then sighed heavily and said:
- I guess I’m still beautiful...Movement during incubation chest the newborn should be uniform and rhythmic, without the presence of noise. Presence of noise in lung tissues or esophagus indicates complications or underformation of tissues and organs. For premature babies whose lungs do not open for a long time, the administration of surfactant is prescribed. During spontaneous breathing of children and further independent work pulmonary system, the ventilation device is turned off.
Medicines for neonatal resuscitation in the delivery room
When reviving a baby who is in serious condition immediately after birth, a decision is made to administer medications to prevent cerebral edema after asphyxia and other pathologies affecting vital organs and systems.
- Administration of adrenaline to maintain heart rate at a dosage of 0.1-0.3 ml/kg of newborn weight. This solution is used in neonatal resuscitation if the beat frequency is less than 60 beats/min.
- Blood substitutes are administered if the baby has a dull heartbeat or pallor skin. Such drugs are saline solution and Ringer's lactate at a dosage of 10 ml/kg of the newborn's body weight.
- Use of Narcan. This is a narcotic drug that is not allowed for use by infants if the mother is a chronic drug addict or was given drugs of this kind several hours before birth.
- Glucose injection is acceptable for babies if the mother has chronic diabetes. The dosage of the drug is 2 mg per 1 kg of child weight. Be sure to use 10 percent glucose dissolved in water.
- Sodium bicarbonate is used in neonates undergoing resuscitation and ventilation only to maintain normal blood pH. If the drug is administered earlier, the child's condition may worsen.
Please note that the use of atropine in modern infant resuscitation is not permitted, and this is prescribed in the updated European protocol.
Rehabilitation and nursing of newborns after resuscitation
Whether the mother can get to the intensive care unit with the newborn and how long he will spend there depends on the complexity of the rescue measures: the more successfully the procedure for restoring vital functions was carried out, the sooner the baby will recover. Now the baby needs careful care and recovery.
After transferring the child to a regular ward, it is important for the mother to establish physical contact with him, while trying with all his might to maintain breast-feeding. The more often the baby is in his mother’s arms, the sooner he adapts to the environment.
Children after long-term resuscitation should eat on time; if they are malnourished, be sure to supplement them with at least 20 cubes of breast milk from a syringe.
Be sure to watch the video about the stages of recovery after resuscitation.
Relevance of the topic. According to WHO, approximately 5-10% of all newborns require medical care in the delivery room, and about 1% require full resuscitation. Providing adequate care to newborns in the first minutes of life can reduce their mortality and/or morbidity by 6-42%. The degree of proficiency of medical personnel present at birth in methods of primary resuscitation of newborns has a positive effect not only on their survival, but also on their further development and level of health in subsequent age periods.
Common goal: improve knowledge on assessing the condition of a newborn, determine indications for resuscitation measures and their volume. Be able to temporarily begin resuscitation, master the skills of resuscitation of a newborn.
Specific goal: Based on the perinatal history, objective examination data, determine the main signs of an emergency condition, carry out differential diagnosis, provide the necessary assistance.
Theoretical issues
1. Preparation for providing resuscitation care to a newborn in the delivery room or operating room.
2. Assessing the condition of the newborn child, determining the need for intervention.
3. Activities after the birth of a child. Ensuring cross-country ability respiratory tract, oxygen therapy, artificial ventilation with a bag and mask, tracheal intubation, chest compressions, etc.
4. Delivery algorithm emergency care newborns with clean amniotic fluid.
5. Algorithm for providing emergency care to newborns in case of contamination of amniotic fluid with meconium.
6. Medicines for primary resuscitation of newborns.
7. Indications for stopping resuscitation.
Indicative basis of activity
During preparation for the lesson, it is necessary to familiarize yourself with the main theoretical issues through the treatment algorithm (Fig. 1) and literature sources.
Preparing to provide resuscitation care to a newborn in the delivery room
Staffing: 1 person who can provide resuscitation assistance; 2 people with these skills for high-risk deliveries where full life support may be required. In case of multiple pregnancy, the presence of several resuscitation teams is necessary. Before each birth, you need to assess the temperature in the room (not lower than 25 ° C), the absence of drafts, select, install and check the functioning of resuscitation equipment:
1. Before birth, turn on the radiant heat source, warm the surface of the resuscitation table to 36-37 °C and prepare warmed diapers.
2. Check the oxygen supply system: presence of oxygen, pressure, flow rate, presence of connecting tubes.
3. Roll the diaper into a roll under the shoulders.
4. Prepare equipment for suctioning the contents of the upper respiratory tract (rubber balloon, adapter for connecting the endotracheal tube directly to the suction tube).
5. Prepare a gastric tube size 8F, a 20 ml syringe for aspiration of gastric contents, an adhesive plaster, scissors.
6. Prepare equipment for artificial pulmonary ventilation (ALV): resuscitation bag (volume no more than 75 ml) and mask. The oxygen flow rate must be at least 5 l/min. Check the functioning of the control valve, the integrity of the bag, the presence of oxygen in the tank, it is advisable to have a pressure gauge.
7. Prepare an intubation kit.
Urgent Care
Activities after the birth of a child
Immediately determine the need for resuscitation. Estimate:
— presence of meconium contamination;
- breathing;
- muscle tone;
- color of the skin;
— determine gestational age (term, premature).
