Providing primary resuscitation care to newborns. Principle of resuscitation A. Preparation for providing resuscitation care to a newborn in the delivery room

Any birth, including planned ones, must take place under the supervision of a resuscitator. There are cases when emergency resuscitation of a newborn is required. There are special indications for its implementation.

During childbirth, the baby's body experiences major changes: The cardiac and pulmonary systems, as well as the central nervous system, begin to work differently. Therefore, one wrong move by the obstetricians and the mother in labor can cost the baby her health and even her life. IN emergency situations The baby may need resuscitation to restore his vital functions. The indications for it are:

• asphyxia (observed by the number of inhalations and exhalations). In a healthy newborn, the number of inhalations ranges from 30-60 times per minute;
• low heart rate. In babies born at term, the frequency of contractions of the heart muscle is 120-160 times; if the baby is not full-term or has congenital cardiac pathology, the pulse drops to 100 units or less;
• unhealthy skin color. Ideally, a child is born with a pink tint to the skin; the blueness of the hands and feet persists for the first 90 years of life. If general cyanosis is observed, this is an indicator to carry out primary resuscitation;
• lack of muscle tone. In healthy babies, it persists from birth to 1-2 months, but if there is no tone immediately after birth, doctors regard this as an intrauterine lesion of the central nervous system and resort to the stages of resuscitation;
• lack of innate reflexes. If the baby is born at term without pathologies, he actively reacts to stimulation (wrinkles and cries when pulling mucus from the nose or getting dressed), and when the baby reacts poorly, this is another indicator for intubating the child.

  

  Note! The Apgar scale provides a complete assessment of the newborn's condition. How to do it rightconduct an assessment and what characteristics distinguish this methodology, .

  Resuscitation of a newborn in the delivery room: what it represents, stages

  The Ministry of Health issued an order to resuscitate infants after birth. This is a set of measures aimed at restoring the vital functions of the fetus if it is prematurely removed from the uterus, as well as if difficulties arise during childbirth.

  If the Apgar score is low and cardiopulmonary activity is impaired, it is imperative to nurse the baby with the help of intensive care.

  Children say! A child after watching a cartoon about three heroes:
  - Mom, you’re still not going to the store to pick up your brother, but maybe we’ll at least get a talking horse?

  First, the first stage of resuscitation is carried out: this includes a full assessment of the child’s condition. Meconium aspiration and diaphragmatic hernia are considered an indisputable indicator for measures to save the life of a newborn.

  

  This stage involves resuscitators, an anesthesiologist, a neonatologist and two pediatric nurses. Everyone performs strictly assigned tasks. If the baby does not breathe on its own, they switch to artificial lung ventilation (ALV) until the skin turns pink. If the child's condition remains the same or worsens, proceed to tracheal intubation.

  Note! If the baby still does not take an independent breath within 15-20 minutes of resuscitation measures, the manipulations are stopped and the death of the newborn is recorded. If the dynamics are positive, they move on to the second stage of resuscitation.

  After the respiratory and cardiac functions have been established, the baby is transferred to the intensive care unit and placed in an incubator with oxygen supply. It controls kidney function, heart rate, blood clotting and intestinal function. The presence of protein, calcium and magnesium in the blood is analyzed. The first feeding of a resuscitated newborn is allowed 12 hours after birth with expressed milk. Nutrition is supplied from a bottle or through a tube, depending on the severity of the baby’s condition.

  Similar measures to save the life of a newborn are carried out during home births or when a baby is born in a depressed state. We recommend watching the training video, which shows the algorithm for carrying out all the actions.

  Neonatal resuscitation kit: equipment and medications

  When important vital functions of the baby’s body are restored, he is placed in an incubator so that the head is below the level of the lungs. This prevents fluid from entering the lungs and aspiration of gastric contents, which can lead to inflammatory process and, as a consequence, the development of pneumonia.

  Pulse monitoring is mandatory; for this purpose, a special sensor is attached to the newborn’s wrist or foot, which can quickly determine the state of heart contractions.

  

  A blood test is carried out regularly, which is taken through an installed umbilical catheter; if necessary, an infusion and the necessary medications are administered into it.

  Artificial pulmonary ventilation (ALV) in newborns is controlled by equipment. Proper oxygen supply is important to prevent the breathing valves from sticking. Respiratory support should be no more than 150 breaths per minute with adequate gas flow.

  Children say! The son looked at himself in the mirror for a long time, then sighed heavily and said:
  - I guess I’m still beautiful...

  Movement during incubation chest the newborn should be uniform and rhythmic, without the presence of noise. The presence of noise in the lung tissues or esophagus indicates complications or underformation of tissues and organs. For premature babies whose lungs do not open for a long time, the administration of surfactant is prescribed. When children breathe spontaneously and the pulmonary system continues to work independently, the ventilation device is turned off.

  

  Medicines for neonatal resuscitation in the delivery room

  When resuscitating an infant in in serious condition immediately after birth, they decide to administer medications to prevent cerebral edema after asphyxia and other pathologies affecting vital organs and systems.

  1. Administration of adrenaline to maintain heart rate at a dosage of 0.1-0.3 ml/kg of newborn weight. This solution is used in neonatal resuscitation if the beat frequency is less than 60 beats/min.
  2. Blood substitutes are administered if the baby has a dull heartbeat or pallor skin. Such drugs are saline solution and Ringer's lactate at a dosage of 10 ml/kg of the newborn's body weight.
  3. Use of Narcan. This narcotic drug, which is not allowed for use by infants if the mother is a chronic drug addict or was injected with drugs of similar content several hours before birth.
  4. Glucose injection is acceptable for babies if the mother has chronic diabetes. The dosage of the drug is 2 mg per 1 kg of child weight. Be sure to use 10 percent glucose dissolved in water.
  5. Sodium bicarbonate is used in neonates undergoing resuscitation and ventilation only to maintain normal blood pH. If the drug is administered earlier, the child's condition may worsen.

  Please note that the use of atropine in modern infant resuscitation is not permitted, and this is prescribed in the updated European protocol.

  

  Rehabilitation and nursing of newborns after resuscitation

  Whether the mother can get to the intensive care unit with the newborn and how long he will spend there depends on the complexity of the rescue measures: the more successfully the procedure for restoring vital functions was carried out, the sooner the baby will recover. Now the baby needs careful care and recovery.

