When resuscitating a newborn, the necessary drugs are administered. Protocol for primary and resuscitation care for a newborn in the delivery room

approved by order of the Minister of Health and Medical Industry of the Russian Federation dated December 28, 1995 No. 372

I. Sequence of provision of primary and resuscitation care newborn in maternity ward.
A. When providing resuscitation care to a newborn in the delivery room, it is necessary to strictly follow a certain sequence of actions.
1. forecasting the need resuscitation measures and preparation for their implementation;
2. assessment of the child’s condition immediately after birth;
3. restoration of free airway patency;
4. restoration of adequate breathing;
5. restoration of adequate cardiac activity;
6. administration of medications.
B. In the process of performing all of the above measures, it is necessary to strictly adhere to the rule - under any circumstances, the newborn must be provided with an optimal temperature regime.
B. The main factors for quick and effective resuscitation of a newborn in the delivery room are:
1. predicting the need for resuscitation;
2. readiness of personnel and equipment to perform resuscitation.

II. Predicting the need for resuscitation.
A. Delivery room staff should be prepared to provide resuscitation care to the newborn much more often than they actually have to do.
B. In most cases, the birth of a child is asphyxiated or drug-induced depression can be predicted in advance based on analysis of antenatal and intrapartum history.
Antenatal risk factors:
late gestosis;
diabetes;
hypertensive syndromes;
Rh sensitization;
history of stillbirths;
maternal infection;
bleeding in II or III trimesters pregnancy;
polyhydramnios;
oligohydramnios;
post-term pregnancy;
multiple pregnancy;
delay intrauterine development fetus;
maternal drug and alcohol use;
use of certain medications in a pregnant woman (magnesium sulfate, adrenergic blockers, reserpine), etc.

Intranatal risk factors:
premature birth;
delayed birth;
C-section;
pathological presentation and position of the fetus;
placental abruption;
placenta previa;
loss of umbilical cord loops;
violation heart rate in the fetus;
application general anesthesia;
anomalies labor activity(discoordination, prolonged, fast and rapid labor);
presence of meconium in amniotic fluid Oh;
infection during childbirth, etc.

Readiness of personnel and equipment to carry out resuscitation measures.
A. Sometimes, despite a careful study of the history and observation of labor, the child is still born with asphyxia. In this regard, the process of preparing for each birth should include:
1. creating an optimal temperature environment for a newborn baby (maintaining the air temperature in the delivery room at least 24 degrees Celsius + installing a preheated radiant heat source);
2. preparation of all resuscitation equipment located in the delivery room and operating room, available for immediate use;
3. ensuring the presence at the birth of at least one person who is fully proficient in newborn resuscitation techniques; one or two other trained members of the duty team should be available in case of an emergency.
B. When the birth of a child with asphyxia is predicted, a resuscitation team consisting of two people trained in all techniques for resuscitating newborns (preferably a neonatologist and a trained pediatric nurse) should be present in the delivery room. Providing care to the newborn should be the sole responsibility of the members of this team.
At multiple pregnancy we must keep in mind the need for an expanded team to be present at the birth.

The cycle "assessment - decision - action".
A. Extremely important aspect resuscitation is an assessment of the child’s condition immediately after birth, on the basis of which a decision is made about necessary actions, and then the actions themselves are performed. Further assessment of the child's condition will form the basis for subsequent decisions and subsequent actions. Effective neonatal resuscitation care in the delivery room can only be provided when a series of assessment-decision-action cycles are implemented.
B. When deciding on the beginning therapeutic measures should be based on the severity of signs of live birth: spontaneous breathing, palpitations (heart rate), pulsation of the umbilical cord, voluntary muscle movements. If all 4 signs of a live birth are absent, the child is considered stillborn and cannot be resuscitated. If a child exhibits at least one of the signs of a live birth, the child must be provided with primary and resuscitation care. The volume and sequence of resuscitation measures depend on the severity of 3 main signs characterizing the vital condition important functions newborn baby: spontaneous breathing, heart rate and color skin In other words, if a child requires intervention for respiratory and cardiac performance, such intervention should be carried out immediately. It should not be delayed until after 1 minute of life, when the first Apgar score is obtained. Such a delay may be too costly, especially if the child has severe asphyxia.
B. An Apgar score should be performed at the end of 1 and 5 minutes of life to determine the severity of asphyxia and the effectiveness of resuscitation measures, including if the child is undergoing artificial ventilation lungs. Thereafter, if continued resuscitation is required, this assessment should be repeated every 5 minutes until 20 minutes of life.

