Any childbirth, including planned, should 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 movement of obstetricians and the woman in labor herself can cost a crumb of health and even life. V emergency situations resuscitation of the baby may be required to restore his vital functions. The indications for her are as follows:
- asphyxia (observed by the number of breaths and exhalations). Have healthy newborn the number of inhalations ranges from 30-60 times per minute;
- low heart rate. In babies born on time, the frequency of contractions of the heart muscle is 120-160 times, if the baby is not full-term or has a congenital heart pathology, the pulse decreases to 100 units or less;
- unhealthy skin color. Ideally, the baby is born with a pink skin tone, and the blueness of the arms and legs persists for the first 90 s 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 the tone is absent immediately after childbirth, doctors regard this as an intrauterine lesion of the central nervous system and resort to resuscitation stages;
- absence congenital reflexes... If the baby is born on time without pathologies, it actively responds to stimulation (frowns and cries when pulling mucus from the nose or dressing), and when the baby reacts weakly, this is another indicator for intubating the child.
Note! The Apgar scale gives a full assessment of the condition of the newborn. How to do it rightevaluate and what characteristics differ this technique, .
Resuscitation of a newborn in the delivery room: what is it, stages
The Ministry of Health has issued an order for the resuscitation of infants after birth. This is a set of activities aimed at returning vital functions the fetus with its premature extraction from the uterus, as well as if difficulties have arisen during childbirth.
It is imperative, with a low Apgar score and impaired cardiopulmonary activity, to nurture the infant with the help of intensive therapy.
Children say! A child after watching a cartoon about three heroes:
- Mom, you still aren't going to the store to pick up your brother, maybe we'll get at least 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 indisputable indicators of 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 ventilation (ALV) until a pink skin tone appears. If the child's condition remains the same or worsens, they proceed to tracheal intubation.
Note! In the event that the baby within 15-20 minutes resuscitation and does not take an independent breath, the manipulations are stopped and the death of the newborn is recorded. With positive dynamics, they pass to the second stage of resuscitation.
After improving the respiratory and cardiac functions, the baby is transferred to the intensive care unit, placed in an incubator with oxygen supply. Here, kidney function, heart rate, blood clotting and bowel function are monitored. 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. Food 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 at home birth or at the birth of a baby in depressed state... We recommend watching a training video, where the algorithm for carrying out all actions is indicated.
Newborn resuscitation kit: equipment and medicines
When the important vital functions of the infant's body are restored, it is placed in an incubator so that the head is below the level of the lungs. This prevents liquids from entering the lungs and aspiration of gastric contents, which can go into inflammatory process and, as a consequence, the development of pneumonia.
It is imperative that the pulse is monitored; for this, a special sensor is attached to the wrist of the newborn or to the foot, which can quickly determine the state of heart contractions.
A blood test is regularly performed, which is taken through an installed umbilical catheter, if necessary, an infusion and the necessary medications are injected into it.
Artificial lung ventilation (ALV) in newborns is controlled by equipment. Correct oxygen supply is important to prevent sticking of the breathing valves. Breathing support should be no more than 150 breaths and breaths per minute with an adequate gas flow.
Children say! The son looked at himself in the mirror for a long time, then he sighed heavily and said:
- I guess I'm still handsome ...During incubation, movement chest the newborn should be uniform and rhythmic, without the presence of noise. The presence of noise in lung tissue or the esophagus speaks of complications or malformation of tissues and organs. For premature babies, whose lungs do not open for a long time, the administration of a surfactant is prescribed. With spontaneous breathing of children and further independent work of the pulmonary system, the ventilation apparatus is turned off.
Medicines for resuscitation of newborns in the delivery room
When reviving an infant in a serious condition immediately after birth, a decision is made to administer drugs to prevent cerebral edema after asphyxiation and other pathologies affecting vital organs and systems.
- The introduction of adrenaline to maintain the heart rate at a dosage of 0.1-0.3 ml / kg of the newborn's weight. Such a solution is used in the intensive care unit of a newborn if the frequency of strokes is less than 60 beats / min.
- Blood substitutes are introduced, if a deaf heartbeat is heard in the baby, pallor is observed skin... Such drugs are saline and Ringer's lactate at a dosage of 10 ml / kg of body weight of a newborn.
- The use of Narcan. This is a narcotic drug that is not allowed to be used by infants if the mother is a chronic drug addict or if she was given drugs of a similar nature several hours before giving birth.
- Glucose injection is acceptable for babies if the mother has chronic diabetes mellitus. The dosage of the drug is 2 mg per 1 kg of the child's weight. Be sure to use 10% glucose dissolved in water.
- Sodium bicarbonate is used for newborns who have undergone resuscitation and ventilation of the lungs, only to maintain a 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 it is possible for a mother to get into intensive care for a newborn and how much time he will spend there depends on the complexity of the course of 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 an ordinary ward, it is important for mom to establish bodily contact with him, while trying with all your might to keep breast-feeding... The more often the baby is in the mother's arms, the sooner it adapts to the environment.
