Fetal & Neonatal Resuscitation

1. Fetal & Neonatal Resuscitation Presented by : Dr. MeenalAggarwal Moderator : Dr. Ramesh

2. Fetal Resuscitation • Important to both Obstetrician and Anaesthesiologist • Role of Anaesthesiologist: • During regional analgesia • When urgent delivery required (Emg LSCS) • Preanaesthetic evaluation is important • Need to evaluate the fetus intrauterine

3. Adaptive responses of fetus to hypoxia: • Decreased HR • Reduction in O2 consumption secondary to cessation of non essential functions such as gross body movements • Redistribution of C.O. to preferentially perfuse vital organs • Switch to Anaerobic cellular metabolism

4. Fetal Heart Rate monitoring: (Nonreassuring FHR) • Continuous Electronic monitoring during labour • (using surface USG, using scalp electrodes) • Normal: 120-160 bpm (tachy: Premature, infection, mild hypoxia, hyperthyroidism, drugs) • (Brady: post maturity, heart block, asphyxia) • Normal variability: 5-25 bpm (scalp electrodes) • (dec variability: fetal sleep, Drugs like meperidine, fetal hypoxia & acidosis) • Decelerations in FHR: • Early decelerations: correspond to uterine contractions, normal (10-40bpm) (vagal discharges)

5. 2. Late decelerations: occur after peak of contraction, s/o fetal compromise (dec O2 at chemoreceptor of SA node) • Variable decelerations: m.c. type, vary in timing and configuration, umblical cord compression (> 30bpm), Asphyxia if >60bpm, >60sec, >30min • Fetal scalp pH Monitoring: • Helps FHR in suggesting fetal status (pH>7.2, vigorous neonate, <7.2 Often depressed neonate ) • Scalp lactate, Fetal ST segment analysis • Adv: Caused reduction in neonatal seizures • Disadv: Inc rate of CS and instrumental deliveries

6. Fetal pulse oximetry: • Probe inserted through cervix, placed b/w fetal cheek and uterine wall • Values: 28-71%, < 30: Abnormal • Persistently low values l/t fetal acidosis • Adv: Early detection of fetal acidosis • Disadv: Inc cost of medical care • No reduction in overall CS rate • A better method to evaluate fetal well being in labour is still required

7. Fetal Monitoring Devices

8. Intra Uterine Resuscitation: • Measures in attempt to improve hypoxia & acidosis • Improving O2 delivery • Improving blood flow • Causes of reductions in fetal oxygenation: • Aortocaval compression • Uterine hyperstimulation • Umblical cord compression • Maternal hypoxemia

9. Maneuvers to increase oxygenation : • Left lateral or knee chest position • Discontinuation of oxytocin infusion • Supplemental maternal O2 administration • Crystalloid infusion • Tt hypotension: vasopressors • Tocolysis: s/c Terbutaline, nitroglycerine • Amnioinfusion

10. Recommendations of Intrapartum Resuscitation

11. Neonatal Resuscitation

12. Introduction Q. Why is it necessary? - In case of failure to make changes in CVS and Resp system at birth Q. When to prepare for it? - Before delivery of baby Delay can be DISASTROUS!!

13. For a successful resuscitation: • Early detection of potential problems • - FHR monitoring (<100 grossly dec. C.O.) • - Fetal Blood Gases & pH (acidosis if inadequate gas exchange or in case of right to left shunt in heart or lung) • Being prepared to treat them

14. Assessment of baby at birth: • Apgar score: useful guide to neonatal well being • 1min score: correlates well with acidosis & survival • 5min score: +/- predictor of neurological outcome • Not fail-proof • Even very acidotic neonates may have relatively normal Apgar score at 1 and 5 min • (have normal HR & BP but are vasocontricted, have pallor)

15. Apgar Score

16. H.R. < 100: Dec C.O. & tissue perfusion • Breathing: begins 30 sec after birth, sustained by 90 sec, N: 30-60bpm • Apnea/bradypnea: severe acidosis, infection, maternal drugs • Tachypnea: hypoxemia, hypovolemia, acidosis, HMD, CNS h’age, maternal narcotics, pulmonary edema • Dec muscle tone: asphyxia, maternal drugs, CNS damage, Myasthenia gravis • Not moving with stimulation: hypoxia, acidosis, CNS damage • Color: blue at birth, pink with blue extremities at 60sec • Central cyanosis beyond 90 sec: hypoxia, CHD, meth Hb

17. Equipment

18. General Care of New born at birth: • Trained person to be available at delivery • As the head is delivered: suctioning of mouth first then nostrils • Body delivered: dry with a sterile towel • Cord clamped: once it stops pulsating, breathing innitiated • Neonate placed in a radiant warmer, bed tilted in slight trendelenburg position • If child is depressed: cord clamped early & immediate resuscitation started • HR (base of umblical cord), resp rate (visible, auscultation)

19. Bulb Suctioning

20. Bulb Suctioning

21. Resuscitation equipment: • Beds: Allow positioning of head below level of lungs • Infrared heater: (36-37 degree) • (if asphyxia 34-35 degree for brain protection) • Suction device (pressure not below -100mmHg) • Equipment for intubation: Laryngoscope straight blade 0 & 00 • ETT’s 2.5, 3.0, 3.5mm, suction catheters • Ventilation systems: allowing rates of 150bpm, PEEP • Prevent over-inflation, measure inflation pressures

