Neonatal Resuscitation: Steps and Resources

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What is Perinatal Asphyxia

Perinatal asphyxia, the failure of a newborn to initiate and sustain breathing, occurs in nearly 10 percent of all births. It can be caused by the newborn being born premature, the mother’s blood pressure dropping or the blood supply to the newborn’s brain being hampered during delivery. It is not often possible to identify an infant before birth that will suffer from asphyxia. Properly treating perinatal asphyxia during the first minutes of life can prevent permanent brain damage. Therefore the American Academy of Pediatrics recommends that hospitals have on staff at all times medical personnel with experience in high-risk deliveries.

How often does Perinatal Asphyxia Occur

Estimates of the incidence of perinatal asphyxia vary depending on the definitions used. In resource-rich countries, the incidence of severe perinatal asphyxia is about 1/1000 live births. In resource-poor countries, perinatal asphyxia is probably much more common. Data from hospital-based studies in such settings suggest an incidence of 5–10/1000 live births. However, this probably represents an underestimate of the true community incidence of perinatal asphyxia in resource-poor countries.

Risk factors of Perinatal Asphyxia

Perinatal asphyxia may occur in utero, during labour and delivery, or in the immediate postnatal period. There are numerous causes, including placental abruption, cord compression, transplacental anaesthetic or narcotic administration, intrauterine pneumonia, severe meconium aspiration, congenital cardiac or pulmonary anomalies, and birth trauma. Postnatal asphyxia can be caused by an obstructed airway, maternal opiates — which can cause respiratory depression — or congenital sepsis.

Outcomes of Perinatal Asphyxia

Mortality: treatment failure measured by rates of death before hospital discharge. Neurological impairment: includes incidence of neurodevelopmental disability assessed at greater than 12 months of age using a validated tool, and severity of hypoxic–ischaemic encephalopathy assessed using a validated tool.

How to Determine if Resuscitation is Needed

To determine which newborns need resuscitation, the American Heart Association suggests a quick evaluation of the following questions:

1. Was the baby born prematurely?
2. Does the amniotic fluid indicate an infection or contain meconium? Is there good muscle tone?
3. Is the baby crying or breathing?

If in the evaluation the answer to all of these questions is “yes,” then resuscitation of the baby is not needed. The baby should be dried, wrapped in a blanket and the breathing monitored.

How to Resuscitate a Newborn Who is Suffering from Perinatal Asphyxia

When a newborn suffers from asphyxia, there are two forms of resuscitation: basic and advanced. Advanced is used only when basic resuscitation has failed, in about one percent of births.

Basic resuscitation involves the “ABC’s”:
A. Airway-establish an open airway by positioning newborn and suctioning
B. Breathing-initiate breathing with oxygen or tactile stimulation
C. Circulation-maintain circulation with chest compressions and/or medicine.

The first step of resuscitation is to dry and keep the baby warm by using a blanket or radiant heater. All materials such as towels and blankets as well as the surface the baby is laid on should be warm. Warming a newborn should stimulate breathing in mild cases of asphyxia. If this does not work within 20 seconds, then the respiration must be evaluated. The upper airway, starting with the mouth and then the nose should be suctioned and checked for blood or meconium.

If the baby is still not breathing, then resuscitation should be initiated by laying the baby on its back and placing the head in a slightly extended position. Ventilation should be started using a mask, bag and the normal surrounding air. Ventilation is important in helping to start the newborn’s breathing on its own and to supply adequate oxygen to organs. If a mask and bag are not available, then mouth to mouth resuscitation must be performed.

After performing ventilation for a minute, it should be stopped briefly to see if spontaneous breathing is occurring. If there is no breathing or crying, or if there is gasping, ventilation should continue. If after 20 minutes, there are no signs of breathing or if breathing is slow, then advanced resuscitation should be commenced.

For the small percentage of babies that do not start breathing from ventilation, intubation can be performed as a part of advanced resuscitation. In extremely ill babies, intubation has been shown to provide better ventilation. Intubation is more convenient than the bag and mask. But it is a procedure that only a practitioner with training and experience should perform. For babies who do not respond to basic resuscitation, oxygen should be used. If the heart rate is low or dropping, then chest compressions can be lifesaving by providing circulation to the body. In rare cases, drugs may be administered to balance acid-base levels, raise the amount of tissue perfusion and stimulate the heart.

Resources about Perinatal Asphyxia

Developmental Follow-Up of Infants Experiencing Perinatal Asphyxia by Neal P. Simon, M.D.”

The clinical diagnosis of perinatal asphyxia is based on several criteria, the two main ones being evidence of cardio-respiratory and neurological depression and evidence of acute hypoxic compromise with acidaemia.

Resource by L.Fuller

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