Resuscitation using a resuscitaire with blender
In term infants receiving resuscitation at birth with positive pressure ventilation, it is best to begin with air rather than 100% oxygen. If despite effective ventilation there is no increase in heart rate or if oxygenation (guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered. If chest compression is administered, higher concentration of oxygen should be considered
As many preterm babies of <32 weeks’ gestation will not reach target saturations in air, blended oxygen and air may be given judiciously and ideally guided by pulse oximetry. Both hyperoxaemia and hypoxaemia should be avoided. A pragmatic starting point of 30% is acceptable and subsequent administration should be guided by oximetry.
Resuscitation using a resuscitaire without blender
If a blend of oxygen and air is not available, resuscitation should be initiated with air.
Switch to 100% oxygen if there is poor response to adequate ventilation. The emphasis should be on effective lung inflation. If chest compression is administered, higher concentration of oxygen should be considered.
Resuscitation with no resuscitaire
Commence resuscitation with Bag/valve/mask using air. The emphasis should be on effective lung inflation.
What to do at birth?
At birth of an infant, note the time, start the clock
In a baby who appears compromised, clamp the cord immediately and proceed to resuscitation.In an uncompromised baby, for both term and preterm infants cord clamping should be delayed by at least 1 minute from complete delivery of the infant. The infant should be at the same level as the placenta ( For more details see Appendix 1).
This time should be used to initiate thermal control (drying and wrapping in warm towel for term babies and preterm babies >32 weeks gestation; plastic bag without drying in babies less than 32 weeks gestation and electric thermal mattress). In a well appearing term baby, ensure that the baby has skin to skin contact with mother. Cover the baby with a warm towel and place a hat on the head. Avoid hyperthermia,
Assess the condition of the infant –breathing and heart rate. Listen to the heart rate with a stethoscope. It is not necessary to count this exactly but you should note whether the heart rate is absent or very slow <60, slow<100 or, normal >100/min.
Assess the need for additional help, more experienced staff or an ambulance throughout the resuscitation.
When to start resuscitation?
The indications for positive pressure ventilation include:-
- Apnoea or ineffective respiratory effort.
- Heart rate less than 100/minute in a compromised baby
- Persistent central cyanosis in facemask oxygen and a low heart rate.
Airway and breathing:
Transfer the baby to the resuscitaire or prepared flat surface with the baby’s head in a neutral position. If the baby is not breathing, perform airway-opening manoeuvres, place the appropriate size mask on the baby’s face over the nose and mouth, and inflate the lungs via the bag/valve/mask or T piece (neopuff). Give the initial five breaths as inflation breaths, 30/5, each 2-3 seconds in order to expand the alveoli and establish resting lung volume. The circuit must include a pressure relief valve.
If birth is where the midwife is the lead professional, these initial inflation breaths can be performed with the baby positioned between the mother’s legs using bag/valve/mask. If further resuscitation is required and there is a resuscitaire available it should be brought into the birthing room.
If birth occurs outside an obstetric unit and the baby requires more resuscitation than 5 inflation breaths, transfer arrangements should be considered, if not already initiated. All resuscitation measures should be continued during transfer to the appropriate neonatal unit.
Reassess after the inflation breaths by auscultating the heart rate with a stethoscope. A pulse oximeter can give a continuous heart rate and oximetry reading in the delivery room. With practice it is possible to attach a pulse oximeter probe and to obtain a useful reading of heart rate and oxygen saturation about 90 s after delivery.If the heart rate has improved you can assume that you have inflated the lung and therefore proceed to ventilation breaths. If the heart rate does not respond to inflation breaths the only way to check that the lungs have been inflated successfully is to see chest move in response to your inflation breaths.
Therefore, if there is no increase in the heart rate, check for chest movement.
If you do not see a heart rate response and there is no chest movement with the inflation breaths assess the need for the following in a systematic manner–
- Reposition – ensure neutral position of baby’s head. It is very easy to over extend the neck during resuscitation!!
- Ensure you have gas flow (at least 6 litres / min).
