Neonatal Asphyxia, Rescuscitation and Beyond Dipak K Guha, Rashmi Guha, Padmapriya Dore
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1NEONATAL ASPHYXIA, RESUSCITATION AND BEYOND
2NEONATAL ASPHYXIA, RESUSCITATION AND BEYOND
Second Edition
Editor-in-Chief Dipak K Guha MD FIAP FRSTM & H FNNF Head of Department of Pediatrics and Senior Consultant Neonatologist Sri Balaji Action Medical Institute New Delhi, India Editors Rashmi Guha MD Senior Consultant Tirath Ram Shah Hospital New Delhi, India Padmapriya Dore DCH DNB Consultant Neonatologist Sri Balaji Action Medical Institute New Delhi, India
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Neonatal Asphyxia, Resuscitation and Beyond
© 2008, Dipak K Guha
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
This book has been published in good faith that the material provided by editors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 1996
Second Edition: 2008
9788184482911
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14 Sector 60, Noida
4
to
all care providers of newborns
and
my parents and in-laws
wife Rashmi
daughter Aditi
granddaughter Abhya, Dhriti, Grandson Aaraj
and son-in-law Vineet Vij
5Foreword
Management of Neonatal Asphyxia, Resuscitation and Beyond has totally changed in the last 4 decades. Gone are those days where vigorous thumping, holding upside down, hot and cold water stimulation or administering stimulants like Nikethamide were accepted as routine treatment. Some babies survived and did well inspite of these insults!
Understanding physiology of perinatal events has rationalized neonatal resuscitation, Dr Dipak Guha's book has simplified this physiology and its application by caregivers very convincingly. Profusely illustrated by simple diagrams, even an educated Traditional Birth Attendant can be trained by this knowledgeable book.
The book Neonatal Asphyxia, Resuscitation and Beyond is essential for anyone who is interested or involved in newborn care be it student, resident, postgraduate, practicing pediatrician or teacher in neonatology.
I hope that Governmental and Non-Governmental organizations caring for newborns follow these methods not only for babies to be born alive but to be born “well.”
Dr Anand Pandit
MD FRCPCH (UK)
Honorary Professor and Director
Department of Pediatrics and Neonatology
KEM Hospital, Pune 411 011
6Preface to the Second Edition
In India, birth asphyxia is the highest contributing factor in perinatal mortality both in the urban and rural population. The ability of the fetus or infant to survive episodes of asphyxia is related to mechanisms that regulate blood flow to the organs of the body. These mechanisms are designed to maintain delivery of oxygen to the vital organs during periods of hypoxia.
Anticipation of the problem even before the birth of the baby and prompt, appropriate and effective resuscitation at birth are the cornerstones of neonatal care—a theme vital to develop strategy for improving the neonatal survival in the country. To achieve this, adequate and appropriate infrastructure, physical facilities and a well-coordinated teamwork of trained health care professionals ranging from level of neonatologists to TBAs and ANMs are required.
Quite understandably each one of us involved in perinatal care must consider every birth as a medical emergency and gear ourselves to provide appropriate state-of-the-art care at birth. Management requires clinical judgement, technical skill, knowledge of physiological principles and team approach.
In 1987 American Heart Association in collaboration with American Academy of Pediatrics developed a training course, which provided a uniform, systematic and action-oriented approach for the resuscitation of the neonates. The National Neonatology Forum has used this neonatal advanced life support training course very effectively and successfully over the past 15–16 years all over the country and NALS had become an immensely popular course.
In 2000 and 2005 International guidelines for neonatal resuscitation have been published with several modifications from the old NALS program and been renamed as Neonatal Resuscitation Program or NRP 2000. It is a consensus of experts in the field representing the most effective practices for resuscitation of the newly born infant, based on current research, knowledge and experience. Though these guidelines are not imposed on any individual or organization, they are intended to serve as foundation for educational programs and national, regional and local processes which establish standards of practice. In this revised second edition, chapters have been reorganized and rewritten with additional new inputs and all the modifications and new guidelines recommended by NRP 2000 and 2005 have been incorporated. To bring out this new look second edition two experienced neonatologists Dr Rashmi Guha and Dr Padmapriya Dore joined me as co-editors and their contribution has been outstanding.