Term active infants with adequate breathing, loud cry and normal physical activity do not require resuscitation. They are placed on the mother's stomach, dried and covered with a dry diaper. Sanitation of the upper respiratory tract is carried out by wiping the mucous membranes of the child’s mouth and nose.
Indications for further assessment of the newborn's condition and determination of the need for intervention:
1. Contamination of amniotic fluid or skin of a newborn with meconium.
2. Absence or decrease in the child’s response to stimulation.
3. Persistent central (diffuse) cyanosis.
4. Premature birth.
If any of these signs are present, newborns require standard initial resuscitation steps and require constant monitoring.
If a newborn needs emergency care, and the amniotic fluid is clear and there is no meconium on the baby’s skin, you must:
1. Place the baby under a radiant heat source on a warm swaddle.
2. Ensure airway patency: position on your back with your head moderately tilted back (roll under your shoulders).
3. Suck out the contents from the mouth, then from the nasal passages. If there is a significant amount of secretion, turn the child's head to the side.
4. Dry your skin and hair with a diaper using quick blotting movements.
5. Remove the wet diaper.
6. Again ensure the correct position of the child.
7. If there is no effective spontaneous breathing, perform one of the tactile stimulation techniques, which is repeated no more than two times (patting the soles, light blows on the heels, rubbing the skin along the spine)1.
8. If the skin of the body and mucous membranes remain cyanotic in the presence of spontaneous breathing, administer oxygen therapy. A free flow of 100% oxygen directed to the child's nose is provided through an anesthetic bag and mask, or through an oxygen tube and the palm of the hand, placed in the form of a funnel, or using an oxygen mask.
Once cyanosis has resolved, oxygen support should be gradually withdrawn so that the child remains pink when breathing room air. The preservation of the pink color of the skin when the end of the tube is removed by 5 cm indicates that the child does not need high concentrations of oxygen.
In case of any contamination of amniotic fluid with meconium:
- it is necessary to assess the activity of the newborn, clamp and cross the umbilical cord, inform the mother about the child’s breathing problems, without taking away the diaper and avoiding tactile stimulation;
- if the child is active - screams or breathes adequately, has satisfactory muscle tone and a heart rate (HR) of more than 100 beats per minute, he is placed on the mother’s stomach and observed for 15 minutes. A baby at risk of meconium aspiration may require subsequent tracheal intubation, even if active after birth;
- in the absence of respiratory distress, provide standard medical care in accordance with clinical protocol medical supervision of a healthy newborn child (Order No. 152 of the Ministry of Health of Ukraine dated April 4, 2005);
- if the newborn has depressed breathing, decreased muscle tone, heart rate less than 100 beats per minute, immediately suck out meconium from the trachea through the endotracheal tube. Aspiration of meconium should be carried out under heart rate control. If bradycardia increases, stop repeated aspiration of meconium and begin mechanical ventilation with a resuscitation bag through an endotracheal tube.
All measures for the initial treatment of a newborn are completed in 30 seconds. The child's condition (breathing, heart rate and skin color) is then assessed to determine whether further resuscitation is necessary2.
Breathing assessment. Normally, the child has active chest excursions, and the frequency and depth of respiratory movements increases a few seconds after tactile stimulation. Convulsive breathing movements are ineffective, and their presence in a newborn requires a complex of resuscitation measures, as with complete absence breathing.
Heart rate assessment. The heart rate should exceed 100 beats per minute. Heart rate is calculated at the base of the umbilical cord, directly at the site of its attachment to the anterior abdominal wall. If the pulse on the umbilical cord is not detected, you need to listen with a stethoscope to the heartbeat over the left side of the chest. Heart rate is calculated for 6 seconds and the result is multiplied by 10.
Skin color assessment. The baby's lips and body should be pink. After normalization of heart rate and ventilation, the child should not have diffuse cyanosis. Acrocyanosis, as a rule, does not indicate low level oxygen in the blood. Only diffuse cyanosis requires intervention.
After eliminating heat loss, ensuring airway patency and stimulating spontaneous breathing The next step in resuscitation should be to support ventilation.
Artificial ventilation with a bag and mask
Indications for mechanical ventilation:
- lack of breathing or its ineffectiveness (convulsive breathing movements, etc.);
- bradycardia (less than 100 beats per minute) regardless of the presence of spontaneous breathing;
- persistent central cyanosis with free flow of 100% oxygen in a child who is breathing independently and has a heart rate of more than 100 beats per minute.
The effectiveness of ventilation is determined: by chest excursion; auscultation data; increase in heart rate; improving skin color.
The first 2-3 breaths are performed, creating an inhalation pressure of 30-40 cm of water column, after which ventilation is continued with an inhalation pressure of 15-20 cm of water column and a frequency of 40-60 per minute. In the presence of pulmonary pathology, ventilation is carried out with an inspiratory pressure of 20-40 cm of water column. Ventilation of newborns is carried out with 100% humidified and warmed oxygen.
After 30 s of positive pressure ventilation, the heart rate and the presence of spontaneous breathing are again determined. Further actions depend on the result obtained.
1. If heart rate is more than 100 beats per minute:
- if spontaneous breathing is present, mechanical ventilation is gradually stopped, reducing its pressure and frequency, a free flow of oxygen is supplied and the skin color is assessed;
— in the absence of spontaneous breathing, continue mechanical ventilation until it appears.