Children after prolonged resuscitation should be fed on time, if they are malnourished, be sure to supplement them with a syringe with at least 20 cubes of breast milk.
Be sure to watch the video that explains the stages of recovery after resuscitation.
Relevance of the topic. According to the WHO, approximately 5-10% of all newborns require medical assistance in the delivery room, and about 1% require full re; animation. Providing adequate care for newborns in the first minutes of life can reduce their mortality and / or morbidity by 6-42%. The degree of knowledge of the medical staff present at childbirth, methods of primary resuscitation of newborns has a positive effect not only on their survival, but also on their further development, the level of health in subsequent age periods.
Common goal: to improve knowledge on the assessment of the condition of the newborn, to determine the indications for resuscitation and their volume. Be able to do your own; temporarily start resuscitation, master the skills of resuscitation of a newborn; leg.
Specific Purpose: based on the perinatal history, physical examination data, determine the main signs of an emergency, conduct differential diagnosis, provide the necessary assistance.
Theoretical questions
1. Preparation for the provision of resuscitation care for a newborn in the delivery room or operating room.
2. Assessment of the condition of the newborn child, determination of the need for intervention.
3. Activities after the birth of the child. Ensuring passability respiratory tract, oxygen therapy, artificial ventilation of the lungs with a bag and mask, tracheal intubation, chest compressions, etc.
4. Algorithm of rendering 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 termination of 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), literature sources.
Preparation for the provision of resuscitation care for a newborn in the delivery room
Staffing: 1 person who can provide resuscitation assistance; 2 people with these skills for high-risk childbirth when full resuscitation may be required. In the case of multiple pregnancies, several resuscitation teams must be present. Before each birth, you need to assess the temperature in the room (at least 25 ° C), the absence of drafts, select, mount and check the functioning of the resuscitation equipment:
1. Before childbirth, turn on the source of radiant heat, warm the surface of the resuscitation table to 36-37 ° C and prepare the warmed diapers.
2. Check the oxygen supply system: presence of oxygen, pressure, flow rate, presence of connecting pipes.
3. Roll up the shoulder roll from the diaper.
4. Prepare equipment for suction of the contents of the upper respiratory tract (rubber balloon, adapter for connecting the endotracheal tube directly to the suction tube).
5. Prepare 8F gastric tube, 20 ml syringe for aspiration of gastric contents, adhesive plaster, scissors.
6. Prepare equipment for artificial lung 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 operation 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 intubation kit.
Urgent care
Postnatal activities
Immediately determine the need for re; animation. Estimate:
- the presence of meconium contamination;
- breathing;
- muscle tone;
- color of the skin;
- determine the gestational age (full-term, premature).
Term, active babies with adequate breathing, loud crying and normal motor activity do not need resuscitation. They are laid out on the mother's belly, dried and covered with a dry diaper. Rehabilitation 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 condition of the newborn and determination of the need for intervention:
1. Meconium contamination of amniotic fluid or newborn skin.
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 should be monitored continuously.
If a newborn needs urgent care, while the amniotic fluid is clean and there is no meconium on the baby's skin, it is necessary:
1. Place the baby under a radiant heat source on a warm diaper.
2. Ensure airway patency: supine position with head tilted back moderately (cushion under the shoulders).
3. Suck the contents from the mouth, then from the nasal passages. In the case of a significant amount of secretion, turn the child's head to one side.
4. Dry your skin and hair with a diaper with quick blotting movements.
5. Remove the wet diaper.
6. Re-position the child in the correct position.
7. If there is no effective spontaneous breathing, carry out one of the tactile stimulation techniques, which is repeated no more than two times (patting on the soles, light blows on the heels, rubbing the skin along the spine) 1.
8. If the skin of the trunk and mucous membranes remain cyanotic in the presence of spontaneous respiration, conduct oxygen therapy. A free flow of 100% oxygen directed to the child's nose should be given through the anesthesia bag and mask, or through the oxygen tube and funnel-shaped palm, or using an oxygen mask.
After the cyanosis is eliminated, oxygen support should be gradually stopped 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 oxygen concentrations.
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 breathing problems in the child, without taking the diapers and avoiding tactile stimulation;
- if the child is active - screams or breathes adequately, has a satisfactory muscle tone and a heart rate (HR) of more than 100 beats per minute, it is laid out on the mother's stomach and observed for 15 minutes. A child at risk of meconium aspiration may require tracheal intubation at a later date, even if he has been active after birth;
- in the absence of respiratory disorders, provide a 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 04.04.2005);
- if the newborn has respiratory depression, decreased muscle tone, heart rate less than 100 beats per minute, immediately suck meconium from the trachea through the endotracheal tube. Aspiration of meconium should be carried out under the control of heart rate. With an increase in bradycardia, stop the repeated aspiration of meconium and start mechanical ventilation with a resuscitation bag through the endotracheal tube.