Neonatal Asphyxia, Resuscitation and Beyond, Second edition primarily based on NRP guidelines deals with intrauterine and natal physiology, perinatal asphyxia and its management, neonatal resuscitation, resuscitation in the community, organization of follow-up services and pertinent legal issues concerning resuscitation in seven chapters with extensive references. The book has been profusely illustrated with figures and tables for better understanding of the NRP guidelines. Our overall objective has been to provide a sound physiological and practical basis for neonatal resuscitation and follow-up care. Those other than specialized in neonatology, care for a vast majority of newly borns. It is for these health care providers, nurses, TBAs, and other personnel involved in newborn care that this book is primarily intended for.7
My task of completing the book has been most pleasurable because of expert in-house editorial assistance provided by Mr Tarun Duneja, General Manager (Publishing) and keen interest taken by Shri Jitendar P Vij, Chairman and Managing Director of M/s Jaypee Brothers Medical Publishers, New Delhi. I am deeply indebted to all of them. My special thanks to Director-Professor Anand Pandit, KEM Hospital, Pune for penning the excellent “Foreword”.
I have no doubt that the care providers of the newborn will find this book very handy and useful at the time of emergency when even a single second matters in neonatal resuscitation.
Dipak K Guha
8Preface to the First Edition
In India, birth asphyxia is the topmost contributing factor in perinatal mortality both in urban and rural population. The ability of the fetus or infant to survive episodes of asphyxia is related to mechanisms that regulate blood flow to the organs of the body. These mechanisms are designed to maintain delivery of oxygen to the vital organs during periods of hypoxia. Anticipation of the problem even before the birth of the baby and prompt, appropriate, and effective resuscitation at birth are the cornerstones of neonatal care—a theme vital to develop strategy for improving the neonatal survival in the country. To achieve this, adequate and appropriate infrastructure, physical facilities and a well-coordinated teamwork of trained health care professionals ranging from level of neonatologists to TBAs and ANMs are required.
Quite understandably each one of us involved in perinatal care must consider every birth as a medical emergency and gear ourselves to provide appropriate state-of-the-art care at birth. Management requires clinical judgement, technical skill, knowledge of physiological principles and team approach.
In 1987 American Heart Association in collaboration with American Academy of Pediatrics developed a training course, which provides a uniform, systematic and action-oriented approach for the resuscitation of the neonates. The National Neonatology Forum has used this neonatal advanced life support training course very effectively and successfully over the past 6–7 years all over the country and NALS had become an immensely popular course.
The text of Neonatal Resuscitation and Beyond (asphyxia and neonatal resuscitation) primarily based on NALS documents, deals with perinatal asphyxia, neonatal resuscitation, resuscitation in the community, Hypoxic ischemic encephalopathy and organisation of follow-up clinic (beyond resuscitation) in five chapters with extensive bibliography on the subjects. The book has been profusely illustrated based on the line of NALS. Our overall objectives have been to provide a sound physiological and experimental basis for state-of-the-art of practical neonatal resuscitation and post-resuscitation follow-up care. A vast majority of the newborns are cared by care providers other than those specialized in neonatology. It is for these physicians, physician extenders, nurses, trained birth attendants, and personnel involved in newborn care, that this book is primarily intended.
I am greatly indebted to my wife Dr Rashmi Guha and dear colleague Dr JP Dadhich for their constructive criticism, suggestions and assistance during preparation of the book. I am most gratified to my lovely daughter Dr Aditi Guha-Vij for designing the cover of the book. My task of completing the book has been most pleasurable because of keen interest taken by Shri Jitendar P Vij of Jaypee Brothers. I am indeed deeply indebted to all of them.
I have no doubt that the care providers of the newborn will find this book very handy and useful at the time of emergency when even a single second matters in neonatal resuscitation.
Dipak K Guha
10ADDENDUM FOR NRP GUIDELINES—2005
Although most of the major changes recommended in NRP guidelines—2005 have been included at appropriate places of the different chapters of the book, editors felt it would be good idea to include the highlights of the changes separately at one place so that readers can better comprehend the latest changes.