  After transferring the baby to a regular ward, it is important for the mother to establish physical contact with him, while trying with all her might to maintain breastfeeding. The more often the baby is in his mother’s arms, the sooner he adapts to the environment.

  Children after long-term resuscitation should eat on time; if they are malnourished, be sure to supplement them with at least 20 cubes of breast milk from a syringe.

  Be sure to watch the video about the stages of recovery after resuscitation.

Neonatal resuscitation and intensive care is a set of therapeutic measures carried out at birth and in the first days of a child’s life in order to remove him from a critical condition, manifested by cardiopulmonary depression at birth: pulse less than 100 beats per minute, hypotension, shortness of breath or apnea. Cardiopulmonary depression occurs in 10-15% of cases; lead to it:

Asphyxia (the most common cause);

Medicines (analgesics and anesthetics) used in obstetrics;

Birth injuries;

Hemorrhagic shock due to intrapartum blood loss due to fetal or feto-maternal transfusion, rupture of umbilical cord vessels;

Congenital diseases of the lungs, heart, central nervous system;

Infectious toxicosis;

Other, unspecified reasons.

What understand under asphyxia newborns?

Asphyxia of newborns is usually understood as follows: pathological condition, in which after birth the child does not have independent breathing or it is shallow and irregular, which does not ensure adequate gas exchange in the body.

What are causes development asphyxia newborns?

Asphyxia of newborns can develop due to fetal hypoxia, airway obstruction due to aspiration of meconium, amniotic fluid, mucus, blood, as well as severe damage to the central nervous system, functional immaturity lung tissue or insufficient production of surfactant, hemodynamic disturbances in the pulmonary circulation and some fetal malformations.

Which factors contribute hypoxia fetus?

A variety of factors - maternal, placental, fetal and the influence of a number of external causes - can lead to hypoxia. Most often, these factors prevent transplacental diffusion of oxygen and carbon dioxide which worsens during childbirth.

What are pathophysiological shifts V body newborns at asphyxia?

During fetal hypoxia, a universal reaction is observed aimed at preserving vital organs and systems. Oxygen deficiency is accompanied by the release of vasoactive substances, which increase peripheral vascular tone and cause fetal tachycardia. There is an increase in blood flow in the placenta, brain, heart, adrenal glands, while at the same time blood flow in the lungs, kidneys, intestines, spleen and skin decreases. Development of metabolic acidosis in conditions of increasing oxygen deficiency leads to disruption of microcirculation and the release of the liquid part of the blood into the tissues. Tissue hypoxia worsens, anaerobic processes and metabolic disorders of glucose, proteins, fats, electrolytes and water predominate.

Electrolyte imbalance in combination with hypoxia and metabolic acidosis has an adverse effect on myocardial function and causes bradycardia.

In case of acute fetal hypoxia, the role of reflex and automatic reactions predominates, aimed at increasing blood flow, increasing cardiac output and changes in excitability respiratory center. During the decompensated stage of acute hypoxia, the fetus develops shock.

How predicted necessity resuscitation newborn?

Acute cerebral ischemia causes damage to the brainstem, basal ganglia and cerebral cortex of the fetus and newborn. Damage to muscles, kidneys and intestines is preceded by changes in the central nervous system and myocardium. Therefore the staff maternity ward must be prepared to provide timely resuscitation assistance in advance.

The birth of a child with asphyxia or cardiopulmonary depression can be predicted based on an analysis of perinatal risk factors (O. G. Frolova, E. I. Nikolaeva, 1981). Antenatal risk includes: late gestosis, diabetes, hypertension syndromes, Rh sensitization and a history of stillbirth, maternal infection, bleeding in the second and third III trimesters pregnancy, polyhydramnios and oligohydramnios, fetal growth retardation, post-term pregnancy, multiple pregnancies, maternal use of drugs, alcohol and certain medications (reserpine, adrenergic blockers, magnesium sulfate).

The group of intranatal risk factors includes: premature, delayed and operative birth, pathological presentation and fetal position, placental abruption and placenta previa, prolapse of umbilical cord loops, anomaly labor activity, use of anesthesia, infection during labor and the presence of meconium in amniotic fluid.

The determining factor in the effectiveness of resuscitation is readiness medical personnel and maternity hospital equipment. When the birth of a child with asphyxia is predicted, maternity ward a team of two trained specialists must be present. Special meaning for a newborn has the preparation of an optimal temperature environment.

When providing care to a newborn in the delivery room, it is important to maintain consistency in the implementation of a set of measures. Firstly, forecasting resuscitation measures and preparing for them. Next is the restoration of airway patency, adequate breathing and cardiac activity. Then the issue of using medications is decided.

How And When held grade functional state

newborn at birth?

Grade functional state of a newborn at birth is carried out at the 1st and 5th minutes of life on the Apgar scale. Five objective signs are assessed at O, 1 and 2 points. The sum of the scores of all 5 signs represents the Apgar score. Average degree pulmonary-cardiac depression is determined by a score of 4-5 points, 0-3 points - severe depression. Assessments at 1 and 5 minutes correlate with survival, and at 10-20 minutes - with the neurological development of the child in the first year of life.

However, immediately after birth, a decision is made to carry out resuscitation measures. Resuscitation is not delayed for a minute.

Signs of live birth include: spontaneous breathing, heartbeat, pulsation of the umbilical cord and voluntary muscle movements. If all 4 signs are absent, the child is considered stillborn. If at least one of the signs is present, the newborn is immediately provided with primary resuscitation care.

What is methodology carrying out primary resuscitation?

Before resuscitation, hands are thoroughly washed with soap and a brush, treated with an antiseptic and gloves are worn. The time of birth of the child is recorded. The child is thoroughly dried with a dry and warm diaper and placed under a source of radiant heat. To ensure airway patency, it can be laid on the left side and the head end of the table lowered down. The supine position often aggravates airway obstruction. The contents of the oropharynx and then the nasal passages are sucked out. Rough and deep sanitation of the oropharynx should be avoided. Catheterize the stomach and aspirate its contents no earlier than after 5 minutes. If these actions are ineffective or if meconium aspiration occurs, the trachea is sanitation with an endotracheal tube under the control of direct laryngoscopy (at a vacuum of no more than 0.1 atm). If the child does not recover spontaneous breathing after wiping and sanitation, gentle tactile stimulation of the heels and feet should be performed. If the child's cyanosis persists,

placed in a 100% oxygen environment at a gas flow of 5 ml/min.