- Re-evaluate the size of the mask and ensure appropriate seal.
- Apply single or double jaw thrust. If you have help it may be easier to use the two person jaw thrust technique.
- Ensure you have inflation pressure of at least 30cm of water and you are delivering long inspiratory times of 2-3 seconds.
- Assess the need to suction the airway under direct vision.
- Assess the need for an oropharyngeal (Guedel) airway?
- Assess the need for higher pressures? Do you need to use a self inflating bag valve mask device?
- At all times evaluate the need for further help.
- Attach the baby to a oxygen saturation monitor if available
If there is a good response to these manoeuvres with an increase in the heart rate, then proceed to ventilation breaths. A rate of 30 ventilation breaths per minute is sufficient. You may need to reduce your inflation pressures appropriately. Watch for the baby’s heart rate, chest movement, breathing effort, oxygen saturations (see guide on flow chart). Assess colour if saturation recording not available and keep on assessing the situation every 30 seconds.
If inadequate response to heart rate or saturations despite good chest movement increase oxygen concentration in a step wise fashion (where a blender is available) using the guide on NLS algorithm (see laminated chart on resuscitaire). If no blender is available, switch to 100% oxygen.
Recently concerns has been expressed that the peak pressure delivered by a Laerdal bag may be far too large and lead to over distension of the lungs, which may contribute to chronic lung disease. It does not deliver effective and measurable positive end expiratory pressure (PEEP). Where possible use a circuit and a T piece that can deliver measured PEEP. The PEEP is required to establish a functional residual capacity. You will need to watch the expansion of the chest during each ventilation breath to decide whether or not the pressures are optimal. With experience you should be able to gauge whether the chest movement is optimal.
Discontinue ventilation when baby has adequate respiratory effort and able to maintain oxygen saturation (colour) and heart rate. Evaluate clinical background, degree of resuscitation and response, work of breathing, colour and tone to ascertain the need to admit to neonatal unit.
Nasal continuous positive airways pressure (CPAP) rather than routine intubation may be used to provide initial respiratory support of all spontaneously breathing preterm infants with respiratory distress. Early use of nasal CPAP should also be considered in those spontaneously breathing preterm infants who are at risk of developing respiratory distress syndrome (RDS).
Absolute indications for endotracheal intubation are:
- Evidence of ineffective ventilation with CPAP or a face mask
- Infant with suspected diaphragmatic hernia
If intubation is required ensure that a good view of the larynx is obtained. The commonest problem is overextension of the neck and deviation from midline. This should be avoided as this gives a distorted view of the upper airway. The baby should be intubated effectively within 30 seconds. If this is not successful you should go back to mask ventilation until the baby is pink. Do not allow the baby to become hypoxic during an attempt to intubate. In a baby who is preterm and intubated give surfactant as soon as intubation is achieved successfully and tube secured.
The laryngeal mask airway should be considered during resuscitation of the newborn if face-mask ventilation is unsuccessful or not feasible. It could be considered an alternative to face mask IPPV in babies >2Kg or >34 weeks gestation. There is limited evidence to evaluate its use in smaller or more premature babies and it has not been evaluated in the context of meconium, and for those requiring chest compressions and administration of medications. (This is now available in all resuscitaires)
If you do not see a good HR response despite good chest movement proceed to chest compression.
If the heart rate remains less than 60/minute despite good chest movement on 5 inflation breaths followed by 30 seconds of ventilation breaths, (It is necessary to be absolutely sure about this), proceed to chest compressions. If the HR is rising, another 30 seconds of ventilation breaths can be continued before starting chest compressions.
Chest compressions necessitate the involvement of a second pair of hands. The chest should be encircled in both hands with the thumbs placed on the lower third of the sternum and the fingers over the spine. The landmark to place your thumbs is 1 cm below the imaginary line joining the nipples. Alternatively locate the xiphisternum and go 1 cm up centrally on the sternum. The depth of cardiac compression should be about 1/3 of the “depth of the chest”. Chest compressions should be done at about 90/minute along with ventilation breaths of 30/minute at a ratio of 3:1. Allow sufficient relaxation time as the coronary arteries are perfused in diastole. The person doing cardiac massage should give their sole attention to this task. This is the preferred method in all cases.