The following highlights of the NRP guidelines were prepared by Dr Sushma Nangia Prof, and Dr Nidhi Chopra, Dept of Pediatrics, Kalawati Saran Hospital, Delhi and was published in January 2008 issue of Delhi Pediatrics, the news bulletin of IAP, Delhi branch.
An International Liaison Committee on resuscitation (ILCOR) has been set up which performs literature review, collects evidence, debates the issues and comes out with consensus recommendations, which are published and widely circulated. The most recent CPR-ECC conference was held in 2005 and the guidelines have been published in circulation, pediatrics, and resuscitation. This article addresses the changes in NRP guidelines from previous guidelines developed in 2000 and in addition the scientific evidence to effect the proposed changes in included wherever feasible.
  1. In the previous NRP guidelines there were five questions to be asked in the assessment block of the flow diagram. if answer to any of these questions was no, then the resuscitator had to proceed to the initial steps. If answer to all was yes, then he had to provide routine care.
    The questions were:
    1. Term gestation?
    2. Breathing or crying?
    3. Good muscle tone?
    4. Clear amniotic fluid?
    5. Color pink?
    As per the new guidelines only four questions have to be asked, the question ‘color pink?’ has been deleted.
    Scientific evidence to effect change: An uncompromised newborn infant will achieve and maintain pink mucous membranes without administration of supplementary oxygen, but neonatal transition is a gradual process. Evidence obtained with continuous Oximetry in uncompromised healthy infants has shown that neonatal transition is a gradual process and healthy newly born term infants may take >10 minutes to achieve a preductal oxygen saturation > 95% and nearly one hour to achieve postductal saturation > 95%.
    AAP AHA 2000 guidelines
    AAP AHA 2005 guidelines
    Initial steps
    If the answer to any of these questions is no, then proceed to initial steps. If answer to all is yes, then provide routine care
    If answer to any of these questions is no then proceed to initial steps. If answer to all is yes, then provide routine care.
    Ask 5 questions
    Ask 4 questions
    1. 1. Full term?
    1. 1. Full term?
    1.2. Clear of meconium?
    1.2. Clear of meconium and no evidence of infection?
    1.3. Breathing or crying?
    1.3. Breathing or crying?
    1.4. Good muscle tone?
    1.4. Good muscle tone?
    1.5. Pink?
  2. After the initial steps of resuscitation, the resuscitator evaluates the newborn. If newborn is breathing spontaneously and has an HR>100 bpm but is cyanotic, the new resuscitation guidelines recommend to give supplemental oxygen as a separate next step. Whereas, the old guidelines include oxygen in initial steps.
    11
    NRP 2000
    NRP 2005
    Initial steps include supplemental oxygen if needed.
    Initial steps do not include giving Supplemental oxygen. Highlighted as a separate next step. (See Flowchart on page vii). If cyanosis persists despite free flow oxygen give positive pressure ventilation.
  3. The term ‘Supportive care’ has been replaced by ‘Observational care’ and ‘Ongoing care’ by ‘Post resuscitation care’ in the new NRP guidelines.
    Scientific evidence to effect change: A newborn who has received initial steps of resuscitation up to free flow oxygen needs to be kept under observation to ensure continuation of smooth transition and to be able to pick up any signs of deterioration, hence the appropriate wording—Observational care. Similarly a baby who has required positive pressure ventilation and beyond, needs to be admitted to the NICU and needs post-resuscitation care with special emphasis on temperature, oxygen, ventilation, glucose and volume and/or pressure support.
  4. As per previous guidelines, if meconium was present in the amniotic fluid, the person carrying out/attending the delivery was guided to suction the mouth, pharynx and nose with a catheter or bulb syringe after the delivery of head out before the delivery of shoulders. This suction is not recommended in the new NRP guidelines.
    Meconium stained liquor
    NRP 2000
    NRP 2005
    In case of meconium stained liquor, before delivery of shoulders routine intrapartum oropharyngeal and nasopharyngeal suctioning should be done
    Routine intrapartum oropharyngeal and nasopharyngeal suctioning of babies born through meconium stained liquor no longer advisable.