Primary or secondary apnea, independent but inadequate breathing are indications for transferring the child to artificial ventilation.

How held ventilation lungs?

Ventilation of the lungs is carried out using a bag or mask. You can use a self-expanding bag and an anesthesia machine bag. The newborn's head is slightly extended and a mask is tightly placed on the face, which is held with the thumb and forefinger and the curve of the palm of the left hand. The mask should cover the chin, mouth and nose. The remaining fingers guide the child's jaw. A ventilation rate of 30-50 per minute is sufficient. When carrying out the first breaths, a pressure of 30-50 cm of water is used. Art., then 15-20 cm is enough. The heart rate is restored after 1 5-30 seconds. When ventilating with a bag, bloating may appear in the abdomen, which disappears after inserting a tube into the stomach.

Excursion of the chest and an increase in heart rate indicate the effectiveness of the measures taken. Independent regular breathing of a newborn can be assessed by heart rate (HR) by auscultation of heart sounds, palpation of the apical impulse or pulse in the carotid and femoral arteries. If the heart rate is less than 100 per minute, mechanical ventilation (artificial pulmonary ventilation) is continued using a mask with 100% oxygen until the heart rate normalizes. Restoration of cardiac activity (heart rate more than 100 per minute) and ongoing cyanosis of the skin and visible mucous membranes are an indication for mask ventilation with 100% oxygen. The child continues to be monitored. Cyanosis of the feet and hands is not a contraindication to placing the baby on the mother's breast.

When And How intubated trachea?

Failure to ventilate a child using a bag or mask for 1 minute is an indication for tracheal intubation. Before intubation, a tube is selected the right size depending on body weight and gestational age

child's age (from 2.5 to 4.0) - When intubating a premature baby, the endotracheal tube is cut at the 1-3 cm mark. You can use a guide, but you should not push it beyond the tip of the tube. Laryngoscopy and tracheal intubation are performed in no more than 20 seconds.

After turning on the laryngoscope lighting, it is taken into left hand holding the baby's head right hand. The laryngoscope blade is inserted between the tongue and the hard palate and advanced to the base of the tongue. By carefully lifting the blade towards the handle of the laryngoscope, you can see the glottis, bounded by the vocal cords and epiglottis. The endotracheal tube is inserted into the oral cavity on the right side at the moment the vocal cords open during inhalation, and is passed to the mark indicating the required insertion depth. The laryngoscope and guidewire are sequentially removed and the correct position of the endotracheal tube is checked by compressing the breathing bag. One can note symmetrical movements of the chest, absence of movements and bloating of the abdomen during inspiration, and during auscultation of the chest - breathing on both sides. During tracheal intubation, a stream of oxygen is delivered to the child's face to reduce hypoxia.

To improve the organization and quality of primary resuscitation care for newborns in the maternity ward since 1996, according to the Order of the Ministry of Health Russian Federation It is mandatory to follow the protocol and fill out the primary resuscitation card by a doctor or, in his absence, a midwife.

When And How carry out indirect massage hearts?

The indication for chest compressions is a heart rate of less than 80 per minute. Indirect cardiac massage can be performed using the index and middle fingers (or middle and ring fingers) or by clasping the chest with the thumbs of both hands. Pressure is carried out at the border of the lower and middle third with an amplitude of 1.5-2 cm and a frequency of 1 20 per minute (2 pressures per second).

The next stage of resuscitation measures is the administration of volumetric drugs and medications.

Which drugs And V what cases use at primary resuscitation newborns? For these purposes, solutions are used: - to replenish the deficit in circulating blood volume: 5% albumin solution, isotonic solution sodium chloride and Ringer's lactate;

4% sodium bicarbonate solution;

Adrenaline solution diluted 2:10,000. How carried out catheterization umbilical veins?

For catheterization of the umbilical vein, umbilical catheters 3.5-4 Fr or 5-6 Fr (No. 6 and No. 8) with one hole at the end are used. The catheter is inserted to a depth of 1-2 cm from the skin level. It is better to remove it immediately after resuscitation measures.

What serves indication For carrying out medicinal therapy?

Absence of heartbeat or bradycardia (heart rate less than 80 per minute) against the background of mechanical ventilation and chest compressions for 30 seconds.

Adrenalin can be administered to increase the strength and frequency of heart contractions and to relieve vasospasm in critically ill newborns. It is administered through an endotracheal tube or through a catheter inserted into the tube, followed by rinsing with a sodium chloride solution. For a more uniform distribution in the lungs and sufficient absorption of adrenaline, mechanical ventilation is continued for some time. Adrenaline can be injected as a stream into the umbilical cord vein and repeated as needed every 5 minutes.

Solutions For replenishment BCC used for acute blood loss or hypovolemia, which is manifested by pallor of the skin, weak pulse, pale spot symptom for more than 3 seconds, low blood pressure and lack of effect from resuscitation measures.

Solutions are injected into the umbilical cord vein at a rate of 10 ml/kg slowly over 5-10 minutes. These measures allow you to replenish your blood volume, improve tissue metabolism, thereby reducing metabolic acidosis. Normalization of pulse, improvement of skin color and increase in blood pressure

indicate effectiveness infusion therapy. You can repeat the infusion of one of these solutions if signs of circulatory disorders persist. The child may maintain bradycardia of less than 80 beats per minute, and decompensated metabolic acidosis is diagnosed. Only in these cases, a 4% sodium bicarbonate solution (2.5 mEq/kg or 4 ml/kg) is injected into the umbilical cord vein. Typically, sodium bicarbonate solution is used in cases of severe chronic hypoxia of the fetus and newborn only against the background of successful mechanical ventilation.

When stop primary resuscitation newborn?

If, against the background of primary resuscitation measures, the child’s heartbeat does not recover within 20 minutes, then resuscitation measures stop.

Resuscitation in the delivery room is only primary emergency assistance children with cardiorespiratory depression. It is necessary to continue observation and place the child in the intensive care unit for continued treatment. Successfully performed primary resuscitation does not prevent possible post-hypoxic complications and unfavorable outcome.