In a very small pre-term baby cardiac massage can be done with two fingers with the back of the baby well supported.
Reassess every 30 seconds and listen to the heart rate (usually after 15 cycles of 3:1). Try to minimise interruptions to ventilation and compressions. The same person should ideally assess the heart rate throughout the resuscitation. Do not stop cardiac massage until the heart rate is consistently > 60/min and rising.
If the heart rate fails to improve after 30 seconds of good quality cardiac compression, drugs should be considered. If birth has occurred outside an obstetric unit the baby will need to be transferred first. The intravenous route is preferred but if the baby is intubated consider intratracheal adrenaline at the dose of 0.5-1ml/Kg of 1in 10,000 solution.
Obtain central venous promptly by catheterising the umbilical vein. Prime the umbilical vein catheter (UVC) with saline prior to insertion to prevent an air embolus. Remember this is an emergency CLEAN procedure but not a sterile procedure – so don’t waste time gowning up!! Blood should be obtained for a gas and blood sugar measurement when you insert the catheter. Very rarely where umbilical venous access cannot be obtained or fails, intraosseus route is an alternative for drug administration in neonatal resuscitation.
Intravenous adrenaline can then be given in a dose of 0.1 mls per Kg of 1:10,000 (first dose). If hypovolaemia is suspected because of a placental abruption or suspected fetal blood loss give volume e.g. 10 mls per Kg of normal saline or, better still, uncrossmatched “O” rhesus negative blood. In Singleton and Princess of Wales (POW) Hospital, this must be collected from blood bank beforehand if trouble is anticipated. In an emergency, the porters should be asked to collect paediatric emergency O negative uncrossmatched blood from the ‘Blood Bank Issue Fridge’. No requisition is necessary. The blood bank technician should be informed after resuscitation even if the blood is not used. Any unused blood should be returned to the blood bank within 30 minutes so that it could be processed for component use.
If there is no response, consider Sodium Bicarbonate 4.2% intravenously in a dose of 2 mmols per Kg (4 mls per Kg) slowly over 1 minute. This should be followed by 0.3 mls/ Kg 1:10,000 adrenaline IV after 3 minutes or so. After each drug flush the line with 1-2 mls of 0.9% saline.Correct hypoglycaemia if blood sugar is less than 2.6 mmol /litre on PCX or cord gas by giving 2.5mls/kg of 10% dextrose. Avoid giving IV dextrose routinely as hyperglycaemia is known to be associated with poor outcome during a hypoxic ischemic insult.
Ensure that adequate ventilation and cardiac compressions are continued throughout these procedures and that the baby is kept as warm as possible.
N.B> In the hospital setting and in babies greater than 36 weeks gestation with evolving moderate to severe encephalopathy (requiring prolonged resuscitation >10 minutes), consider the appropriateness of therapeutic hypothermia. This could be initiated by switching off any active source of heating on the resuscitaire.
Ensure that the parents receive adequate support and information as they will be extremely frightened and listening to everything that is going on.
When to stop resuscitation?
Births in hospital
In a newly-born infant with no detectable cardiac activity despite high quality resuscitation, and with cardiac activity that remains undetectable for 10 min, it is appropriate to consider stopping resuscitation. The decision to continue resuscitation efforts beyond 10 min with no cardiac activity is often complex and may be influenced by issues such as the availability of therapeutic hypothermia and intensive care facilities, the presumed aetiology of the arrest, the gestation of the infant, the presence or absence of complications, and the parents’ previous expressed feelings about acceptable risk of morbidity. The difficulty of this decision-making emphasises the need for senior help to be sought as soon as possible.
Where a heart rate has persisted at less than 60 min-1 without improvement, during 10–15 min of continuous resuscitation, the decision to stop is much less clear. No evidence is available to recommend a universal approach beyond evaluation of the situation on a case-by-case basis by the resuscitating team and senior clinicians. The decision to stop resuscitation should be discussed with the parents carefully by experienced clinicians.