    Scientific evidence to effect change: A large multicentric trial conducted to evaluate the effect of routine intrapartum Oropharyngeal suctioning in babies born through meconium stained amniotic fluid on development of Meconium aspiration syndrome revealed no beneficial effect of this intervention and hence, this has been done away with in the present guidelines.
  5. The new NRP guidelines, do not recommend providing free flow oxygen throughout the suction procedure of a non vigorous baby born through meconium stained amniotic fluid which was recommended earlier.
  6. Earlier the NRP guidelines recommended the use of bag and mask with 100% oxygen. The new guidelines too recommend the use of 100% oxygen when positive pressure ventilation is required during resuscitation of term babies but
    1. If the clinician chooses to start resuscitation with room air, it recommends the use of supplemental oxygen, up to 100% to be used if there is no appreciable improvement within 90 seconds following birth.
    2. In situations where supplemental oxygen is not readily available, NRP guides to administer positive-pressure with room air.
    Scientific evidence to effect change: There is some evidence, although small, and in select group of full term babies with mild to moderate asphyxia, to suggest that resuscitation with air is likely to be as effective as 100% oxygen in terms of survival. There is no data, however, on preterm infants and in babies with severe asphyxia. The available data at least support the fact, that where a choice exists, it is becoming progressively easier to justify using room air, rather than oxygen to start resuscitation, with oxygen kept in reserve to be used in case of inadequate response.
  7. The new guidelines introduce the use of ‘T-piece resuscitator’ to resuscitate the newborns, the other two devices used for ventilating the newborns are self inflating bag and flow inflating bag.
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    Oxygen
    NRP 2000
    NRP 2005
    1. Use of 100 % oxygen is recommended when baby is cyanotic or when positive pressure ventilation is required during neonatal resuscitation.
    1. For term babies
    • 1.1. Use of 100% oxygen is recommended when baby is cyanotic or when positive pressure ventilation is required during neonatal resuscitation.
    • 1.2. If oxygen is needed during resuscitation, one may begin with less than 100% oxygen or room air. If so, supplementary oxygen should also be available to use if there is no appreciable improvement within 90 seconds after birth
    • 1.3. Use of variable concentration of oxygen guided by pulse oximetry may improve the ability to achieve normoxia more quickly.
    • 1.4. In situations where supplementary oxygen is not readily available positive pressure ventilation should be started with room air.
    Scientific evidence to effect change: It is being increasingly recognized that uncontrolled (unmeasured) positive pressure breaths applied to apneic newborns in an attempt to achieve ‘normal chest movements’ with the first and subsequent artificial breaths may be injurious to these infants. Experimental data to this effect reveal that histologic lung injury becomes demonstrable with as few as six large positive pressure breaths given in the delivery room. Moreover, volume delivered with these breaths may be much in excess of what is necessary. There is insufficient evidence for use of PEEP in the delivery room as of now, but it must be employed wherever subsequent respiratory support is required beyond the immediate birth revival. In light of these, the ‘T-piece resuscitator’, a flow controlled pressure limited mechanical device has been introduced.
  8. After giving positive pressure ventilation the improvement was assessed by increasing heart rate, improving color and spontaneous breathing. In addition the new NRP guidelines recommend the use of ‘improving muscle tone’ as an indicator of improvement but stresses mainly on increasing heart rate.
  9. The NRP guidelines recommend insertion of an 8 French feeding tube in newborns requiring positive pressure ventilation with a bag and mask for longer than several minutes. Earlier the length of the feeding tube to be inserted was measured from the ‘bridge of nose to the earlobe and from earlobe to the xiphoid process’. The new NRP guidelines recommend the distance from ‘bridge of nose to the earlobe and from earlobe to a point halfway between the xiphoid process and the umbilicus’.
  10. Earlier the NRP suggested the use of CO2 detector for confirmation of the tube. The new NRP guideline recommends the use of CO2 detector for checking the position of the endotracheal tube as a routine practice. This may have no role in brief period of intubation for clearing of meconium from trachea.
  11. New NRP guidelines introduce the use of laryngeal mask airway (LMA). Laryngeal mask airway (LMA) can be used when positive pressure ventilation by bag and mask or mask and T-piece resuscitator is ineffective and attempts at intubation are not feasible or are unsuccessful.