2. If heart rate is from 60 to 100 beats per minute:
— continue mechanical ventilation;
— if mechanical ventilation was carried out with room air, anticipate the transition to the use of 100% oxygen, the need for tracheal intubation.
3. Heart rate is less than 60 beats per minute:
- begin chest compressions at a rate of 90 compressions per minute, continue mechanical ventilation with 100% oxygen at a rate of 30 breaths per minute, and determine the need for tracheal intubation.
Heart rate is monitored every 30 s until it exceeds 100 beats per minute and spontaneous breathing is established.
Carrying out mechanical ventilation for several minutes requires the introduction of an orogastric tube (8F) in order to prevent inflation of the stomach with air and subsequent regurgitation of gastric contents.
Indirect cardiac massage indicated if heart rate is less than 60 beats per minute after 30 seconds of effective ventilation with 100% oxygen.
Perform indirect cardiac massage by pressing on the lower third of the sternum. She is below conditional line, which connects the nipples. It is important not to press on the xiphoid process to avoid rupture of the liver.
Two indirect massage techniques are used, according to which pressure is applied to the sternum:
first - two thumbs, while the remaining fingers of both hands support the back;
the second - with the tips of two fingers of one hand: II and III or III and IV; while the second hand supports the back.
The depth of compression should be one third of the anteroposterior diameter of the chest.
The frequency of pressure is 90 per minute.
It is important to coordinate chest compressions with mechanical ventilation, avoiding performing both procedures simultaneously, and not removing your fingers from the surface of the chest during the pause between pressures. After every three pressures on the sternum, a pause is made for ventilation, after which the pressures are repeated, etc. In 2 seconds you need to make 3 pressures on the sternum (90 per 1 minute) and one ventilation (30 per 1 minute). Stop chest compressions if the heart rate is more than 60 beats per minute.
Tracheal intubation can be carried out at all stages of resuscitation, in particular:
- if necessary, suck out meconium from the trachea;
— if long-term ventilation is necessary to increase its effectiveness;
- to facilitate the coordination of chest compressions and ventilation;
- for the administration of adrenaline;
- if you suspect a diaphragmatic hernia;
- with deep prematurity.
Use of medications. Administration of drugs is indicated if, despite adequate ventilation of the lungs with 100% oxygen and chest compressions for 30 seconds, the heart rate remains less than 60 beats per minute.
During primary resuscitation of newborns, medications are used: adrenaline; means that normalize bcc; sodium bicarbonate, antagonists of narcotic drugs.
Adrenalin. Indications for use:
- Heart rate less than 60 beats per minute after at least 30 seconds performing mechanical ventilation 100% oxygen and chest compressions;
- absence of heart contractions (asystole) at any time during resuscitation.
Adrenaline is administered as quickly as possible intravenously or endotracheally at a dose of 0.1-0.3 ml/kg of solution at a concentration of 1: 10,000. The concentration of the solution is 1: 10,000 (to 0.1 ml of 0.1% solution of adrenaline hydrochloride or add 0.9 ml of isotonic sodium chloride solution to 0.1 ml of 0.18% adrenaline hydrogen tartrate solution).
Endotracheally, adrenaline is injected from a syringe directly into the tube or through a probe inserted into the tube. In this case, a solution of adrenaline at a concentration of 1: 10,000 can be further diluted with an isotonic solution to a final volume of 1 ml or the endotracheal tube (probe) can be rinsed with an isotonic sodium chloride solution (0.5-1.0 ml) after administering an undiluted dose. In case of endotracheal administration, it is recommended to always use a dose of 0.3-1.0 ml/kg. After injecting epinephrine into the trachea, it is important to immediately perform several effective positive pressure ventilations.
If there is no effect, the injection of adrenaline is repeated every 3-5 minutes, repeated injections only intravenously.
Large doses of intravenous epinephrine are not recommended for resuscitation of newborns, since their administration can cause damage to the baby's brain and heart.
Means that normalize bcc: 0.9% sodium chloride solution; lactated Ringer's solution; in order to correct significant blood loss (with clinical signs hemorrhagic shock) - transfusion of O(I) Rh(-) red blood cells. Indications for use:
- lack of response of the child to resuscitation measures;
- signs of blood loss (pallor, weak pulse, persistent tachycardia or bradycardia, no signs of improvement in blood circulation, despite all resuscitation measures).
With the development of hypovolemia, children whose condition does not improve during resuscitation are administered intravenously slowly, over 5-10 minutes, up to 10 ml/kg of one of the indicated solutions (isotonic sodium chloride solution is recommended).3
Sodium bicarbonate indicated for the development of severe metabolic acidosis during prolonged and ineffective resuscitation against the background of adequate mechanical ventilation. A 4.2% solution at a dose of 4 ml/kg or 2 mEq/kg is injected into the umbilical cord vein slowly, no faster than 2 ml/kg/min. The drug should not be administered until the newborn's lungs are ventilated.
Antagonists of narcotic drugs (naloxone hydrochloride)
Indications for use: persistent severe respiratory depression during positive pressure ventilation, with normal heart rate and skin color in a child whose mother was administered narcotic drugs during the last 4 hours before birth. Naloxone hydrochloride is administered at a concentration of 1.0 mg/ml solution, at a dose of 0.1 mg/kg IV. When administered intramuscularly, the effect of naloxone is slow; when administered endotracheally, it is ineffective.