All activities for the primary treatment of a newborn are performed in 30 seconds. After that, the child's condition (breathing, heart rate and skin color) is assessed to resolve the issue of the need for further resuscitation2.
Respiration assessment. Normally, the child has active chest excursions, and the frequency and depth of respiratory movements increase a few seconds after tactile stimulation. Convulsive breathing movements are ineffective, and their presence in a newborn requires a complex of resuscitation measures, as in complete absence breathing.
Assessment of heart rate. The heart rate should be greater than 100 beats per minute. The 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. The heart rate is calculated for 6 s and the result is multiplied by 10.
Skin color assessment. The baby's lips and torso 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 maintain ventilation.
Artificial ventilation of the lungs with a bag and mask
Indications for mechanical ventilation:
- lack of breathing or its ineffectiveness (convulsive respiratory movements, etc.);
- bradycardia (less than 100 beats per minute), regardless of the presence of spontaneous breathing;
- persistent central cyanosis when a free flow of 100% oxygen is supplied to a child who breathes independently and has a heart rate of more than 100 beats per minute.
The efficiency of ventilation is determined: by chest excursion; auscultation data; an increase in heart rate; improving the color of the skin.
The first 2-3 breaths are performed, creating an inspiratory pressure of 30-40 cm of water column, after which ventilation is continued with an inspiratory 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. IVL for newborns is carried out with 100% humidified and warmed oxygen.
After 30 s ventilation of the lungs under positive pressure, the heart rate and the presence of spontaneous breathing are again determined. Further actions depend on the result obtained.
1. If the heart rate is more than 100 beats per minute:
- in the presence of spontaneous breathing, mechanical ventilation is gradually stopped, reducing its pressure and frequency, a free flow of oxygen is supplied and the color of the skin is assessed;
- in the absence of spontaneous breathing, continue mechanical ventilation until it appears.
2. If the heart rate is from 60 to 100 beats per minute:
- continue mechanical ventilation;
- if mechanical ventilation was carried out with room air, foresee the transition to the use of 100% oxygen, the need for tracheal intubation.
3. Heart rate less than 60 beats in 1 minute; chickpeas:
- start an indirect cardiac massage with a frequency of 90 compressions per minute, continue mechanical ventilation with 100% oxygen with a frequency of 30 breaths per minute and determine the need for tracheal intubation.
Heart rate control is carried out every 30 s until it exceeds 100 beats per minute and spontaneous breathing is established.
Ventilation for several minutes requires the introduction of an orogastric tube (8F) in order to prevent the stomach from bloating with air and subsequent regurgitation of gastric contents.
Indirect cardiac massage indicated if the heart rate is less than 60 beats per minute after 30 seconds of effective ventilation of the lungs with 100% oxygen.
An indirect cardiac massage is performed by pressing on the lower third of the sternum. She is below conditional line that connects the nipples. It is important not to press on the xiphoid process to avoid rupture of the liver.
Two techniques of indirect massage are used, according to which the sternum is pressed:
the first - two thumbs, while the rest of the 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 other hand supports the back.
The depth of pressure should be one third of the anteroposterior chest diameter.
The frequency of pressing is 90 per minute.
It is important to coordinate the chest compressions with mechanical ventilation, avoiding the simultaneous carrying out of both procedures, and not to remove the fingers from the surface of the chest in the pause between pressures. After every three pressures on the sternum, a pause is made for ventilation, after which the pressures are repeated, etc. For 2 s, you need to make 3 pressure on the sternum (90 in 1 minute) and one ventilation (30 in 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 re; animation, in particular:
- if necessary, suck the meconium from the trachea;
- if necessary, continuous ventilation in order to increase its efficiency;
- to facilitate the coordination of chest compressions and ventilation;
- for the introduction of adrenaline;
- if you suspect the presence of a diaphragmatic hernia;
- with deep prematurity.
The use of medicines. The introduction of drugs is indicated if, despite adequate ventilation of the lungs with 100% oxygen and chest compressions for 30 s, the heart rate remains less than 60 beats per minute.
During the primary resuscitation of newborns, medications are used: adrenaline; means that normalize the BCC; sodium bicarbonate, antagonists of narcotic drugs.
Adrenalin. Indications for use:
- Heart rate less than 60 beats per minute after at least 30 seconds mechanical ventilation 100% oxygen and chest compressions;
- absence of heart contractions (asystole) at any time of resuscitation.
Epinephrine is administered as quickly as possible intravenously or endotracheally at a dose of 0.1-0.3 ml / kg of a solution at a concentration of 1: 10,000. The concentration of the solution is 1: 10,000 (to 0.1 ml of a 0.1% solution of epinephrine hydrochloride or 0.9 ml of isotonic sodium chloride solution is added to 0.1 ml of 0.18% solution of epinephrine hydrotartrate).