What are complications after transferred critical state?

These include metabolic disorders: lactic acidosis can persist for a long time, causing insufficiency of cardiac output and impaired peripheral blood flow. Alkalies and dopamine are used for therapeutic purposes.

Hypoglycemia occurs, which is corrected by the administration of glucose (8 ml/kg/min), and hypocalcemia. Only for convulsions is correction performed with calcium gluconate.

Complications from the central nervous system are manifested by cerebral edema, convulsions, coma and insufficient secretion of antidiuretic hormone due to excessive volumes of injected fluid, hemorrhage or cerebral infarction.

Acute renal failure caused by acute tubular (less often medullary and cortical) necrosis or

thrombosis renal vein. These conditions are treated with careful fluid and electrolyte management. After asphyxia, atony of the bladder may develop, which requires its emptying even by catheterization.

Myocardial damage can lead to hypertension, small output syndrome, and persistent metabolic acidosis. These conditions are diagnosed by radiographs, revealing an increase in the size of the heart. Echocardiography shows impaired ventricular function. Careful calculations of infusion volumes and amounts of electrolytes, the use of cardiotonic drugs, oxygen and alkali make it possible to stop these complications.

Complications from the lungs include respiratory distress syndrome, hypertension, and impaired fluid utilization by the lungs. A picture of shock lung and pneumothorax may develop. Meconium aspiration and septic conditions cause and complicate hypoxia.

In the long-term post-resuscitation period, other changes in the central nervous system, disorders water-salt metabolism, adrenal insufficiency and other insufficiency endocrine organs, dysfunction of the liver and gastrointestinal tract.

Which therapy held at availability neurological violations?

Diagnosis and treatment must be comprehensive, taking into account the cause and clinical features. Convulsions occur in 0.1 -1.5% of cases and are a prognostically significant symptom. The cause of tonic and myoclonic convulsions can be hypoxic-ischemic lesions of the central nervous system. Focal lesions of brain structures (infarction, intracerebral and subarachnoid hemorrhages) are accompanied by clonic convulsions. They develop with disturbances in the metabolism of potassium, magnesium, sodium and pyridoxine, hypoglycemia, birth defects metabolism. The causes of seizures in newborns can be infections, withdrawal syndrome due to maternal drug addiction, toxic conditions, etc.

Children undergo EEG studies. The diagnosis is differentiated based on an assessment of family and perinatal history, physical data, biochemical studies

blood parameters, gas composition, antibody titer to TORCH-complex infections, lumbar puncture, ultrasound, EEG and others special research CNS.

Addressing the underlying cause is the cornerstone of treating seizures. Correction of metabolic disorders is carried out with solutions of glucose, calcium gluconate, magnesium sulfate and pyridoxine hydrochloride. For metabolic acidosis, sodium bicarbonate is used. Removal of toxins is carried out using exchange transfusions and peritoneal dialysis. CNS infections are treated with antibacterial drugs.

Anticonvulsant therapy may not be effective in some children. Phenobarbital up to 20 mg/kg body weight is used as an anticonvulsant. Specific EEG findings are an indication for the use of other anticonvulsants.

Intraventricular hemorrhage (IVH) is manifested by shock, acidosis, pallor of the skin and anemia, apnea, bradycardia, convulsions and other various neurological symptoms. Most hemorrhages are asymptomatic. About 50% of IVH develop in the first day, the same amount in the first three days. There are: subependimal IVH (1st degree), without dilatation of the ventricles of the brain (2nd degree), with dilatation of the ventricles (3rd degree) and hemorrhage in the brain tissue (4th degree). A complication of IVH in most cases is hydrocephalus.

Prevention of premature birth, adequate protocol for primary resuscitation, stabilization of hemodynamics and blood volume, maintenance of normal arterial and intraventricular pressure, neurosonographic monitoring of the expansion of the ventricles of the brain can prevent serious neurological complications.

Treatment of slowly increasing dilation of the ventricles of the brain is carried out with drugs that reduce the production of cerebrospinal fluid (diacarb 10-60 mg/kg/day) or osmotic diuretics (glycerol). In children who have suffered severe IVH, the mortality rate is 50%, in 10% of survivors, hydrocephalus develops, and all have manifestations of encephalopathy.

Which medicinal Events must be applied at newborns With syndrome respiratory disorders (HAPPY BIRTHDAY)? The goal of SDR therapy is to relieve respiratory failure and prevention of its complications.

A newborn with SDD must be given correct position in the crib. He should lie with his shoulder girdle raised and his head slightly thrown back and turned to the side. It is necessary to turn the child more often. The upper respiratory tract is often cleared of mucus using a catheter and suction. Until the symptoms of hypoxia completely disappear, oxygenation is carried out with warmed and humidified oxygen.

In low birth weight newborns with immature lungs that are unable to synthesize and secrete surfactant (leading to atelectasis), type I SDR most often occurs. The risk group for the development of type I SDD includes children with diabetic fetopathy and those born with asphyxia.

SDR type II occurs when the lungs are unable to stop producing fluid after birth. Meconium aspiration occurs in a small number of children when intrauterine water is stained with meconium.

Clinical and radiological monitoring help to diagnose the features and dynamics of SDR and timely correct therapy. Increasing respiratory failure and the appearance of infiltrates on a chest X-ray are indications for percussion vibration massage chest every 3-4 hours. In severe SDR type I, exogenous surfactant is used in the first hours of life. It is administered into the respiratory tract once in the form of a suspension in saline solution. Corticosteroids promote the maturation of the lung surfactant system. Optimal function external respiration is achieved by normalizing tidal volume and preventing collapse of the lungs during exhalation. Ventilation parameters are controlled by the child’s blood gas composition and x-ray examination. An important point prevention and treatment of SDD is feeding the child with native mother's milk from the first minutes or hours of life. Depending on the severity of the condition, methods and volumes of administration of milk are chosen.

res probe. Mother's native milk promotes the production of its own surfactant, provides calories, water-electrolyte, hormonal and metabolic balance of the child's body.

What are causes And therapy cordially- vascular violations in newborns?