Naloxone should not be prescribed to a child from a mother with suspected drug addiction or from a mother who is undergoing long-term drug treatment. This may cause severe cramping. The child's breathing can also be suppressed by other drugs administered to the mother (magnesium sulfate, non-narcotic analgesics, anesthetics), but their effect will not be blocked by the administration of naloxone.
If the child’s condition does not improve despite effective mechanical ventilation and chest compressions, administration of drugs, exclude abnormalities in the development of the respiratory tract, pneumothorax, diaphragmatic hernia, birth defects hearts.
Resuscitation of the newborn is stopped if, despite the correct and complete implementation of all resuscitation measures, there is no cardiac activity for 10 minutes.
1 It is prohibited to pour cold or hot water, direct a stream of oxygen into the face, squeeze the chest, hit the buttocks and carry out any other measures whose safety for a newborn has not been proven.
2 The Apgar score characterizes general state newborn and the effectiveness of resuscitation measures and is not used to determine the need for resuscitation, its volume or the timing of resuscitation measures. The Apgar score should be assessed at 1 and 5 minutes after the baby is born. If the assessment result at the 5th minute is less than 7 points, it should be additionally carried out every 5 minutes until the 20th minute of life.
Literature
1. Order of the Ministry of Health of Ukraine No. 437 dated 08/31/04 “On the approval of clinical protocols for the provision of medical assistance for difficult conditions in children at the hospital and pre-hospital stages.”
2. Order of the Ministry of Health of Ukraine No. 152 dated 04/04/2005 “On the approval of the clinical protocol for medical supervision of a healthy newborn baby.”
3. Order of the Ministry of Health of Ukraine No. 312 dated 06/08/2007 “On the approval of the clinical protocol for initial resuscitation and post-resuscitation care for newborns.”
4. Uncomplicated topics in pediatrics: Beg. pos_b. / Volosovets O.P., Marushko Yu.V., Tyazhka O.V. ta inshi / Ed. O.P. Volosovtsia and Yu.V. Marushko. - Kh.: Prapor, 2008. - 200 p.
5. Emergency conditions in children / Petrushina A.D., Malchenko L.A., Kretinina L.N. and others / Ed. HELL. Petrushina. — M.: LLC “Meditsinskoe” information Agency", 2007. - 216 p.
6. Peshiy M.M., Kryuchko T.O., Smiyan O.I. Uncomplicated assistance in pediatric practice. - Poltava; Sumi, 2004. - 234 p.
7. Emergency medical care for children prehospital stage/ G.I. Posternak, M.Yu. Tkacheva, L.M. Beletskaya, I.F. Volny / Ed. G.I. Belebezeva. - Lvov: Medicine for the World, 2004. - 186 p.
Additional
1. Aryaev M.L. Neonatology. - K.: ADEF - Ukraine, 2006. - 754 p.
2. Handbook of neonatology: Trans. from English / For ed. Jonah Cleorti, Anne Stark. - K.: Fund for Helping Children of Chornobyl, 2002. - 722 p.
3. Shabalov N.P. Neonatology: Textbook for students and residents of pediatric faculties medical institutes. — Second edition, corrected and expanded. - St. Petersburg: Special Literature, 1997. - T. 1. - 496 p.
4. Reanimation of newborns: Pidruchnik / Ed. J. Cavintela: Translation from English. - Lviv: Spolom, 2004. - 268 p.
According to statistics, every tenth newborn child receives medical care in the delivery room, and 1% of all births require a full range of resuscitation actions. High level of training medical personnel allows you to increase your chances of life and reduce possible development complications. Adequate and timely resuscitation of newborns is the first step towards reducing mortality and disease development.
Basic Concepts
What is neonatal intensive care? This is a series of activities that are aimed at revitalizing the child’s body and restoring lost functions. It includes:
- intensive care methods;
- use of artificial lung ventilation;
- installation of a pacemaker, etc.
Full-term babies do not require resuscitation measures. They are born active, scream loudly, pulse and heart rate are within normal limits, the skin is pink, and the child responds well to external stimuli. Such children are immediately placed on the mother's stomach and covered 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 response. 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. Similar treatment aimed at eliminating possible complications work stoppage important organs.
If the patient cannot independently maintain homeostasis, then resuscitation of the newborn includes either inserting a pacemaker.
What is needed to perform resuscitation in the delivery room?
If the need for such activities is small, then one person will be required to carry them out. In case of a difficult pregnancy and waiting for a full range of resuscitation actions, there are two specialists in the maternity room.
Resuscitation of a newborn in the delivery room requires careful preparation. Before the birth process, you should check that everything you need is available and make sure that the equipment is in working condition.
- You need to connect a heat source so that the resuscitation table and diapers are warmed up, roll one diaper into a roll.
- Check whether the oxygen supply system is installed correctly. There must be a sufficient amount of oxygen, correctly adjusted pressure and flow rate.
- The readiness of the equipment required for suctioning the contents of the respiratory tract should be checked.
- Prepare instruments to remove gastric contents in case of aspiration (probe, 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 guides, a laryngoscope with different blades and spare batteries, scissors and gloves.
What makes events successful?
Neonatal resuscitation in the delivery room is based on the following principles of success:
- availability of resuscitation team - resuscitators must be present at all births;
- coordinated work - the team must work harmoniously, complementing each other as one big mechanism;
- qualified staff - every resuscitator must have high level knowledge and practical skills;
- work taking into account the patient’s reaction - resuscitation actions should begin immediately when the need arises, further measures are carried out depending on the reaction of the patient’s body;
- serviceability of equipment - equipment for resuscitation must be in working order and accessible at all times.