Endotracheal epinephrine is injected from a syringe directly into the tube or through a tube inserted into the tube. In this case, a solution of adrenaline at a concentration of 1: 10,000 can be additionally diluted with an isotonic solution to a final volume of 1 ml, or the endotracheal tube (probe) can be rinsed with an isotonic solution of sodium chloride (0.5-1.0 ml) after the administration of an undiluted dose. In the case of endotracheal administration, it is always recommended to use a dose of 0.3-1.0 ml / kg. After adrenaline is injected into the trachea, it is important to perform several effective positive pressure ventilation at once.
If there is no effect, the administration of adrenaline is repeated every 3-5 minutes, repeated administrations are only intravenous.
Large doses of IV adrenaline for resuscitation of newborns are not recommended, since their administration can cause damage to the brain and heart of the child.
BCC normalizing agents: 0.9% sodium chloride solution; Ringer's lactate solution; in order to correct significant blood loss (with clinical signs hemorrhagic shock) - transfusion of O (I) Rh (-) erythrocyte mass. Indications for use:
- lack of reaction of the child to resuscitation measures;
- signs of blood loss (pallor, pulse of weak filling, persistent tachycardia or bradycardia, no signs of improved blood circulation, despite all resuscitation measures).
With the development of hypovolemia, children whose condition does not improve during resuscitation are injected intravenously slowly, over 5-10 minutes, up to 10 ml / kg of one of these 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. Into the umbilical cord vein slowly, not faster than 2 ml / kg / min 4.2% solution at a dose of 4 ml / kg or 2 meq / kg. The drug should not be administered until ventilation of the newborn's lungs is established.
Narcotic drug antagonists (naloxone hydrochloride)
Indication for use: persistent severe respiratory depression during ventilation under positive pressure, with normal heart rate and skin color in a child whose mother was injected with narcotic drugs during the last 4 hours before childbirth. 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, and when administered endotracheally, it is ineffective.
Do not prescribe naloxone to a child from a mother with suspected drug dependence or from a mother who is on long-term drug treatment. This can cause severe seizures. The child's breathing can 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, drug administration, to exclude anomalies in the development of the respiratory tract, pneumothorax, diaphragmatic hernia, congenital 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 Do not pour cold or cold water on your child. hot water, direct a stream of oxygen to the face, squeeze the chest, beat on the buttocks and carry out any other measures, the safety of which has not been proven for a newborn.
2 Apgar score characterizes general state the newborn and the effectiveness of resuscitation measures and is not used to determine the need for resuscitation, its volume or the moment of resuscitation. Appraisal on the Apgar scale should be carried out at the 1st and 5th minutes after the birth of the child. If the result of the assessment on the 5th minute is less than 7 points, it should be additionally carried out every 5 minutes up to the 20th minute of life.
Literature
1. Order of the Ministry of Health of Ukraine No. 437 ved 31.08.04 "On the consolidation of clinical protocols for providing medical aid for children who are not equipped with a health care system".
2. Order of the Ministry of Health of Ukraine No. 152 ved 04.04.2005 "About the hardening of the medical protocol to watch a healthy newborn child".
3. Order of the Ministry of Health of Ukraine No. 312 ved 06/08/2007 "On the consolidation of the clinical protocol of the first reanimation and the development of new aid to the new ward."
4. Non-ad hoc workshops in pediatrics: Navch. posib. / Volosovets O.P., Marushko Yu.V., Tyazhka O.V. that іnshі / Ed. O.P. Volosovtsya and Yu.V. Marushko. - Kh.: Prapor, 2008 .-- 200 p.
5. Emergencies in children / Petrushina A.D., Malchen-ko L.A., Kretinina L.N. and others / Ed. HELL. Petrushina. - M .: LLC "Medical information Agency", 2007. - 216 p.
6. Peshiy M.M., Kryuchko T.O., Smiyan O.I. Uninvolved help 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. Belebeziev. - Lviv: Medicine svitu, 2004 .-- 186 p.
Additional
1. Aryaev M.L. Neonatology. - K .: ADEF - Ukraine, 2006 .-- 754 p.
2. Book of neonatology: Per. from eng. / Ed. John Cleorty, Ann Stark. - К .: Fund for additional assistance to children of Chornobil, 2002. - 722 p.
3. Shabalov N.P. Neonatology: A Textbook for Students and Residents of Pediatric Faculties medical institutes... - Second edition, revised and enlarged. - SPb .: 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 is provided medical assistance in the delivery room, and 1% of all those born need a full range of resuscitation actions. High level of preparation medical staff allows you to increase the chances of life and reduce possible development 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 aimed at revitalizing the child's body and restoring the lost functions. It includes:
- intensive care methods;
- the use of artificial ventilation;
- installation of a pacemaker, etc.
Full-term babies do not require resuscitation. They are born active, they scream loudly, the pulse and heart rate are within normal limits, the skin is pink in color, the child reacts well to external stimuli. Such children are immediately placed on the mother's belly and covered with a dry, warm diaper. The mucous contents are aspirated from the respiratory tract to restore their patency.