In heart failure, metabolism is incomplete. The main reasons are: disorders of myocardial contractility, conduction disturbances and increased load (pressure and filling volume). This is accompanied by increased cardiac output and dysfunction of both the left and right parts of the heart. In cases of predominant heart failure, the child is provided with a positive nitrogen balance, diuretics, digoxin and metabolic drugs are used. Cardiogenic shock develops with a complicated course of asphyxia, acidosis, hypoglycemia, congenital heart defects, impaired myocardial function, low levels of potassium and calcium in the blood, as well as in the final stages of other types of shock (hypovolemic, septic and hypotensive).

Which therapy held newborns With insufficiency functions adrenal glands?

The presence of adrenal suppression requires replacement therapy. Collapse with severe depression general condition is an indication for the use of hydrocortisone 5 mg/kg. Quick effect provides intravenous administration of the drug.

Resuscitation of newborns in the delivery room is based on a strictly defined sequence of actions, including predicting the occurrence of critical situations, assessing the condition of the child immediately after birth and carrying out resuscitation measures aimed at restoring and maintaining respiratory and circulatory function.

Predicting the likelihood of a child being born with asphyxia or drug-induced depression is based on an analysis of antenatal and intrapartum history.

Risk factors

Antenatal risk factors include maternal diseases such as diabetes mellitus, hypertension syndromes, infections, and maternal drug and alcohol use. Among the pathologies of pregnancy, it should be noted polyhydramnios or oligohydramnios, postmaturity, intrauterine growth retardation and the presence multiple pregnancy.

Intrapartum risk factors include: premature or delayed birth, abnormal presentation or position of the fetus, placental abruption, prolapse of umbilical cord loops, use of general anesthesia, anomalies of labor, the presence of meconium in the amniotic fluid, etc.

Before resuscitation begins, the child’s condition is assessed based on the following signs of live birth:

• the presence of spontaneous breathing,
• heartbeat,
• umbilical cord pulsations,
• voluntary muscle movements.

If all 4 signs are absent, the child is considered stillborn and cannot be resuscitated. The presence of at least one sign of live birth is an indication for the immediate initiation of resuscitation measures.

Resuscitation algorithm

The resuscitation algorithm is determined by three main features:

• the presence of independent breathing;
• heart rate;
• skin color.

The Apgar score is assessed, as was customary, at the 1st and 5th minutes to determine the severity of asphyxia, but its indicators do not have any effect on the volume and sequence of resuscitation measures.

Primary care newborns in the maternity hospital

Initial activities (duration 20-40 s).

In the absence of risk factors and clear amniotic fluid, the umbilical cord is cut immediately after birth, the baby is wiped dry with a warm diaper and placed under a radiant heat source. If there is a large amount of mucus in the upper respiratory tract, then it is suctioned from oral cavity and nasal passages using a balloon or catheter connected to an electric suction device. In the absence of breathing, light tactile stimulation is carried out by patting the feet 1-2 times.

In the presence of asphyxia factors and pathological impurities in the amniotic fluid (meconium, blood), aspiration of the contents of the oral cavity and nasal passages is performed immediately after the birth of the head (before the birth of the shoulders). After birth, pathological impurities are aspirated from the stomach and trachea.

I. First assessment of condition and action:

A. Breathing.

Absent (primary or secondary epnea) - start mechanical ventilation;

Independent, but inadequate (convulsive, superficial, irregular) - start mechanical ventilation;

Independent regular - assess heart rate (HR).

B. Heart rate.

Heart rate less than 100 beats per minute. - carry out mask ventilation with 100% oxygen until heart rate normalizes;

B. Skin color.

Completely pink or pink with cyanosis of the hands and feet - observe;

Cyanotic - inhale 100% oxygen through a face mask until cyanosis disappears.

Mechanical ventilation technique

Artificial ventilation is carried out with a self-expanding bag (Ambu, Penlon, Laerdal, etc.) through a face mask or endotracheal tube. Before starting mechanical ventilation, the bag is connected to an oxygen source, preferably through a gas mixture humidifier. Place a cushion under the child's shoulders and tilt his head slightly back. The mask is applied to the face so that the upper part of the obturator rests on the bridge of the nose, and the lower part on the chin. When pressing on the bag, the excursion of the chest should be clearly visible.

Indications for the use of an oral airway during mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the inability to ensure free patency of the airways when the child is positioned correctly.

Tracheal intubation and switching to mechanical ventilation through an endotracheal tube are indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation within 1 minute, as well as apnea or inadequate breathing in a child with a gestational age of less than 28 weeks.

Artificial ventilation is carried out with a 90-100% oxygen-air mixture with a frequency of 40 breaths per minute and an inhalation to exhalation time ratio of 1:1.

After ventilation of the lungs for 15-30 seconds, the heart rate is again monitored.

If the heart rate is above 80 per minute, continue mechanical ventilation until adequate spontaneous breathing is restored.

If the heart rate is less than 80 beats per minute, while continuing mechanical ventilation, begin chest compressions.

Indirect cardiac massage technique

The child is placed on a hard surface. Using two fingers (middle and index) of one hand or two thumbs of both hands, apply pressure on the border of the lower and middle third of the sternum with a frequency of 120 per minute. The displacement of the sternum towards the spine should be 1.5-2 cm. Ventilation of the lungs and cardiac massage are not synchronized, i.e. Each manipulation is carried out in its own rhythm.

30 seconds after the start of closed cardiac massage, the heart rate is again monitored.

If the heart rate is above 80 beats per minute, stop cardiac massage and continue mechanical ventilation until adequate spontaneous breathing is restored.

If the heart rate is below 80 per minute, continue chest compressions, mechanical ventilation and begin drug therapy.

Drug therapy

If asystole or heart rate is below 80 beats per minute, adrenaline is immediately administered at a concentration of 1:10,000. To do this, 1 ml of ampoule solution of adrenaline is diluted in 10 ml saline solution. The solution prepared in this way is taken in an amount of 1 ml into a separate syringe and injected intravenously or endotracheally at a dose of 0.1-0.3 ml/kg body weight.

Heart rate is re-monitored every 30 seconds.

If heart rate recovers and exceeds 80 beats per minute, stop cardiac massage and administration of other medications.

If there is asystole or heart rate below 80 beats per minute, continue chest compressions, mechanical ventilation and drug therapy.

Repeat the administration of adrenaline at the same dose (if necessary, this can be done every 5 minutes).

