Resuscitation

Principles of Management.

• Temperature regulation. Ensure adequate warmth for the baby to prevent hypothermia which leads to decreased metabolic which cause additional stress to the baby.
• Ensure adequate oxygenation to the baby to prevent hypoxia by administration of oxygen and monitoring oxygen perfusion. An endotracheal tube should be inserted  and oxygen administered
• Prevention of hypoglycemia by regular monitoring blood glucose and if risk for hypoglycemia is identified administer dextrose as per prescription.

Steps for Resuscitation

TABCs of resuscitation

STEP 1

• Dry the baby, wipe the baby’s mouth with gauze and remove any wet cloth.

STEP 2

Clear the air way by;

• Suck blood or mucus from mouth using a bulb syringe or mucus extractor.
• Position baby’s head in a neutral position with head extended.
• Place a small towel under the shoulders to maintain the position.

STEP 3

Support breathing by;

• Stand at the baby`s head, apply ambu-bag and a small mask to the baby’s face ensuring that the mask covers the face and mouth to form a seal.
• Give five inflation breaths (each 2-3seconds duration).
• Observe response by looking at the chest movements (chest rising) or increase in the heart rate. (if chest does not rise then reapply mask, reposition baby’s head, and suction.)
• Continue ventilating at a rate of 30-40 breathes for a minute.
• Circulation/External Cardiac Massage
• Chest compression should be performed when the heart rate is less than 100b/m and falling inspite adequate ventilation
• If no heart beats are recorded after one minute, do external compressions.
• Wrap your palms around the baby`s chest, placing the thumbs / first finger over the lower part of the sternum.
• Chest is compressed at rate of 100–120 times 1 minute at a ratio of 3 compressions to one ventilation
• Use the thumb to gently compress the chest, depressing it ½ to ¾ inch each time.
• If in 20 minutes the breathing is not established. Consider intubation.  
• When the infant has no spontaneous breathing then continuous positive pressure ventilation (CPPV)  should be started with bag and mask.
• The rate of chest compressions in one minute should be 90 along with 30 PPVs, (3:1), a total of 120 events.
• If the heart rate is <60, despite of effective ventilation, chest compression and two intravenous doses of adrenaline (Epinephrine), the sodium bicarbonate 4.2% solution (0.5mmol/ml) can be administered using 2–4ml / kg (1-2mmol/ml) by slow intravenous.

Adrenaline (Epinephrine)

• This is indicated if the heart rate is <60, despite 1 min of effective ventilation and chest compression. An initial dose of 0.1-0.3 ml/kg of 1:10,000 solution give i.v. repeated after 3 minutes for a further two doses. 

10% dextrose

• (Hypoglycemia is not usually a problem) 3mls/kg i.v via the umbilical vein to correct low blood sugar of <2.5mmol/L
• Volume replacement
• On rare occasions, bradycardia will not respond to volume expansion and bradycardia that does not respond to chest compressions or drugs is suggestive of hypovolemia–0.9% normal saline 10 ml /kg initially via the umbilical vein. 

Naloxone hydrochloride

• This is not an emergency drug parse it is a powerful anti-opioid drug used to reverse the effects of maternal narcotic drugs given towards the end of first stage of labour (Preceding 3hours.) 
• Dose 0.1–0.2 mg per kilogram body weight intramuscular. 

Calcium gluconate

• A dose of 100mg kg body weight and 150 adrenaline 0.1-0.5mg/kg 1 min given for severe bradycardia or cardiopulmonary arrest
• Vitamin K–given prophylaxis against bleeding disorder.

Drugs 

• If there is no heart beat after 1 minute of breathing for the baby:
• Inject 0.5 mls of 1;10,000 adrenaline solution intravenously or through the umbilical vein. Give 1 to 2 mls per kilogram body weight of 25% dextrose solution intravenously.
• Continue to monitor response to resuscitation by using APGAR score.
• • If the baby responds to resuscitation  keep the baby warm and transfer to the special unit (NICU).
  • If baby is breathing well, keep reassuring the mother
  • If baby is breathing well, breast feeding should be encouraged. If no response discontinue resuscitation.