Cardiopulmonary resuscitation is considered an emergency. It is carried out in case of respiratory arrest and cardiac arrest. After such an intervention, in case of a favorable result, the basics of intensive care are applied. Similar treatment aims to eliminate possible complications work stoppages important organs.
If the patient cannot independently maintain homeostasis, then the resuscitation of the newborn includes either the setting of a pacemaker.
What is needed for resuscitation in the delivery room?
If the need for the provision of such events is small, then one person will be required to conduct them. In case of severe pregnancy and expectation of a full range of resuscitation actions, two specialists are in the maternity ward.
Resuscitation of a newborn in the delivery room requires careful preparation. Before the delivery process, you should check the availability of everything you need and make sure that the equipment is working.
- It is necessary to connect a heat source so that the resuscitation table and the diapers are warmed up, roll one diaper in the form of a roller.
- Check if the oxygen supply system is installed correctly. There must be sufficient oxygen, properly adjusted pressure and flow rate.
- The readiness of the equipment that is required for aspiration of the contents of the respiratory tract should be checked.
- Prepare instruments for the removal of gastric contents in case of aspiration (probe, syringe, scissors, fixing material), meconium aspirator.
- Prepare and check the integrity of the resuscitation bag and mask and intubation kit.
The intubation kit consists of endotracheal tubes with guides, a laryngoscope with different blades and spare batteries, scissors and gloves.
What is the success of the events?
Resuscitation of newborns in the delivery room is based on the following principles of success:
- the availability of the resuscitation team - resuscitators must be present at all births;
- coordinated work - the team must work harmoniously, complementing each other as one large mechanism;
- qualified staff - every resuscitator should have high level knowledge and practical skills;
- work taking into account the patient's reaction - resuscitation actions should begin immediately when they are needed, further measures are carried out depending on the reaction of the patient's body;
- serviceability of equipment - equipment for resuscitation must be serviceable and available at any time.
Reasons for the need for events
TO etiological factors oppression of the work of the heart, lungs and other vital organs of the newborn include the development of asphyxia, birth trauma, development congenital pathology, toxicosis of infectious genesis and other cases of unexplained etiology.
Pediatric resuscitation of newborns and its need can be predicted even during the period of gestation. In such cases, the resuscitation team should be ready to provide immediate assistance to the baby.
The need for such events may appear under the following conditions:
- a lot or lack of water;
- overburdening;
- maternal diabetes;
- hypertonic disease;
- infectious diseases;
- fetal malnutrition.
There are also a number of factors that already arise during childbirth. If they appear, the need for resuscitation can be expected. Such factors include bradycardia in a child, cesarean section, premature and rapid labor, previa or placental abruption, uterine hypertonicity.
Asphyxia of newborns
The development of disturbances in the processes of respiration with hypoxia of the body causes the appearance of disorders on the part of the circulatory system, metabolic processes and microcirculation. Further, there is a disorder in the work of the kidneys, heart, adrenal glands, and brain.
Asphyxia requires immediate intervention to reduce the possibility of complications. The causes of breathing disorders:
- hypoxia;
- impaired airway patency (aspiration with blood, mucus, meconium);
- organic lesions of the brain and central nervous system;
- developmental defects;
- insufficient amount of surfactant.
Diagnosis of the need for resuscitation is carried out after assessing the child's condition on the Apgar scale.
| What is evaluated | 0 points | 1 point | 2 points |
| Breathing state | 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, limbs are bluish | Pink |
| Muscle tone | Absent | The limbs are slightly bent, the tone is weak | Active movements, good tone |
| Reaction to irritation factors | Absent | Weakly expressed | Well pronounced |
Assessment of the state of up to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia medium severity. Resuscitation of a newborn with asphyxiation is carried out immediately after assessing his general condition.
The sequence of the condition assessment
- The baby is placed under a heat source and the skin is dried with a warm diaper. The contents are aspirated from the nasal cavity and mouth. Tactile stimulation is performed.
- Respiration is assessed. In the case of a normal rhythm and presence loud scream, go to the next stage. In case of irregular breathing, mechanical ventilation is carried out with oxygen for 15-20 minutes.
- The heart rate is assessed. If the pulse is above 100 beats per minute, proceed to the next stage of the examination. In the case of less than 100 strokes, mechanical ventilation is performed. Then the effectiveness of the measures is assessed.
- Pulse below 60 - chest compressions + mechanical ventilation.
- Pulse from 60 to 100 - mechanical ventilation.
- Pulse above 100 - mechanical ventilation in case of irregular breathing.
- After 30 seconds, with the ineffectiveness of indirect massage with mechanical ventilation, it is necessary to carry out drug therapy.
- An examination of the color of the skin is carried out. Pink color indicates normal condition child. With 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 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 the left side. This will stop the aspiration process and allow the contents of the mouth and nose to be removed. The contents are carefully aspirated without deep insertion of the aspirator.
If such 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 mechanical ventilation.