If the patient has signs of acute hypovolemia, which is manifested by pallor, weak thready pulse, low blood pressure, then the child is advised to administer a 5% albumin solution or saline solution at a dose of 10-15 ml/kg body weight. Solutions are administered intravenously over 5-10 minutes. If signs of hypovolemia persist, repeated administration of these solutions in the same dose is permissible.

Administration of sodium bicarbonate is indicated for confirmed decompensated metabolic acidosis (pH 7.0; BE -12), as well as in the absence of effect from mechanical ventilation, cardiac massage and drug therapy(suspected severe acidosis preventing cardiac recovery). Sodium bicarbonate solution (4%) is injected into the umbilical cord vein at the rate of 4 ml/kg body weight (2 mEq/kg). The rate of drug administration is 1 mEq/kg/min.

If within 20 minutes after birth, despite full resuscitation measures, the child’s cardiac activity is not restored (no heartbeats), resuscitation in the delivery room is stopped.

At positive effect from resuscitation measures, the child should be transferred to the intensive care unit (ward), where specialized treatment will continue.

Primary neonatal resuscitation

Death is the death of body cells due to the cessation of their supply of blood, which carries oxygen and nutrients. Cells die after sudden stop heart and breathing, although quickly, are not instantaneous. The cells of the brain, especially the cortex, that is, the department on the functioning of which consciousness, spiritual life, and human activity as an individual depend, suffer most from the cessation of oxygen supply.

If oxygen does not enter the cells of the cerebral cortex within 4–5 minutes, they are irreversibly damaged and die. Cells of other organs, including the heart, are more viable. Therefore, if breathing and blood circulation are quickly restored, the vital activity of these cells will resume. However, this will only be the biological existence of the organism, consciousness, mental activity either they will not be restored at all, or they will be profoundly changed. Therefore, the revival of a person must begin as early as possible.

That is why everyone needs to know the methods of primary resuscitation of children, that is, to learn a set of measures to provide assistance at the scene of an incident, prevent fatal outcome and revitalization of the body. It is everyone’s duty to be able to do this. Inactivity while waiting for medical workers, no matter what its motivation - confusion, fear, inability - should be considered as a failure to fulfill a moral and civic duty towards a dying person. If this concerns your beloved baby, it is simply necessary to know the basics of resuscitation care!

Carrying out resuscitation for a newborn

How is primary resuscitation of children performed?

Cardiopulmonary and cerebral resuscitation (CPCR) is a set of measures aimed at restoring the basic vital functions of the body (heart and breathing) impaired in terminal conditions in order to prevent brain death. This resuscitation is aimed at reviving a person after breathing has stopped.

The leading causes of terminal conditions that developed outside medical institutions, V childhood are a syndrome sudden death newborns, car trauma, drowning, obstruction of the upper respiratory tract. The maximum number of deaths in children occurs under the age of 2 years.

Periods of cardiopulmonary and cerebral resuscitation:

• The period of basic life support. In our country it is called the immediate stage;
• Period of further life support. It is often referred to as a specialized stage;
• The period of prolonged and long-term life support, or post-resuscitation.

At the stage of basic life support, techniques are performed to replace (“prosthetics”) the vital functions of the body - the heart and breathing. In this case, the events and their sequence are conventionally designated by a well-remembered abbreviation of three English letters ABS:

- from English airway, literally opening the airways, restoring airway patency;

– breath for victim, literally – breathing for the victim, mechanical ventilation;

– circulation his blood, literally – ensuring his blood flow, external massage hearts.

Transportation of victims

Functionally justified for transporting children is:

• with severe hypotension - horizontal position with the head end lowered by 15°;
• in case of damage to the chest, acute respiratory failure of various etiologies - semi-sitting;
• in case of spinal injury – horizontal on the backboard;
• for fractures pelvic bones, damage to the abdominal organs - legs bent at the knees and hips; joints and spread to the sides (“frog position”);
• for injuries of the skull and brain with lack of consciousness - horizontal on the side or on the back with the head end raised by 15°, fixation of the head and cervical spine spine.

Should be provided in all medical institutions where childbirth could potentially occur. Work in the maternity ward should be organized in such a way that in cases of cardiopulmonary resuscitation the employee who conducts it from the first minute could have been assisted by at least two other medical workers.

Antenatal risk factors for the development of newborn asphyxia.

1. Diabetes mellitus

2. Preeclampsia

3. Hypertensive syndromes

4. Rhesus sensitization

5. History of stillbirth

6. Clinical signs maternal infections

7. Bleeding in the second and third trimester of pregnancy

8. Polyhydramnios

9. Low water

10. Multiple pregnancy

11. Intrauterine growth restriction

12. Maternal drug and alcohol use

13. Use of drugs that depress the breathing of a newborn (promedol)

14. Presence of developmental anomalies

15. Abnormal CTG readings before childbirth.

Intrapartum risk factors

1. Premature birth up to 37 weeks

2. Late birth beyond 42 weeks

3. Caesarean

4. Placental abruption

5. Placenta previa

6. Loss of umbilical cord loops

7. Pathological position of the fetus

8. General anesthesia

9. Anomaly of labor

10. Presence of miconium in amniotic fluid

11. Fetal heart rhythm disturbances

12. Histocia of the shoulders

13. Instrumental birth - forceps, vacuum extraction

In cases where the birth of a child is predicted to be up to 32 weeks of gestation, a resuscitation team should be on duty in the delivery room. After the birth of a child, it is necessary to record the time of his birth and begin resuscitation measures, regardless of the initial condition of the newborn. Apgar score at the first and fifth minutes of life and at 10 minutes. Amount of 8 or more points is satisfactory. Condition, 4-7 moderate asphyxia

The protocol for primary resuscitation of newborns includes

1. Initial measures - restoration of airway patency

2. Artificial ventilation

3. Indirect cardiac massage

4. Administration of medications

The child’s condition in the first minutes of life is assessed according to three criteria:

1. Presence and nature of spontaneous breathing

2. Heart rate

3. Skin color

Criteria for the effectiveness of resuscitation are:

1. Regular effective spontaneous breathing

2. Heart rate more than 100 beats/min.

Initial activities include:

1. Maintaining body temperature - drying children over 28 weeks is simply blotted with a diaper; if up to 28 weeks - wet, they are placed in a plastic bag with a slit for the head.