22. JR circuit • Blood gases & pH measurements • Arterial blood pressure • Pulse oximeter • Normal SaO2: 87%-95% (starts at 60%, by 10min 90%) • Normal PaO2: 55-70mm Hg Umbilical arterial catheter

24. Tracheal suctioning: • Suctioning done before starting ventilation if thick meconium, or major vaginal bleed has occurred • If meconium present, pharynx and mouth suctioned as soon as head is delivered • Suction applied to ETT and ETT withdrawn while suctioning, laryngoscope left in place, tube reinserted • O2 continuously blowing over face of neonate • Monitor HR • Suctioning of stomach (may regurgitate and aspirate later) • If Apgar 9 or 10, tracheal suction not required (even if mec.)

25. Nasal Suctioning

26. Pulmonary Resuscitation: • If H.R. < 100 bpm & SaO2 <85%, consider intubation • IPPV at 30-60 bpm, start with room air (titrate with SpO2) • Hold every 5th breath for 2 sec, PEEP 3-5cm H2O • Avoid excessive pressures • Tracheal Intubation: • Head in neutral or sniffing position • ETT: 2.5 mm for <1.5 kg, 3.0 for 1.5-2.5 kg, 3.5 for >2.5 kg • Distance: 7,8,9,10 cm for 1,2,3,4 kg infant • Capnography: ?reliable (small VT, Low pulmbloodflow)

27. Positioning of Baby

29. Placement of Mask

30. Adequacy of ventilation: • B/L breath sounds: misleading (can be transmitted within small chest) • Equal chest rise • Becomes pink, initiates breathing, Normal HR • P insp : < 25cm H2O, if stiff lung higher pressure required (Pulmonary edema, meconium aspiration, diaphragmatic hernia) • RR: 150-200 bpm, P insp: 15-20cm H2O • If PaO2 > 70-80mmHg or SaO2 > 94%, Dec FiO2 • Monitor HR (hypoxic, prone to arrhythmia during intubation)

31. Bag & Mask Ventilation

32. Surfactant Administration: • Reduced incidence of HMD, Deaths, Interstitial emphysema • Dose: 5ml/kg into trachea at or shortly after birth • Briefly reduces saturation, then rises rapidly • Need to decrease inflation pressures (as compliance improves) • Often supported with nasal CPAP (avoids intubation)

33. Volume Resuscitation: • If condition doesn’t improve with ventilation,O2 & stimulation • Umbilical A. catheter (ABG & volume expansion) • Correction of acidosis: • For Respiratory acidosis: Mechanical ventilation • For Metabolic acidosis: NaHCO3 (only if ventilation is adequate or else CO2 retention occurs), THAM (Dec CO2) • If Apgar =< 2 at 2min or =<5 at 5 min, give NaHCO3 2meq/kg, while ventilation continues • If pH< 7.00, PaCO2 < 35mmHg, correct 1/4th base deficit

34. If pH > 7.10, Continue ventilation, delay HCO3 • If pH decreases or unchanged, correct 1/4th of base deficit, keep ventilating • Cause of metabolic acidosis: Poor tissue perfusion (hypovolemia, heart failure) • pH < 7.00, may induce cardiac failure • Hypoglycemia may cause Heart failure (so monitor RBS during resuscitation) • Expansion of intravascular volume: • Hypovolemia (if cord clamped early, intrauterine asphyxia, placental abruption)

35. Detection of hypovolemia: • Arterial BP • Physical examination (skin color, capillary refill time, pulse volume, extremity temperature) • CVP (2-8cm H2O) • Tt of hypovolemia: • Crystalloids, Blood (Rh –ve O Gp), Albumin • Usually 10-20ml/kg volume adequate (may be even 50% of blood vol) • Avoid overexpansion, l/t Systemic HTN & I.C.bleed (in preterm) • Hypoglycemia, Hypo Ca, Hyper Mg (Ca gluconate)

36. Cardiac massage: Ratio: 3:1 (Compression: ventilation) • If HR at 1min < 80 bpm despite ventilation & stimulation, intubation done & closed chest massage started • 2 methods: 2 finger, 2 thumb techniques • Depth: 2-2.5cm • Rate: 120 times/min • Not to interrupt ventilation during chest compression • Effectiveness: ABG, Arterial BP, Pupils (should be midposition or constricted) • If cardiac origion known, ratio 15:2

37. Methods of giving chest compressions

38. Drugs to be given in minimum volume of fluid (to prevent hypervolemia)

39. Post- Resuscitation care: • Temperature (36.5-37.5 degree C) • Therapeutic hypothermia: for babies with evolving moderate to severe hypoxic-ischemic encephalopathy • Oxygenation (SaO2) • CO2: 35-45mm Hg • Blood sugar (70-100mg%), 2ml/kg D10 bolus f/b 6-8ml/kg/min • Tt in neonatal intensive care facilities

40. Thank You