Reasons for the need for events
TO etiological factors oppression of the heart, lungs and other vital organs of the newborn include the development of asphyxia, birth injuries, development congenital pathology, toxicosis of infectious origin and other cases of unknown etiology.
Pediatric neonatal resuscitation and its need can be predicted even during the period of pregnancy. In such cases, a team of resuscitators must be ready to immediately provide assistance to the baby.
The need for such measures may arise in the following conditions:
- high or low water levels;
- post-maturity;
- maternal diabetes;
- hypertonic disease;
- infectious diseases;
- fetal malnutrition.
There are also a number of factors that already arise during childbirth. If they occur, you can expect the need for resuscitation measures. Such factors include bradycardia in the child, cesarean section, premature and rapid labor, placenta previa or abruption, uterine hypertonicity.
Asphyxia of newborns
The development of impaired breathing processes with hypoxia of the body causes the appearance of disorders in the circulatory system, metabolic processes and microcirculation. Next, a disorder in the functioning of the kidneys, heart, adrenal glands, and brain appears.
Asphyxia requires immediate intervention to reduce the possibility of complications. Causes of breathing disorders:
- hypoxia;
- airway obstruction (aspiration of blood, mucus, meconium);
- organic damage to the brain and central nervous system;
- developmental defects;
- insufficient amount of surfactant.
The need for resuscitation is diagnosed after assessing the child’s condition using the Apgar scale.
| What is being assessed | 0 points | 1 point | 2 points |
| Breathing status | Absent | Pathological, irregular | Loud scream, rhythmic |
| Heart rate | Absent | Less than 100 beats per minute | More than 100 beats per minute |
| Skin color | Cyanosis | Pink skin, bluish limbs | Pink |
| State of muscle tone | Absent | Limbs are slightly bent, tone is weak | Active movements, good tone |
| Reaction to irritant factors | Absent | Weakly expressed | Well expressed |
A score of up to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia medium degree gravity. 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.
- A breathing assessment is performed. In case of normal rhythm and presence loud scream, move on to the next stage. In case of irregular breathing, mechanical ventilation is performed with oxygen for 15-20 minutes.
- Heart rate is assessed. If the pulse is above 100 beats per minute, proceed to the next stage of examination. In case of less than 100 beats, mechanical ventilation is performed. Then the effectiveness of the measures is assessed.
- Pulse below 60 - indirect cardiac massage + mechanical ventilation.
- Pulse from 60 to 100 - mechanical ventilation.
- Pulse above 100 - mechanical ventilation in case of irregular breathing.
- After 30 seconds, if indirect massage with mechanical ventilation is ineffective, it is necessary to carry out drug therapy.
- Skin color is examined. Pink color indicates in good condition child. In case of cyanosis or acrocyanosis, it is necessary to give oxygen and monitor the baby’s condition.
How is primary resuscitation performed?
Be sure to wash and treat your hands with antiseptic and wear sterile gloves. The time of birth of the child is recorded, and after the necessary measures are taken, it is documented. The newborn is placed under a heat source and wrapped in a dry, warm diaper.
To restore airway patency, you can lower the head end and place the child on his left side. This will stop the aspiration process and allow the contents of the mouth and nose to be removed. Carefully suck out the contents without resorting to deep insertion of the aspirator.
If such measures do not help, resuscitation of the newborn continues by sanitation of the trachea using a laryngoscope. After breathing appears, but there is no rhythm, the child is transferred to mechanical ventilation.
The neonatal resuscitation and intensive care unit admits the child after initial resuscitation measures to provide further assistance and maintaining vital functions.
Ventilation
The stages of neonatal resuscitation include 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 operation respiratory and cardiovascular systems.
This set of measures is carried out using a mask or bag. The newborn's head is tilted back slightly and a mask is placed on the face. It is held with the index fingers and thumbs. The rest is used to remove the child's jaw.
The mask should be on the chin, nose and mouth. It is enough to ventilate the lungs at a frequency of 30 to 50 times per minute. Ventilating with a bag may cause air to enter the stomach cavity. You can remove it from there using
To monitor the effectiveness of the exercise, you need to pay attention to the rise of the chest and changes in heart rate. The child continues to be monitored until full recovery rhythm of breathing and heart contractions.
Why and how is intubation performed?
Primary resuscitation of newborns also includes tracheal intubation, if mechanical ventilation is ineffective for 1 minute. Right choice intubation tubes - one of important points. It is done depending on the baby’s body weight and gestational age.
Intubation is also performed in the following cases:
- the need to remove meconium aspiration from the trachea;
- carrying out prolonged ventilation;
- facilitating the management of resuscitation measures;
- injection of adrenaline;
- deep prematurity.
The laryngoscope is illuminated and held in the left hand. Right hand holding the newborn's head. The blade is inserted into the mouth and passed 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 with right side into the oral cavity and passed through vocal cords at the moment of their opening. This happens as you inhale. The tube is carried out to the planned mark.
The laryngoscope is removed, then the guidewire. The correct insertion of the tube is checked by squeezing the breathing bag. Air enters the lungs and causes chest excursion. Next, the oxygen supply system is connected.