2. Sanitation of the oropharynx is indicated only for those newborns who have not developed independent breathing during the first 10 minutes of life or who have a large amount of discharge.

3. Tactile stimulation - carried out either by patting the feet or stroking the back.

4. Artificial ventilation. Indications for mechanical ventilation: 1. Lack of breathing, 2. Irregular breathing, 3. Heart rate less than 100 beats/min.

Immediate inbation:

1. Children with suspected diaphragmatic hernia

2. Children born with an admixture of myconium in the amniotic fluid or with depressed spontaneous breathing

3. For children born before 27 weeks for the purpose of prophylactic administration of sulfoctant.

Evaluation of the effectiveness of mechanical ventilation through a face mask

The main criterion for effectiveness is a heart rate of more than 100. It must be assessed 30 seconds after the start. The heart rate assessment lasts 6 seconds.

Heart rate less than 60 - intubation is performed and mechanical ventilation begins using a tube. If you can’t intubate within 20 seconds, continue to breathe through the mask and then try to intubate again.

If bradycardia persists, chest compressions are started against the background of mechanical ventilation through a tube.

The heart rate is more than 60 but less than 100 - mechanical ventilation continues for another 30 seconds, then the heart rate is assessed; if bad - intubation.

Heart rate is more than 100 - continue mechanical ventilation until spontaneous breathing is restored.

Indications for tracheal intubation

1. Children with suspected diaphragmatic hernia.

2. Children with meconium in the amniotic fluid in the absence of spontaneous breathing

3. Children born before 27 weeks for the purpose of professional administration of suloctant.

4. If mask ventilation is ineffective when the heart rate is less than 60 for 30 seconds.

5. If effective mask ventilation is insufficient, if from 60 to 100 for 60 seconds.

6. If necessary, perform indirect cardiac massage.

Indirect cardiac massage

1. The frequency of ventilation to compressions is 3:1.

2. After the massage begins, 30 seconds later we evaluate the heart rate - if it is more than 60, then stop the indirect cardiac massage, if below 60, then continue.

Drug therapy

Adrenaline if the frequency is less than 60 after 30 seconds of indirect massage. 0.3 ml per kg body weight.

Saline solution - acute blood loss or hypovolumia - 10 ml per kg slowly.

sodium bicarbonate acidosis, lack of effect from the above. 4 ml per kg of 4% solution at a rate of 2 ml per kg per minute. End of resuscitation 10 minutes from the start of the measures taken, if not effective.

1. General principles

Immediately after the birth of the head, mucus is removed from the nasopharynx and oropharynx of the fetus using a rubber bulb or a catheter connected to a special suction. When the baby is fully born, he is wiped dry with a sterile towel. After spontaneous breathing appears or the pulsation of the umbilical cord ceases, a clamp is applied to the umbilical cord and the newborn is placed in an incubator, giving him a position with the head end slightly lowered. In case of obvious asphyxia, the umbilical cord is immediately clamped and resuscitation is started. Normally, a newborn takes his first breath within 30 seconds after birth, and stable spontaneous breathing is established within 90 seconds. The normal respiratory rate is 30-60/min, and heart rate is 120-160/min. Breathing is assessed by auscultation of the lungs, heart rate - by auscultation of the lungs or palpation of the pulse at the base of the umbilical cord.

In addition to breathing and heart rate, it is necessary to evaluate the color of the skin, muscle tone and reflex excitability. The generally accepted method is to assess the child’s condition on the Apgar scale (Table 43-4), carried out at the 1st and 5th minute of life. The Apgar score at 1 minute of life correlates with survival, and at 5 minutes - with the risk of neurological disorders.

The norm is an Apgar score of 8-10 points. Such children need only mild stimulation (patting the feet, rubbing the back, vigorously drying with a towel). The catheter is carefully passed through each nasal passage to exclude choanal atresia, and through the mouth into the stomach to exclude esophageal atresia.

2. Meconium in amniotic fluid

An admixture of meconium in amniotic fluid is observed in approximately 10% of all births. Intrauterine hypoxia, especially at a gestational age of more than 42 weeks, is often associated with thick meconium staining of the amniotic fluid. With intrauterine hypoxia, the fetus experiences deep convulsive breaths, during which meconium, along with amniotic fluid, can enter the lungs. During the first breaths after birth, meconium moves from the trachea and main bronchi to the small bronchi and alveoli. Thick meconium or containing solid particles can close the lumen of the small bronchi, which causes severe respiratory failure, which occurs in 15% of cases when meconium is mixed in the amniotic fluid. In addition, with this complication there is a high risk of persistence of the fetal type of circulation (Chapter 42).

If the amniotic fluid is lightly stained with meconium, sanitation of the respiratory tract is not required. If amniotic fluid thickly stained with meconium ( pea soup), then immediately after the birth of the head, before removing the shoulders, the obstetrician must quickly suck out the contents of the nasopharynx and oropharynx using a catheter. Immediately after birth, the newborn is placed on a heated table, the trachea is intubated and the tracheal contents are aspirated. A special suction is connected directly to the endotracheal tube, which is slowly removed. If meconium is detected in the trachea, intubation and aspiration of the contents are continued until it stops flowing through the tube - but no more than three times, after which further attempts cease to be effective. A mask is placed near the newborn's mouth through which humidified oxygen is supplied. It is also necessary to suction the stomach contents to prevent passive regurgitation of meconium. Meconium aspiration is a risk factor for pneumothorax (the incidence of pneumothorax with meconium aspiration is 10%, while with vaginal delivery it is 1%).

3. Asphyxia of the newborn

To resuscitate a newborn, it is necessary to: at least two people: one ensures airway patency and conducts

TABLE 43-4. Apgar score

Ventilator, the second performs indirect cardiac massage. The participation of a third person, who catheterizes the vessels, introduces medications and infusion solutions.

The most common cause of asphyxia in a newborn is intrauterine hypoxia, so the key to resuscitation is to normalize breathing. One more important reason asphyxia is hypovolemia. Causes of hypovolemia: too early clamping of the umbilical cord, too high position of the child relative to the birth canal at the time of clamping the umbilical cord, prematurity, bleeding in the mother, crossing the placenta during caesarean section, sepsis, cross-circulation in twins.

