FRCA Notes

Neonatal Resuscitation

This topic is absent from the intermediate curriculum, which is replete of a smorgasbord of other neonatal topics.

The below-linked BJA Education article suggests that 'any anaesthetist providing obstetric care should maintain familiarity with current practices in neonatal resuscitation'.

Resources

  • Most infants adapt well to extra-uterine life, though some require help with stabilisation or resuscitation
  • 85% will breathe spontaneously without intervention
    • 10% respond after drying/stimulation/airway opening
    • 5% receive PPV
    • 0.4 - 2% require intubation
    • <0.3% require chest compression
    • 0.05% receive adrenaline

Ante-partum maternal factors Ante-partum foetal factors Intra-partum factors
Infection IUGR Evidence of foetal compromise e.g. non-reassuring CTG
GDM <36 weeks or >40 weeks gestation Meconium
PIH | PET | Eclampsia Multiple pregnancy Breech delivery or other malpresentation
High BMI Oligohydramnios Instrumental delivery e.g. forceps, ventouse
Short stature Polyhydramnios LSCS <39 weeks
Pre-term labour without steroids Serious congenital abnormality Emergency LSCS
No antenatal care Anaemia General anaesthesia
Macrosomia MOH inc. placental abruption
Cord prolapse


Cord clamping

  • Where immediate stabilisation or resuscitation is not required, aim to delay cord clamping for at least 60s (longer periods may be more beneficial)
  • Where immediate stabilisation or resuscitation is required:
    • Delay cord clamping if it is possible to safely undertake interventions with cord intact
    • If delayed cord clamping not possible, consider milking the cord in those >28 weeks gestation

  • Delayed cord clamping:
    • Results in higher neonatal blood volumes after birth
    • Improves iron stores in infancy and therefore fewer blood transfusions
    • Improves haemodynamic stability during the transition from foetal to neonatal life
    • Associated with lower incidence of intraventricular haemorrhage
    • Associated with lower infant mortality rates

Temperature management

  • Monitor temperature regularly e.g. with skin temperature probe
  • Target temperature between 36.5°C and 37.5°C
  • Methods for maintaining temperature:
    • Dry neonate at birth
    • Maintain a warm delivery room (between 23°C and 25°C, and >25°C for infants less than 28 weeks' gestation)
    • Use a radiant warmer
    • Plastic wrap and chemical mattress in pre-term infants to prevent hypothermia
  • In appropriate circumstances, consider therapeutic hypothermia after resuscitation

Airway & ventilatory management

  • If not breathing, stimulate ± suction nose/mouth if evidence of secretions obstructing the airway
  • Consider tracheal suction if born through meconium-stained amniotic fluid and obstruction is suspected

  • Start PPV using a mask if inadequate respiratory effort/apnoeic or HR <100bpm
    • FiO2 0.21 and PIP 30cmH2O in term infants
    • FiO2 0.21 - 0.35 and PIP 20-25cmH2O in pre-term infants <35 weeks
  • Use PEEP 5-6cmH2O as it helps in the generation of FRC which will allow the lungs to stay inflated

  • Target preductal SpO2 values (saturations on monitor on right hand) of 85% at 5mins and 90% at 10mins

  • If HR <60bpm or chest compressions are required then:
    • Use alternative airway e.g. intubate, supraglottic device
    • Increase FiO2 to 1.0

Perform rapid assessment

  • E.g. the Apgar score at 1min (i.e. the above steps should all take place within 60s if necessary)

  • Developed by an obstetric anaesthetist to determine the effect of anaesthesia on neonates
  • It should be performed at 1mins and 5mins ± 10mins if earlier scores low

  • It consists of:
    • Appearance i.e. skin colour
    • Pulse i.e. heart rate (>100bpm satisfactory)
    • Grimace e.g. reflex irritability
    • Activity e.g. muscle tone
    • Respiration
  • Each is scored 0 - 2, with a maximum score of 10

Scoring and significance

  • A 1min score of ≤3 does not predict any individual infants outcome

  • A 5min score of ≤3 correlates with neonatal mortality, but does not predict individual future neurologic dysfunction
    • Most infants with low Apgar scores will not develop cerebral palsy
    • However, low 5min score increases the relative risk of cerebral palsy by 20 - 100x compared to an infant with an Apgar score of ≥7

  • A 10min score of ≤3 is associated with increased risk of poor neurological outcome

  • Continued respiratory support is required if, after initial assessment & intervention;
    • There is inadequate or irregular breathing
    • HR <100bpm

Lung inflation

  • If evidence of inadequate respiration, aim to start PPV ideally within 60 seconds
  • Give 5 inflation breaths, maintaining inflation pressure for 2 - 3s
    • FiO2 0.21 and PIP 30cmH2O in term infants
    • FiO2 0.21 - 0.35 and PIP 20-25cmH2O in pre-term infants <35 weeks
    • PEEP of 5 - 6cmH2O

  • Saturations monitoring is required and oxygen should be titrated to avoid hypoxia or hyperoxia
  • Accept pre-ductal saturations of 85% at 5mins, 90% at 10mins and wean oxygen if >95%

CPR

  • If HR <60bpm or absent after 30 seconds of ventilation, start CPR
  • Increase FiO2 to 1.0
  • Delivery of CPR:
    • 3:1 compressions to ventilations
    • 15 cycles every 30 seconds
    • Two-thumb (encircling) technique
  • Reassess HR and chest movement every 30s
  • Consider vascular access and drugs if HR <60bpm after 30s

Vascular access

  • Peripheral venous access is likely to be difficult, and suboptimal for vasopressor administration
  • Options therefore include:
    • Umbilical vein cannula
    • IO access
    • Peripheral or central access for post-resuscitation care

Drugs

  • Adrenaline
    • Indicated if HR <60bpm despite 60s of chest compressions
    • 20μg/kg IV or IO
    • 50-100μg/kg via trachea if intubated and no other access
    • Subsequent doses every 3 - 5mins if HR <60bpm

  • Volume resuscitation
    • 10ml/kg of O-negative blood or isotonic crystalloid in suspected shock
    • 2 - 4ml/kg of 4.2% NaHCO3 in prolonged, unresponsive resuscitation to reverse intracardiac acidosis

  • Glucose
    • 2.5ml/kg of 10% dextrose IV or IO
    • For prolonged resuscitation to reduce likelihood of hypoglycaemia

Aetiologies

  • If prolonged resusctiation consider alternative aetiologies such as:
    • Pneumothorax
    • Unrecognised congenital abnormalities e.g. congenital diaphragmatic hernia
    • Hypovolaemia/haemorrhage