The department of resuscitation and intensive care of newborns accepts the child after primary resuscitation measures to provide further assistance and maintenance of vital functions.
Lung ventilation
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 the state of breathing;
- persistent cyanosis with normal work respiratory and cardiovascular systems.
This set of activities is carried out using a mask or bag. The head of the newborn is tilted back a little and a mask is applied to the face. It is held with index and thumbs. The rest of the child's jaw is taken out.
The mask should be on the chin, nose and mouth areas. It is sufficient 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 using
In order 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 full recovery respiration and heart rate.
Why and how is intubation performed?
Primary neonatal resuscitation 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 body weight of the child and his gestational age.
Intubation is also performed in the following cases:
- the need to remove the aspiration of meconium from the trachea;
- continuous ventilation;
- facilitating the manageability of resuscitation measures;
- the introduction of adrenaline;
- deep prematurity.
On the laryngoscope, light is turned on and taken in the left hand. Right hand hold the head of the newborn. The blade is inserted into the mouth and held up 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 pass through vocal cords at the moment of their opening. This happens while inhaling. The tube is held up to the planned mark.
The laryngoscope is removed, then the conductor. The correct insertion of the tube is checked by squeezing the breathing bag. Air enters the lungs and causes an excursion of the chest. Next, the oxygen supply system is connected.
Indirect cardiac massage
Resuscitation of a newborn in the delivery room includes which is shown with a heart rate of 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 performed with the thumbs of both hands, and the rest of the fingers are involved in supporting the back. The resuscitator-neonatologist applies pressure on the border of the middle and lower third of the sternum so that the chest sags 1.5 cm. The frequency of pressing is 90 per minute.
It is imperative to ensure that inhalation and pressing on the chest are not carried out at the same time. In the pause between pressing, you can not remove your hands from the surface of the sternum. Pressing the bag is done after every three pressing. For every 2 seconds, you need to carry out 3 pressures and 1 ventilation.
Actions in case of water contamination with meconium
Features of neonatal resuscitation include assistance with staining the amniotic fluid with meconium and assessing the child on the Apgar scale of less than 6 points.
- During childbirth after the appearance of the head from birth canal immediately aspirate the contents of the nasal cavity and mouth.
- After birth and placing the baby under a heat source, before the first breath, it is advisable to intubate 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 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 measures are ineffective for more than 30 seconds, medications are used.
Resuscitation of newborns involves the use of adrenaline, means to restore the volume of circulating blood, sodium bicarbonate, naloxone, dopamine.
Errors that are prohibited
It is strictly forbidden to carry out activities, the safety of which has not been proven:
- pour water over the baby;
- squeeze his chest;
- hitting the buttocks;
- direct an oxygen stream to the face and the like.
Albumin solution cannot be used to increase the initial BCC, as this increases the risk of death in the newborn.
Resuscitation does not mean that the baby will have any deviations 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 having a baby with asphyxiation or drug depression is based on an analysis of the antenatal and intrapartum history.
Risk factors
Antenatal risk factors include maternal diseases such as diabetes mellitus, hypertensive syndromes, infection, and the mother's use of drugs and alcohol. Of the pathology of pregnancy, it should be noted high or low water, prolonged pregnancy, delay intrauterine development fetus and the presence of multiple pregnancies.
Intranatal risk factors include: premature or delayed labor, abnormal presentation or fetal position, placental abruption, prolapsed umbilical cord loops, use of general anesthesia, anomalies generic activity, the presence of meconium in the amniotic fluid, etc.
Before the start of resuscitation measures, the child's condition is assessed by signs of live birth:
- the presence of spontaneous breathing,
- palpitations,
- pulsation of the umbilical cord,
- voluntary muscle movements.
In the absence of all 4 signs, 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 start of resuscitation measures.
Resuscitation Algorithm
The resuscitation care algorithm is determined by three main features:
- the presence of spontaneous breathing;
- heart rate;
- the color of the skin.
Assessment on the Apgar scale is made, 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 hospital
Initial activities(duration 20-40 s).
In the absence of risk factors and light amniotic fluid, the umbilical cord is crossed immediately after birth, the child is wiped dry with a warm diaper and placed under a source of radiant heat. If there is a large amount of mucus in the upper respiratory tract, then it is sucked out from oral cavity and nasal passages using a balloon or catheter connected to an electric suction. In the absence of breathing, light tactile stimulation is carried out by 1-2 times patting on the feet.
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;
Self-Regular - Assess your heart rate (HR).
B. Heart rate.
Heart rate less than 100 beats per minute. - carry out mask ventilation with 100% oxygen until the heart rate is normalized;
B. Skin color.
Completely pink or pink with cyanosis of hands and feet - observe;
Cyanotic - inhale 100% oxygen through a face mask until cyanosis disappears.