Indirect cardiac massage
Resuscitation of a newborn in the delivery room includes that indicated when the heart rate is less than 80 beats per minute.
There are two ways to perform indirect massage. When using the first, pressure on the chest is carried out using the index and middle finger 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. The resuscitator-neonatologist applies pressure at the border of the middle and lower third of the sternum so that the chest sag by 1.5 cm. The frequency of pressure is 90 per minute.
It is imperative to ensure that inhalation and pressing on the chest are not carried out simultaneously. During the pause between pressures, you cannot remove your hands from the surface of the sternum. Pressing the bag is done after every three pressures. For every 2 seconds you need to perform 3 pressures and 1 ventilation.
Actions in case of water contamination with meconium
Features of neonatal resuscitation include assistance with meconium staining of amniotic fluid and an Apgar score of less than 6 points for the child.
- During childbirth, after the head emerges from birth canal Immediately aspirate the contents of the nasal and oral cavity.
- After birth and placing the baby under a heat source, before the first breath, it is advisable to perform intubation with a 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 contains an admixture of meconium, then it is necessary to reintubate the newborn with another tube.
- Ventilation is established only after all contents have been removed.
Drug therapy
Pediatric neonatal resuscitation 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 measures are ineffective for more than 30 seconds, medications are used.
Resuscitation of newborns involves the use of adrenaline, means to restore circulating blood volume, sodium bicarbonate, naloxone, and dopamine.
Mistakes that are prohibited
It is strictly prohibited to carry out activities whose safety has not been proven:
- pour water over the baby;
- squeeze his chest;
- strike the buttocks;
- direct a stream of oxygen into the face and the like.
Albumin solution should not be used to increase the initial volume of blood volume, as this increases the risk of death in the newborn.
Carrying out resuscitation measures 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.
Resuscitation of newborns in the delivery room is based on a strictly defined sequence of actions, including predicting the occurrence of critical situations, assessing the condition of the child immediately after birth and carrying out resuscitation measures aimed at restoring and maintaining respiratory and circulatory function.
Predicting the likelihood of a child being born with asphyxia or drug-induced depression is based on an analysis of antenatal and intrapartum history.
Risk factors
Antenatal risk factors include maternal diseases such as diabetes mellitus, hypertension syndromes, infections, and maternal drug and alcohol use. Among the pathologies of pregnancy, it should be noted high or low water intake, post-term pregnancy, delay intrauterine development fetus and the presence of multiple pregnancies.
Intrapartum risk factors include: premature or delayed birth, abnormal presentation or position of the fetus, placental abruption, prolapse of umbilical cord loops, use of general anesthesia, anomalies labor activity, the presence of meconium in amniotic fluid, etc.
Before resuscitation begins, the child’s condition is assessed based on the following signs of live birth:
- the presence of spontaneous breathing,
- heartbeat,
- umbilical cord pulsations,
- voluntary muscle movements.
If all 4 signs are absent, the child is considered stillborn and cannot be resuscitated. The presence of at least one sign of live birth is an indication for the immediate initiation of resuscitation measures.
Resuscitation algorithm
The resuscitation algorithm is determined by three main features:
- the presence of independent breathing;
- heart rate;
- skin color.
The Apgar score is assessed, as was customary, at the 1st and 5th minutes to determine the severity of asphyxia, but its indicators do not have any effect on the volume and sequence of resuscitation measures.
Primary care newborns in the maternity hospital
Initial activities(duration 20-40 s).
In the absence of risk factors and clear amniotic fluid, the umbilical cord is cut immediately after birth, the baby is wiped dry with a warm diaper and placed under a radiant heat source. If there is a large amount of mucus in the upper respiratory tract, then it is suctioned from oral cavity and nasal passages using a balloon or catheter connected to an electric suction device. In the absence of breathing, light tactile stimulation is carried out by patting the feet 1-2 times.
In the presence of asphyxia factors and pathological impurities in the amniotic fluid (meconium, blood), aspiration of the contents of the oral cavity and nasal passages is performed immediately after the birth of the head (before the birth of the shoulders). After birth, pathological impurities are aspirated from the stomach and trachea.
I. First assessment of condition and action:
A. Breathing.
Absent (primary or secondary epnea) - start mechanical ventilation;
Independent, but inadequate (convulsive, superficial, irregular) - start mechanical ventilation;
Independent regular - assess heart rate (HR).
B. Heart rate.
Heart rate less than 100 beats per minute. - carry out mask ventilation with 100% oxygen until heart rate normalizes;
B. Skin color.
Completely pink or pink with cyanosis of the hands and feet - observe;
Cyanotic - inhale 100% oxygen through a face mask until cyanosis disappears.
Mechanical ventilation technique
Artificial ventilation is carried out with a self-expanding bag (Ambu, Penlon, Laerdal, etc.) through a face mask or endotracheal tube. Before starting mechanical ventilation, the bag is connected to an oxygen source, preferably through a gas mixture humidifier. Place a cushion under the child's shoulders and tilt his head slightly back. The mask is placed on the face so that it top part The obturator lay on the bridge of the nose, and the lower one on the chin. When pressing on the bag, the excursion of the chest should be clearly visible.
Indications for the use of an oral airway during mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the inability to ensure free patency of the airways when the child is positioned correctly.
Tracheal intubation and switching to mechanical ventilation through an endotracheal tube is indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation within 1 minute, as well as for apnea or inadequate breathing in a child with a gestational age of less than 28 weeks.