    13
    Positive pressure ventilation (PPV)
    NRP 2000
    NRP 2005
    1. Devices
    • 1.1. Use self inflating bag or flow inflating bag to provide PPV during resuscitation
    1. Devices
    • 1.1. Flow controlled pressure limited mechanical devices (e.g. T-piece resuscitator) also an acceptable method of administering PPV especially in preterm babies.
    • 1.2. Laryngeal Mask Airway (LMA) is effective for ventilating term and near term babies.
    • 1.3. LMA should not to be used
    • 1.3.1. In the setting of meconium stained amniotic fluid
    • 1.3.2. When chest compression is required
    • 1.3.3. In VLBW babies
    • 1.3.4. For delivery of medications
    2. Checking effectiveness
    • 2.1. Improvement indicating by three signs: increasing heart rate, improving color and spontaneous breathing
    2. Checking effectiveness
    • 2.1. Primary measure of improvement in increasing heart rate.
    • 2.2. If heart rate not improving assess chest movements and check breath sounds.
    However, LMA should not be used in the setting of meconium stained amniotic fluid, when chest compression is required, in VLBW or for delivery of medications.
    Endotracheal intubation
    NRP 2000
    NRP 2005
    1. Tube position may be confirmed by capnography.
    1. Capnography (exhaled CO2) recommended method of confirming tube placement. This may have no role in brief period of intubation for clearing meconium from trachea.
  12. Use of sodium bicarbonate was recommended in the earlier guidelines after the administration of volume during the process of resuscitation. The new guidelines suggest administration of sodium bicarbonate as a post resuscitation measure and not a part of resuscitation.
  13. The new NRP guidelines recommend only intravenous route for administration of naloxone. The endotracheal route for administration of naloxone suggested earlier is not recommended.
    Medications
    NRP 2000
    NRP 2005
    1. Epinephrine or naloxone can be given through endotracheal (ET) route.
    1. Naloxone not to be given by ET route. Epinephrine perferable by intravenous route only.
    Scientific evidence to effect change: There is complete lack of data on endotracheal administration of naloxone in newborns and hence, endotracheal administration of naloxone is not recommended. As regards epinephrine, if the endotracheal route is to be used the limited available evidence suggests need for using higher dose than the currently recommended 0.01 to 0.03 mg/kg dose, however, in view of the paucity of high quality clinical data regarding endotracheal administration, the intravenous route should be used as soon as venous access is established.
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  14. The new NRP guideline recommends the use of 18–20 G percutaneous needle for draining a suspected pneumothorax instead of 21–23 G butterfly needle as recommended earlier.
  15. The new NRP guideline prefers double lumen 10 F orogastric catheter (replog) to evacuate the stomach contents in suspected congenital diaphragmatic hernia.
  16. The new NRP guidelines suggest discontinuation of resuscitation efforts after 10 minutes of absent heart rate following complete and adequate resuscitation efforts. Earlier a time of 15 minutes was recommended.
  17. Earlier the NRP suggested to withhold the resuscitation in confirmed gestation <23 weeks or birth weight <400 g, anencephaly or babies with confirmed trisomy13 or 18. The new guideline suggests non-initiation of resuscitation in conditions with almost certain death of unacceptable high morbidity in survivors as in confirmed gestation <23 weeks or birth weight <400 g or anencephaly or babies with confirmed trisomy 13 or 18. It also suggests to take into account the parental desires for non-initiation of resuscitation in conditions with uncertain prognosis in which survival is borderline.
    NRP 2000
    NRP 2005
    Discontinuation
    1. Discontinuation of resuscitative efforts after 15 minutes of absent heart rate in spite of complete and adequate resuscitation efforts.
    1. After 10 minutes of continuous and adequate efforts if there are no signs of life (no heart rate and no respiratory effort) discontinue of resuscitative efforts.
    Withholding resuscitation
    1. Non-initiation of resuscitation in following conditions
    1. Non-initiation of resuscitation in following conditions
    • 1.1. Confirmed gestation less than 23 weeks or birth weight <400 g
    1.1. In conditions with almost certain death or unacceptable high morbidity in the survivors as in following conditions
    • 1.1.1. Confirmed gestation less than 23 weeks or birth weight <400 g
    • 1.1.2. Anencephaly
    • 1.1.3. Babies with confirmed trisomy 13 or 18.