Artificial ventilation technique
Artificial ventilation of the lungs is carried out with a self-expanding bag (Ambu, Penlon, Laerdal, etc.) through a face mask or an endotracheal tube. Before the start of mechanical ventilation, the bag is connected to an oxygen source, preferably through a gas mixture humidifier. A roller is placed under the child's shoulders and the head is slightly thrown back. The mask is applied to the face so that it top the obturator lay on the bridge of the nose, and the lower one on the chin. When pressing on the bag, an excursion of the chest should be clearly traced.
Indications for the use of an oral airway for mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the inability to ensure free airway with proper positioning of the child.
Intubation of the trachea and the transition to mechanical ventilation through an endotracheal tube is indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation for 1 minute, as well as for apnea or inadequate breathing in a child with gestational age less than 28 weeks.
Artificial ventilation of the lungs is carried out with 90-100% oxygen-air mixture with a frequency of 40 breaths per minute and a ratio of the time of inhalation to exhalation of 1: 1.
After ventilation of the lungs for 15-30 seconds, the heart rate is monitored again.
If the heart rate is above 80 per minute, continue ventilation until adequate spontaneous breathing is restored.
If the heart rate is less than 80 beats per minute - while continuing the ventilation, start chest compressions.
Technique of indirect heart massage
The child is laid down on a hard surface. Two fingers (middle and forefinger) of one hand or two thumbs of both hands produce pressure on the border of the lower and middle third of the sternum at a frequency of 120 per minute. The displacement of the sternum towards the spine should be 1.5-2 cm. Ventilation and cardiac massage do not synchronize, i.e. each manipulation is carried out in its own rhythm.
30 seconds after the start closed massage the hearts again control the heart rate.
If the heart rate is above 80 beats per minute, stop cardiac massage and continue ventilation until adequate spontaneous breathing is restored.
If the heart rate is below 80 per minute, continue chest compressions, mechanical ventilation and start drug therapy.
Drug therapy
With asystole or heart rate below 80 beats per minute, adrenaline is immediately administered at a concentration of 1: 10000. For this, 1 ml of an ampouled solution of adrenaline is diluted in 10 ml saline... The solution prepared in this way is collected 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 of body weight.
Heart rate is monitored every 30 seconds.
If the heart rate recovers and exceeds 80 beats per minute, stop cardiac massage and other medications.
If asystole or heart rate is below 80 beats per minute, continue chest compressions, mechanical ventilation, and drug therapy.
Repeat the injection of epinephrine 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 threadlike pulse, low blood pressure, then the child is shown the introduction of a 5% albumin solution or saline solution at a dose of 10-15 ml / kg of body weight. The solutions are administered intravenously over 5-10 minutes. With persisting signs of hypovolemia, repeated administration of these solutions in the same dose is permissible.
The introduction of sodium bicarbonate is indicated with a confirmed decompensated metabolic acidosis(pH 7.0; BE -12), as well as in the absence of the effect of mechanical ventilation, cardiac massage and drug therapy(suspected severe acidosis that prevents the restoration of cardiac activity). A solution of sodium bicarbonate (4%) is injected into the umbilical cord vein at the rate of 4 ml / kg of body weight (2 meq / kg). The rate of drug administration is 1 meq / kg / min.
If within 20 minutes after birth, despite the full resuscitation measures carried out, 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 be continued.
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, but not instantaneously. The cells of the brain suffer the most from the cessation of oxygen supply, especially of the cerebral cortex, that is, the department on the functioning of which consciousness, spiritual life, and human activity as a person depend.
If oxygen does not enter the cells of the cerebral cortex within 4 - 5 minutes, then they are irreversibly damaged and die. Cells of other organs, including the heart, are more viable. Therefore, if respiration and blood circulation are quickly restored, then the vital activity of these cells will resume. However, this will only be the biological existence of an organism, while consciousness, mental activity either they will not recover at all, or they will be deeply changed. Therefore, the revitalization 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 master the complex of measures to provide assistance at the scene of the accident, prevent death and revitalize the body. It is everyone's duty to be able to do this. Waiting inactivity medical professionals whatever it may be 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 crumbs, it is simply necessary to know the basics of intensive care!
Resuscitation of a newborn
How is primary resuscitation of children carried out?
Cardiopulmonary and cerebral resuscitation (CLCR) is a set of measures aimed at restoring the basic vital functions of the body (heart and respiration), disturbed in terminal states, in order to prevent brain death. Such resuscitation is aimed at reviving a person after stopping breathing.
Leading reasons terminal states developed outside hospitals, in childhood are the syndrome sudden death newborns, car injury, drowning, obstruction of the upper respiratory tract. The maximum number of deaths in children occurs between the age of 2 years.
Periods of cardiopulmonary and cerebral resuscitation:
- The period of elementary life support. In our country, it is called the immediate stage;
- The period of further life support. It is often referred to as a specialized stage;
- The period of prolonged and long-term maintenance of life, or postresuscitation.