Births outside an obstetric unit
All resuscitation measures should be continued during transfer to the appropriate neonatal unit.Any decision to discontinue resuscitation should be made in the receiving hospital by the neonatal doctor and/or after discussion with the neonatal consultant.
When not to start resuscitation?
- If the baby is obviously macerated or known to have died in-utero.
- If there are known to be lethal congenital abnormalities and this course of action has to be agreed previously between the Obstetrician and the parents (Although beware!–sometimes antenatal diagnosis may be inaccurate!)
- A baby of <23 weeks gestation unless there is uncertainty about the gestation
- Take care when listening for the heart rate. It is easy to miss a very slow heart rate
What to do if resuscitation is not effective?
If resuscitation is not effective the following possibilities should be considered:-
- Check equipment, gas supply, adequacy of oxygen
- ET tube is not in the trachea – consider visualizing the larynx to confirm if this is the case. Also consider that the tube might be in the right main bronchus. In this situation the air entry on the right is better than on the left. Withdraw the tube to an appropriate length to correct the problem.
- Consider that the baby may have a pneumothorax – air entry will be unequal and the apex beat may be displaced.
- Consider that there may be hypoplastic lungs, particularly if there is a history of prolonged rupture of membranes or oligohydramnios or fetal abnormality such as absent kidneys.
- Consider that there may be another diagnosis such as a diaphragmatic hernia – in this situation the apex beat is usually displaced to the right and the abdomen is scaphoid.
Effectiveness of resuscitation:
Most term infants will not need resuscitation and for the majority who do, the outcome should be satisfactory as long as the steps detailed above are followed. Babies with no risk factors and those who respond quickly to simple steps of resuscitation can be observed closely on postnatal ward. Babies with underlying risk factors who require prolonged resuscitation should be admitted to to the neonatal unit.
- Maintain temperature and airway support as required
- Ensure early intravenous access if indicated and maintain normal blood sugar levels.
- The case notes must be completed thoroughly by all staff involved.
- It is also helpful to record the time at which the heart rate was first noted to be >100/ min, the time of the baby’s first gasp and time to establish regular spontaneous breathing. This gives useful information for prognosis.
- A paired cord arterial and venous blood sample should be obtained to determine the level of acidosis present at birth.
- An early blood gas on the baby will also help to determine the effectiveness of resuscitation.A blood glucose and lactate measurement should be documented with the blood gases.
- All other relevant documentation should be completed e.g. transfer/incident forms.
Talking to parents:
Support, time and information should be given to the parents who will be very distressed by events. It is important that the team caring for the newborn baby informs the parents of the baby’s progress. At delivery, adhere to local plans for routine care and, if possible, hand the baby to the mother at the earliest opportunity. If resuscitation is required inform the parents of the procedures undertaken and why they were required. Record carefully all discussions and decisions in the mother’s notes prior to delivery and in the baby’s records after birth. Where there is a high risk of failure e.g. very preterm babies, or profound fetal distress from an abruption, It is important to counsel parents as to the possibility of unsuccessful resuscitation.
- Wyllie J, Perlman JM, Kattwinkel J et al. on behalf of the Neonatal Resuscitation Chapter Collaborators. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015; 95: e171-e203.
- Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation 2015;95:242-62.
- Lundstrom KE, Pryds O, Greisen G. Oxygen at birth and prolonged cerebral vasoconstriction in preterm infants. Arch Dis Child 1995;75:F81-86.
- Harris AP, Sendak MJ, Donham RT. Changes in arterial oxygen saturations immediately after birth in the human neonate. J Pediatr 1986;109-117.
- Ramji S, Ahuja S, Thirupuram S et al. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res 1993;34;809-12.
- Saugstad OD, Rootwelt T,Aalen O. Resuscitation of asphyxiated newborn infants with room air or oxygen: An international controlled Trial: The Resair 2 Study. Pediatrics 1998;102:e1.
- BAPM Position Statement on Therapeutic Hypothermia in Hypoxic- Ischemic Encephalopathy 2010