    • 1.2. Anencephaly
    1.2. In conditions associated
    with high rate of survival and acceptable morbidity resuscitation always indicated (gestation of 25 weeks or more).
    • 1.3. Babies with confirmed trisomy 13 or 18
    1.3. In conditions with uncertain prognosis in which survival is borderline take into account parental desires.
 
PRETERM INFANTS
New NRP guidelines lay specific emphasis on resuscitation of preterm infants < 32 weeks of gestation. A whole new chapter has been added to emphasize the maturational vulnerability of this group of babies and that the guidelines for resuscitation of preterm newborns should be gentler with special emphasis on temperature and oxygen.
The salient features are:
  1. Temperature maintenance
    1. Use of portable warming pad under the layers of towels has been suggested.
    2. Placing the preterm <28 weeks gestation below the neck, in a reclosable polyethylene bag, without first drying the skin has been recommended.
    15
    Scientific evidence to effect change: Preterm infants continue to be at risk for significant hypothermia when treated as per the earlier recommendations (Place under radiant warmer, dry, remove wet linen). In addition, few observational studies and two randomized controlled trials confirmed the efficacy of plastic bags or plastic wrapping (food grade heat, resistant plastic), in addition to customary radiant heat, in significantly improving admission temperature of premature babies of less than 28 weeks gestation when compared with standard care. Hence, use of reclosable polythene bag is being recommended.
  2. Oxygen, how much?
    1. The new NRP guideline recommends the use of oxygen blender and pulse oximetry.
    2. The amount of oxygen given initially is anywhere between 21 and 100% and then increased or decreased according to the clinical assessment and the reading from the pulse oximeter.
      1. For initial few minutes a saturation of 70–80% is acceptable as long as O2 saturation is increasing and heart rate is increasing.
      2. If saturation is < 85% and is not increasing then the guideline recommends to increase the concentration of O2 (or to increase the positive pressure if chest wall is not moving).
      3. If saturation is >95%, the NRP guidelines recommend decreasing the concentration of O2.
      4. If heart rate doesn't respond by increasing quickly the new NRP recommends correction of ventilation problems and use of 100% oxygen.
      5. If blender is not available, use of 100% oxygen is recommended.
  3. CPAP
    New guidelines suggest use of CPAP with the flow inflating bag or the T-piece resuscitator if the baby is breathing spontaneously and has a heart rate of >100 bpm but appears to have labored respirations or is cyanotic or having low oxygen saturations.
  4. Surfactant administration
    The new NRP guidelines suggest the administration of surfactant in delivery room in preterms <30 weeks gestation after resuscitation.
    Synopses of the changes advocated in the present guidelines have been outlined along with evidence to this effect wherever applicable. It is apparent that tremendous progress has been made in the recent pass as regards the collection of scientific evidence, its interpretation and translation of the data into guidelines for clinical practice and application.
A large number of gaps in knowledge have been identified and possible issues for research related to resuscitation have been outlined.
This standard uniform action oriented approach to resuscitation aims at providing evidence-based quality care a birth. If applied in a timely appropriate unhurried manner, it is anticipated that this modality alone has the potential to make a difference in the life of 1 million babies. It is strongly recommended that all health personnel involved in the care at birth should be suitably trained and certified in the art, science and skills related to neonatal resuscitation.
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Flow chart: Neonatal resuscitation
REFERENCES
  1. Neonatal resuscitation guidelines. Circulation 2005; 112: IV-188–IV-195.
  1. Kattwinkel J Textbook of neonatal resuscitation, 4th edition, American Academy of Pediatrics and American Heart Association,  Elk Grove Village,  Illinois, 2000.
  1. Summary of Major Changes to the 2005. AAP/AHA Emergency Cardiovascular Care Guidelines for Neonatal Resuscitation: Translating Evidence-based guidelines to the NRP. http://www.aap.org/NRP. Accessed on 12 December 2005.
  1. Kattwinkel J Textbook of Neonatal Resuscitation, 5th edition, American Heart Association,  Elk Grove Village,  Illinois, 2005.