Neonatal resuscitation Mr Matthews Apgar Score The Apgar

Neonatal resuscitation Mr Matthews

Apgar Score • The Apgar score is a score describing an infant's condition for each sign at 1 minute and 5 minutes after the birth. • If the score is below 7, it is continued every 5 minutes until normal or 20 minutes of age. • A score of 7– 10 is considered normal, while 4– 7 might require some resuscitative measures • A baby with Apgar score of 3 and below requires immediate resuscitation.

Apgar score 0 1 2 Arms and legs flexed Active movements A Activity Absent (muscle tone) P Pulse G Grimace (reflex irritability) Appearance Blue or pale Body pink, (skin colour) blue extremities A R Respiration Absent Below 100 bpm No response Grimace Absent Slow, irregular Above 100 bpm Sneeze, cough, cry Pink all over Regular

WHICH BABIES REQUIRE RESUSCITATION? q Most Newly Born Babies Are Vigorous q. Only Approximately 10% Newborns Require Some Assistance q. Only 1% Need Major Resuscitative Measures, e. g. Intubation, Chest Compressions, And/Or Medications, To Survive

• Can you describe an Apgar score in preterm infants? • Is the Apgar score a good indicator of long-term neurological outcome?

NEWBORN RESUSCITATION v THE CLINICAL SEQUENCES? v HOW TO BE READY & CARRY OUT RESUSCITATION?

THE WHO Guidelines q ANTICIPATE Ø Be Prepared For Every Birth By Having Skill To Resuscitate Ø Review The Risk Factors, If Any, For Perinatal Asphyxia Ø Clearly Decide On The Responsibilities Of Each Hlth Care Provider During NR Ø Remember That The Mother Is Also At Risk Of Complications v The Following Questions Should Be Answered After Every Birth: ü Is The Amniotic Fluid Clear Of Meconium? ü Is The Newborn Baby Breathing Or Crying? ü Is There A Good Muscle Tone? ü Is The Color Pink? ü Is The Newborn Baby Born At Term? q Immediately If The Answer = No To Any Of These, Then Consider Resuscitation

PREPARATION FOR RESUSCITATION: PERSONNEL AND EQUIPMENT FACTS Ø Every Delivery To Be Attended By At Least 1 Person Whose Only Responsibility Is The Baby & Who Is Capable Of Initiating Resuscitation Ø Either That Person Or Someone Else Who Is Immediately Available Should Have Skills Required To Perform A Complete Resuscitation Ø When Resuscitation Is Anticipated, Additional Personnel Should Be Present In The DR Before The Delivery Occurs ü Prepare Necessary Equipment ü Turn On Radiant Warmer ü Check Resuscitation Equipment

• § § § § PREPARE FOR BIRTH 2 Clean Towels For Thermal Protection & Small Blanket A Suction Device ( Mucus Extractor) A Radiant Heater (If available) A Draught-Free Delivery Room > 25 o. C Clean Delivery Kit For Cord Care, Gloves Two Infant Masks (Normal) A Clock § An Additional Set Of Equipment In Reserve • For Multiple Births • OTHERS Oral Airway Ambubag Stethoscope Endotracheal Tubes Laryngoscope Face Mask Oxygen Delivery Unit 50% Dextrose Water Normal Saline/Ringers Lactate Umbilical Catheter

RESUSCITATION PROCESS INITIAL STEP: AIRWAY (Strategy A) A Ø Airway – Positioned, Free & Cleared As Necessary* Ø Provide Warmth Ø Dry & Stimulate The Baby To Breathe Ø Open Airway By Positioning The Newborn In “Sniffing” Position: On Back, Slightly Extending Neck. “Sniffing” Position Aligns Posterior Pharynx, Larynx, & Trachea v Suction Mouth First, Then Nose; “M” Before “N” B B *Consider Intubation Of Trachea At This Point (For Depressed Newborn With Meconium-Stained Fluid) C

THE NEXT STEP: BREATHING (Strategy B) q If Apneic Or HR < 100 bpm: Provide Positive-Pressure Ventilation (PPV) Ø If Breathing, & HR >100 bpm But Baby Is Cyanotic, Then Offer Supplemental O 2 ØIf Cyanosis Persists, Provide PPV – With 100% O 2 Or Room Air If 100% O 2 N/A Ø

NEXT STEP: CIRCULATION/CARDIAC (Strategy C) q If HR<60 bpm Despite Adequate Ventilation For 30 Seconds: ü Provide Chest Compressions As You Continue Assisted Ventilation ü Then Evaluate Again; If HR Still <60 bpm, Then Start Strategy D

HOW PERFORM CHEST COMPRESSIONS & VENTILATIONS? q Thumb Technique: Ø Place Your Thumbs Side By Side Or, On A small Baby, 1 Over The Other, Just Above Xyphoid. The Other Fingers Provide Support Needed For The Back Ø You Pressure As To Depress The Sternum To A Depth 1/3 Of The Ant/Post Diameter Of The Chest, Approximately; Then Release Ø The Downward Stroke Should Be Somewhat Shorter Than Duration Of The Release Ø Your Thumbs Should Remain In Contact With The Chest At All Times v RATE? 90 Compressions + 30 Breaths Per Minute i. e. Sequence Of: 3 to 1 o ” 1 and 2 and 3 and Breath, and 1 and 2 and 3 and Breath …. . . ”

NEXT STEP: Drug(s) (Strategy D) q If HR Is <60 bpm Despite Adequate Ventilation & Chest Compressions : ü Administer Epinephrine & Continue Assisted Ventilation With Chest Compressions Ø Epinephrine Dose: ü The Recommended IV Or Endotracheal Dose Is: 0. 1 - 0. 3 m. L/kg , Of 1: 10, 000 Solution (0. 01 to 0. 03 mg/kg) Repeated Every 3 To 5 Minutes As Indicated ü Higher Doses Associated With Increased Risk Of ICH & Myocardial Damage q No Differing Dose For Premature Newborn Babies

VITAL Points In The Neonatal Resuscitation Flow Diagram q The Most Important & Effective Action In NR Is To Ventilate Baby’s Lungs q Effective P-PV In Secondary Apnea Usually Results In Rapid HR Improvement q If HR Does Not Increase, Ventilation Could Be Inadequate And/Or Chest Compressions & Epinephrine May Be Needed q HR <60 bpm → Additional Steps Needed q HR >60 bpm → Chest Compressions Can Be Stopped q HR >100 bpm & Breathing → P-PV Can Be Stopped q Time Line: If No Improvement After 30 Seconds, Proceed To Next Strategy/Step

Potentially Hazardous Forms Of Stimulation q Slapping Back Or Buttocks q Squeezing Rib Cage q Forcing Thighs Onto Abdomen q Dilating Anal Sphincter q Hot Or Cold Compresses Or Baths q Shaking q DRUGS, e. g. Hydrocortisone, Na. HCO 3 - Especially With Apnea