If the neonate's condition does not improve despite adequate respiratory resuscitation, vascular access and gas analysis should be performed. arterial blood; pneumothorax should be excluded (prevalence 1%) and congenital anomalies respiratory tract, including tracheoesophageal fistula (1:3000-5000 newborns) and congenital diaphragmatic hernia (1:2000-4000).

The Apgar score in the 1st minute of life allows you to standardize the approach to resuscitation measures: (1) mild asphyxia (5-7 points): stimulation (wiping the body, patting the feet, sanitation of the respiratory tract) is indicated in combination with inhalation pure oxygen through a face mask located near the mouth; (2) moderate asphyxia (3-4 points: mechanical ventilation with a breathing bag through a mask is indicated; (3) severe asphyxia (0-2 points): immediate tracheal intubation is indicated, external cardiac massage may be required.

Indications for mechanical ventilation in a newborn: (1) apnea; (2) Heart rate

If, despite adequate ventilation, the heart rate does not exceed 80/min, then closed cardiac massage is indicated.

For tracheal intubation (Fig. 43-3), a Miller laryngoscope is used. The size of the laryngoscope blade and endotracheal tube depends on the child’s weight: 2 kg - 1 and 3.5 mm. If the tube is selected correctly, then at a pressure in the respiratory tract of 20 cm of water. Art. there is a slight discharge of the respiratory mixture. Intubation of the right main bronchus is ruled out by auscultation. The depth of insertion of the endotracheal tube (from its distal end to the child’s lips) is calculated as follows: add 6 to the child’s weight in kilograms, the result is expressed in centimeters. It is advisable to perform pulse oximetry using a handheld sensor. Using a transcutaneous oxygen tension monitoring device is also quite informative, but setting it up takes a lot of time.

External cardiac massage

External cardiac massage is indicated when, after 30 seconds of adequate mechanical ventilation with 100% oxygen, the heart rate is
Cardiac massage is performed simultaneously with mechanical ventilation with 100 oxygen. The frequency of compressions on the sternum should be 90-120/min (Fig. 43-4). Cardiac massage technique described for children younger age(Chapter 48), can be used for newborns weighing > 3 kg. The ratio of the frequency of pressure and blowing should be 3:1, so that 90 pressures and 30 blows are performed within 1 minute. It is necessary to periodically check your heart rate. When heart rate > 80/min, indirect cardiac massage is stopped.

Rice. 43-3. Intubation of a newborn. The head is placed in a neutral position. The laryngoscope is held between the large and index finger left hand, holding the middle and ring chin. The little finger of the left hand presses on the hyoid bone, which helps to see vocal cords. The best view is provided by a straight blade, for example, Miller laryngoscope No. 0 or No. 1

Vascular access

Most optimal method Vascular access involves installing a 3.5F or 5F catheter into the umbilical vein. It is necessary that the distal tip of the catheter is located directly below the skin level and the reverse flow of blood when pulling the syringe plunger is free; transfused for deeper insertion hypertonic solutions can go directly to the liver.

Catheterization of one of the two umbilical arteries, which allows for blood pressure monitoring and facilitates arterial blood gas analysis, is technically more difficult. Special catheters have been developed for the umbilical artery, allowing not only to measure blood pressure, but also to carry out long-term monitoring of PaO2 and SaO2. Needs to be done necessary measures to prevent air from entering the vein or artery.

Infusion therapy

Of the newborns who require resuscitation, some full-term and two-thirds of preterm infants are hypovolemic. Hypovolemia is diagnosed by arterial hypotension and pale skin in combination with a poor response to resuscitation measures. In newborns, blood pressure correlates with blood volume, so all newborns should have their blood pressure measured. Normally, blood pressure depends on weight and ranges from 50/25 mm Hg. Art. (weight 1-2 kg) up to 70/40 mm Hg. Art. (weight > 3 kg). Arterial hypotension indicates hypovolemia. To replenish the bcc, red blood cells of group 0(I) Rh (neg) are used, combined with maternal blood, or a 5% albumin solution or Ringer's solution with lactate at a dose of 10 ml/kg. More rare causes arterial hypotension include hypocalcemia, hypermagnesemia and hypoglycemia.

Rice. 43-4. Indoor massage hearts in a newborn. Both hands clasp the newborn so that the thumbs are located on the sternum immediately below the line connecting both nipples, and the remaining fingers are closed on the back surface of the body. The depth of indentation of the sternum is 1-2 cm, the frequency of compressions is 120/min. (Reproduced with modifications from Neonatal life support, Part VI. JAMA 1986;255:2969.)

Medications

A. Adrenaline: Indications: asystole; Heart rate is less than 80 beats/min, despite adequate ventilation and cardiac massage. A dose of 0.01-0.03 mg/kg (0.1-0.3 ml/kg solution 1:10,000) is administered every 3-5 minutes until the effect is achieved. If there is no venous access, it can be inserted into the trachea through an endotracheal tube.

B. Naloxone: Indications: relief of respiratory depression caused by the administration of opioids to the mother in the last 4 hours before birth. Dose: 0.01 mg/kg IV or 0.02 mg/kg IM. If the mother has a history of opioid abuse, naloxone may cause withdrawal symptoms in the fetus.

B. Other medications: B in some cases Other medications are also used. Sodium bicarbonate (dose 2 mEq/kg body weight, 1 ml of solution contains 0.5 mEq) is indicated only for severe metabolic acidosis, verified by arterial blood gas analysis. Sodium bicarbonate is also used during prolonged resuscitation (> 5 minutes), especially if it is technically impossible to analyze arterial blood gases. The rate of administration should not exceed 1 mEq/kg/min to avoid hyperosmolarity and intracranial hemorrhage. In addition, to avoid hyperosmolarity-related damage to hepatocytes, the distal tip of the catheter should not be in the liver. Calcium gluconate 100 mg/kg (or calcium chloride 30 mg/kg) is indicated only for documented hypocalcemia or suspected hypermagnesemia (usually due to maternal magnesium sulfate); clinical manifestations include hypotension, decreased muscle tone, and vasodilation. Glucose (200 mg/kg, use a 10% solution) is indicated only for documented hypoglycemia, since hyperglycemia worsens neurological deficits. Surfactant is indicated for respiratory distress syndrome in premature infants and can be administered into the trachea through an endotracheal tube.