At the stage of elementary life support, techniques are performed to replace ("prosthetics") the vital functions of the body - the heart and respiration. At the same time, the events and their sequence are conventionally designated by a well-remembered abbreviation of three English letters ABS:
- from the English. airway, literally opening the airways, restoring the patency of the airways;
- breath for victim, literally - breath for the victim, mechanical ventilation;
- circulation his blood, literally - ensuring his blood flow, external massage of the heart.
Transportation of victims
Functionally justified for transporting children is:
- with severe hypotension - horizontal position with the head end lowered by 15 °;
- with damage to the chest, acute respiratory failure different etiology- semi-seated;
- in case of spinal injury - horizontal on the shield;
- with fractures of the pelvic bones, damage to the abdominal organs - the legs are bent at the knees and hip; joints and spread apart ("frog position");
- for injuries of the skull and brain with a lack of consciousness - horizontal on the side or on the back with a raised head end by 15 °, fixation of the head and cervical spine.
Should be provided in all treatment facilities, where childbirth can potentially occur. Work in the maternity ward should be organized in such a way that in cases of the beginning of cardiopulmonary resuscitation, the employee who conducts it from the first minute can be assisted by at least two other medical workers.
Antenatal risk factors for neonatal asphyxia.
1. Diabetes mellitus
2. Preeclampsia
3. Hypertensive syndromes
4. Rh sensitization
5. History of stillbirth
6. Clinical signs infections in the mother
7. Bleeding in the second and third trimester of pregnancy
8. Polyhydramnios
9. Low water
10. Multiple pregnancy
11. Retardation of intrauterine growth of the fetus
12. Mother's use of drugs and alcohol
13. The use of drugs that depress the breathing of a newborn (promedol)
14. Presence of developmental anomalies
15. Abnormal CTG indices before childbirth.
Intranatal risk factors
1. Premature birth up to 37 weeks
2. Delayed labor for more than 42 weeks
3. Caesarean
4. Detachment of the placenta
5. Placenta previa
6. Loops of the umbilical cord
7. Pathological position of the fetus
8. General anesthesia
9. Anomaly of labor
10. The presence of myconium in the amniotic fluid
11. Violation of the fetal heart rhythm
12. Histotia of the shoulder
13. Instrumental childbirth - forceps, vacuum extraction
In cases where the birth of a child is predicted up to 32 weeks of gestation, an intensive care 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 start providing resuscitation measures, regardless of the initial state of the newborn. Apgar score at the first and fifth minute of life and at 10 minutes. The sum of 8 or more points is satisfactory. Comp, 4-7 moderate asphyxia
The protocol for primary resuscitation of newborns includes
1. Initial measures - restoration of airway creepiness
2. Artificial ventilation
3. Indirect cardiac massage
4. Administration of medicines
Assessment of the child's condition in the first minutes of life is carried out on three grounds:
1. The presence and nature of spontaneous breathing
2. Heart rate
3. Skin color
The criteria for the effectiveness of the resuscitation are:
1. Regular effective spontaneous breathing
2. Heart rate over 100 beats / min.
Initial activities include:
1. Maintaining body temperature - drying babies for more than 28 weeks is simply soaked with a diaper, if up to 28 weeks - in a wet form, it is placed in a plastic bag with a slot for the head.
2. Sanitation of the oropharynx is indicated only for those newborns who, during the first 10 minutes of life, did not develop spontaneous breathing or if there is a large amount of discharge.
3. Tactile stimulation - carried out either by patting on the feet or stroking on the back.
4. Artificial ventilation of the lungs. Indications for mechanical ventilation: 1. Lack of breathing, 2. Irregular breathing, 3. Heart rate less than 100 beats / min.
Immediate incubation:
1. Children with suspected diaphragmatic hernia
2. Children born with an admixture of myconium in the amniotic fluid or with oppressed spontaneous breathing
3. Children born up to 27 weeks for the purpose of prophylactic administration of sulfoctant.
Evaluation of the effectiveness of mechanical ventilation through a face mask
The main criterion of effectiveness is the heart rate over 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 ventilation begins on the tube. If in 20 seconds it is not possible to intubate, continue breathing through the mask, then try to intubate again.
With persisting bradycardia, they begin to compress the heart 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 it is bad - intubation.
Heart rate 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 within 27 weeks for the purpose of professional introduction of sulloctant.
4. If mask ventilation is ineffective when the heart rate is less than 60 for 30 seconds.
5. In case of insufficient effective mask ventilation, if from 60 - 100 for 60 sec.
6. If necessary, performing an indirect cardiac massage.
Indirect cardiac massage
1. IVL frequency to 3: 1 compressions.
2. After the massage begins, 30 seconds later, we estimate the heart rate - if more than 60, then stop the chest compressions, if it is 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 of body weight.
Saline - acute blood loss or hypovolumia - 10 ml per kg slowly.
sodium bicarbonate acidosis, no effect from the above. 4 ml per kg 4% solution at a rate of 2 ml per kg per minute. End of resuscitation From the beginning of the measures taken after 10 minutes, if not effective.
Loading ...