Artificial ventilation is carried out with a 90-100% oxygen-air mixture with a frequency of 40 breaths per minute and an inhalation to exhalation time ratio of 1:1.
After ventilation of the lungs for 15-30 seconds, the heart rate is again monitored.
If the heart rate is above 80 per minute, continue mechanical ventilation until adequate spontaneous breathing is restored.
If the heart rate is less than 80 beats per minute, while continuing mechanical ventilation, begin chest compressions.
Indirect cardiac massage technique
The child is placed on a hard surface. Using two fingers (middle and index) of one hand or two thumbs of both hands, apply pressure on the border of the lower and middle third of the sternum with a frequency of 120 per minute. The displacement of the sternum towards the spine should be 1.5-2 cm. Ventilation of the lungs and cardiac massage are not synchronized, i.e. Each manipulation is carried out in its own rhythm.
30 seconds after start closed massage hearts control heart rate again.
If the heart rate is above 80 beats per minute, stop cardiac massage and continue mechanical ventilation until adequate spontaneous breathing is restored.
If the heart rate is below 80 per minute, continue chest compressions, mechanical ventilation and begin drug therapy.
Drug therapy
If asystole or heart rate is below 80 beats per minute, adrenaline is immediately administered at a concentration of 1:10,000. To do this, 1 ml of ampoule solution of adrenaline is diluted in 10 ml saline solution. The solution prepared in this way is taken in an amount of 1 ml into a separate syringe and injected intravenously or endotracheally at a dose of 0.1-0.3 ml/kg body weight.
Heart rate is re-monitored every 30 seconds.
If heart rate recovers and exceeds 80 beats per minute, stop cardiac massage and administration of other medications.
If there is asystole or heart rate below 80 beats per minute, continue chest compressions, mechanical ventilation and drug therapy.
Repeat the administration of adrenaline at the same dose (if necessary, this can be done every 5 minutes).
If the patient has signs of acute hypovolemia, which is manifested by pallor, weak thready pulse, low blood pressure, then the child is advised to administer a 5% albumin solution or saline solution at a dose of 10-15 ml/kg body weight. Solutions are administered intravenously over 5-10 minutes. If signs of hypovolemia persist, repeated administration of these solutions in the same dose is permissible.
Administration of sodium bicarbonate is indicated for confirmed decompensated metabolic acidosis(pH 7.0; BE -12), as well as in the absence of effect from mechanical ventilation, cardiac massage and drug therapy(suspected severe acidosis preventing cardiac recovery). Sodium bicarbonate solution (4%) is injected into the umbilical cord vein at the rate of 4 ml/kg body weight (2 mEq/kg). The rate of drug administration is 1 mEq/kg/min.
If within 20 minutes after birth, despite full resuscitation measures, the child’s cardiac activity is not restored (no heartbeats), resuscitation in the delivery room is stopped.
At positive effect from resuscitation measures, the child should be transferred to the intensive care unit (ward), where specialized treatment will continue.
Primary neonatal resuscitation
Death is the death of body cells due to the cessation of their supply of blood, which carries oxygen and nutrients. Cells die after sudden stop heart and breathing, although quickly, are not instantaneous. The cells of the brain, especially the cortex, that is, the department on the functioning of which consciousness, spiritual life, and human activity as an individual depend, suffer most from the cessation of oxygen supply.
If oxygen does not enter the cells of the cerebral cortex within 4–5 minutes, they are irreversibly damaged and die. Cells of other organs, including the heart, are more viable. Therefore, if breathing and blood circulation are quickly restored, the vital activity of these cells will resume. However, this will only be the biological existence of the organism, consciousness, mental activity either they will not be restored at all, or they will be profoundly changed. Therefore, the revival of a person must begin as early as possible.
That is why everyone needs to know the methods of primary resuscitation of children, that is, to learn a set of measures to provide assistance at the scene of an incident, prevent death and revive the body. It is everyone’s duty to be able to do this. Inactivity while waiting medical workers, no matter what it is motivated by - confusion, fear, inability - should be considered as a failure to fulfill a moral and civic duty in relation to a dying person. If this concerns your beloved baby, it is simply necessary to know the basics of resuscitation care!
Carrying out resuscitation for a newborn
How is primary resuscitation of children performed?
Cardiopulmonary and cerebral resuscitation (CPCR) is a set of measures aimed at restoring the basic vital functions of the body (heart and breathing) impaired in terminal conditions in order to prevent brain death. This resuscitation is aimed at reviving a person after breathing has stopped.
Leading reasons terminal conditions, developed outside medical institutions, in childhood are a syndrome sudden death newborns, car trauma, drowning, obstruction of the upper respiratory tract. The maximum number of deaths in children occurs under the age of 2 years.
Periods of cardiopulmonary and cerebral resuscitation:
- The period of basic life support. In our country it is called the immediate stage;
- Period of further life support. It is often referred to as a specialized stage;
- The period of prolonged and long-term life support, or post-resuscitation.
At the stage of basic life support, techniques are performed to replace (“prosthetics”) the vital functions of the body - the heart and breathing. At the same time, the events and their sequence are conventionally designated by a well-remembered abbreviation of three English letters ABS:
- from English airway, literally opening the airways, restoring airway patency;
– breath for victim, literally – breathing for the victim, mechanical ventilation;
– circulation his blood, literally – ensuring its blood flow, external massage of the heart.
Transportation of victims
Functionally justified for transporting children is:
- in case of severe hypotension - horizontal position with the head end lowered by 15°;
- in case of chest injury, acute respiratory failure of various etiologies– semi-sitting;
- in case of spinal injury – horizontal on the backboard;
- for fractures of the pelvic bones, injuries to the abdominal organs - the legs are bent at the knees and hips; joints and spread to the sides (“frog position”);
- for injuries of the skull and brain with lack of consciousness - horizontal on the side or on the back with the head end raised by 15°, fixation of the head and cervical spine.
Should be provided in all medical institutions where childbirth could potentially occur. Work in the maternity ward should be organized in such a way that in cases where cardiopulmonary resuscitation begins, the employee who carries it out from the first minute can be assisted by at least two other medical workers.
Antenatal risk factors for the development of newborn asphyxia.
1. Diabetes mellitus
2. Preeclampsia
3. Hypertensive syndromes
4. Rhesus sensitization
5. History of stillbirth
6. Clinical signs maternal infections
7. Bleeding in the second and third trimester of pregnancy
8. Polyhydramnios
9. Low water
10. Multiple pregnancy
11. Intrauterine growth restriction
12. Maternal drug and alcohol use
13. Use of drugs that depress the breathing of a newborn (promedol)
14. Presence of developmental anomalies
15. Abnormal CTG readings before childbirth.
Intrapartum risk factors
1. Premature birth before 37 weeks
2. Late birth beyond 42 weeks
3. Caesarean
4. Placental abruption
5. Placenta previa
6. Loss of umbilical cord loops
7. Pathological position of the fetus
8. General anesthesia
9. Anomaly of labor
10. Presence of miconium in amniotic fluid
11. Fetal heart rhythm disturbances
12. Histocia of the shoulders
13. Instrumental birth - forceps, vacuum extraction
In cases where the birth of a child is predicted to be up to 32 weeks of gestation, a resuscitation team should be on duty in the delivery room. After the birth of a child, it is necessary to record the time of his birth and begin resuscitation measures, regardless of the initial condition of the newborn. Apgar score at the first and fifth minutes of life and at 10 minutes. Amount of 8 or more points is satisfactory. Condition, 4-7 moderate asphyxia
The protocol for primary resuscitation of newborns includes
1. Initial measures - restoration of airway patency
2. Artificial ventilation
3. Indirect cardiac massage
4. Administration of medications
The child’s condition in the first minutes of life is assessed according to three criteria:
1. Presence and nature of spontaneous breathing
2. Heart rate
3. Skin color
Criteria for the effectiveness of resuscitation are:
1. Regular effective spontaneous breathing
2. Heart rate more than 100 beats/min.
Initial activities include:
1. Maintaining body temperature - drying children over 28 weeks is simply blotted with a diaper; if up to 28 weeks - wet, they are placed in a plastic bag with a slit for the head.
2. Sanitation of the oropharynx is indicated only for those newborns who have not developed independent breathing during the first 10 minutes of life or who have a large amount of discharge.
3. Tactile stimulation - carried out either by patting the feet or stroking the back.
4. Artificial ventilation. Indications for mechanical ventilation: 1. Lack of breathing, 2. Irregular breathing, 3. Heart rate less than 100 beats/min.
Immediate inbation:
1. Children with suspected diaphragmatic hernia
2. Children born with an admixture of myconium in the amniotic fluid or with depressed spontaneous breathing
3. For children born before 27 weeks for the purpose of prophylactic administration of sulfoctant.
Evaluation of the effectiveness of mechanical ventilation through a face mask
The main criterion for effectiveness is a heart rate of more than 100. It must be assessed 30 seconds after the start. The heart rate assessment lasts 6 seconds.
Heart rate less than 60 - intubation is performed and mechanical ventilation begins using a tube. If you can’t intubate within 20 seconds, continue to breathe through the mask and then try to intubate again.
If bradycardia persists, chest compressions are started against the background of mechanical ventilation through a tube.
The heart rate is more than 60 but less than 100 - mechanical ventilation continues for another 30 seconds, then the heart rate is assessed; if bad - intubation.
Heart rate is more than 100 - continue mechanical ventilation until spontaneous breathing is restored.
Indications for tracheal intubation
1. Children with suspected diaphragmatic hernia.
2. Children with meconium in the amniotic fluid in the absence of spontaneous breathing
3. Children born before 27 weeks for the purpose of professional administration of suloctant.
4. If mask ventilation is ineffective when the heart rate is less than 60 for 30 seconds.
5. If effective mask ventilation is insufficient, if from 60 to 100 for 60 seconds.
6. If necessary, perform indirect cardiac massage.
Indirect cardiac massage
1. The frequency of ventilation to compressions is 3:1.
2. After the massage begins, 30 seconds later we evaluate the heart rate - if it is more than 60, then stop the indirect cardiac massage, if below 60, then continue.
Drug therapy
Adrenaline if the frequency is less than 60 after 30 seconds of indirect massage. 0.3 ml per kg body weight.
Saline solution - acute blood loss or hypovolumia - 10 ml per kg slowly.
sodium bicarbonate acidosis, lack of effect from the above. 4 ml per kg of 4% solution at a rate of 2 ml per kg per minute. End of resuscitation 10 minutes from the start of the measures taken, if not effective.
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