III. Stages of providing primary and resuscitation care to a newborn in the delivery room.
Main stages primary care and resuscitation of a newborn born with asphyxia or drug-induced depression are listed below:
1. Initial activities. Carrying out initial activities indicated for all children who at birth have at least one of the signs of a live birth.
A. Initial measures in the absence of risk factors for the development of asphyxia and light amniotic fluid.
1. When a child is born, record the time (turn on the clock on the table or look at the wall clock).
2. Immediately after cutting the umbilical cord, place the baby under a radiant heat source.
3. Wipe it dry with a warm diaper.
4. Remove the wet diaper from the table.
5. Place the child in a position with his head slightly thrown back on his back with a bolster under his shoulders or on his right side.
6. Upon separation large quantity mucus from the upper respiratory tract (URT), first suck out the contents oral cavity, then the nasal passages using a balloon, a De Lee catheter or a special catheter for the sanitation of the upper respiratory tract, connected through a tee to an electric suction, with a discharge of no more than 100 mm Hg. Art. (0.1 atm). (When sanitation of the upper respiratory tract with a catheter, you must not touch back wall sips!).
7. If after sanitation of the upper respiratory tract the child is not breathing, perform light tactile stimulation by patting the feet 1-2 times (but no more!).

NB! THE ENTIRE PROCESS OF INITIAL EVENTS SHOULD TAKE NO MORE THAN 20 SECONDS.
B. Initial measures in the presence of risk factors for asphyxia and pathological impurities in the amniotic fluid (meconium, blood, turbid).
1. When the head is born (before the shoulders are born!), suck out the contents of the oral cavity and nasal passages with a catheter measuring at least 10 Fr (No. 10).
2. Immediately after the birth of the child, record the time (turn on the clock on the table or look at the wall clock).
3. In the first seconds after birth, apply clamps to the umbilical cord and cross it, without waiting for the pulsation to stop.
4. Place the child under a radiant heat source.
5. Place the child in a supine position with a bolster under the shoulders, with the head slightly thrown back and the head end lowered 15-30 degrees.
6. Suck out the contents of the oral cavity and nasal passages using a De Lee catheter or a special catheter for sanitation of the upper respiratory tract. Gastric suctioning should be performed no earlier than 5 minutes after birth to reduce the likelihood of apnea and bradycardia.
7. Under the control of direct laryngoscopy, perform sanitation of the trachea with an endotracheal tube (not a catheter!) of the appropriate diameter, connected through a tee to an electric pump, with a discharge of no more than 100 mm Hg. Art. (0.1 atm).
8. Wipe the baby dry with a warm diaper.
9. Remove the wet diaper from the table.

NB! THE ENTIRE PROCESS OF INITIAL EVENTS IN THIS CASE SHOULD NOT TAKE MORE THAN 40 SECONDS.
1. First assessment of the child’s condition after birth.
A. Breathing assessment.
1. absent (primary or secondary apnea) - start artificial ventilation (ALV);
2. independent, but inadequate (convulsive, “gasping” type, or irregular, superficial) - start mechanical ventilation;
3. independent regular - assess heart rate.

Heart rate (HR) assessment.
Determine your heart rate in 6 seconds using one of three methods:
auscultation of heart sounds,
palpation of the apex beat,
palpation of the pulse in the carotid, femoral or umbilical arteries (by pulsation of the umbilical cord).
Multiply your heart rate for 6 seconds by 10 to get your heart rate per minute.
Possible options assessments and next steps:
1. Heart rate less than 100 beats per minute - perform mask ventilation with 100% oxygen until recovery normal heart rate;
2. Heart rate is more than 100 beats per minute - evaluate the color of the skin.
B. Assessment of skin color.
Possible assessment options and further actions:
1. completely pink or pink with cyanosis of the hands and feet - observe. If everything is fine, apply it to the mother’s breast;
2. cyanotic skin and visible mucous membranes - inhale 100% oxygen through a face mask until cyanosis disappears.

1. Artificial ventilation.
A. Indications for mechanical ventilation.
Ventilation should be started if, after initial measures, the child:
there is no spontaneous breathing (apnea);
spontaneous breathing is inadequate (such as “gasping”, irregular, superficial).
B. Ventilation technique.
Ventilation is performed using a self-expanding bag (Ambu, Penlon Laerdal, Blue Cross, etc.) either through a face mask or through an endotracheal tube. Although ventilation through an endotracheal tube is usually more effective, it requires tracheal intubation, which can waste valuable time. And if intubation is performed ineptly and not on the first try, there is a high risk of complications.
In most cases, timely and effective result provides mask ventilation. The only contraindication to mask ventilation is suspicion of diaphragmatic hernia.

1. Ventilation through a face mask.
a) Before starting mechanical ventilation:
connect it to an oxygen source, optimally through a humidifier/heater of the air-oxygen mixture,
select a face mask of the required size depending on the expected body weight of the fetus (it is better to use a mask with a soft obturator),
b) Place the mask on the child’s face so that it top part The obturator lay on the bridge of the nose, and the lower one on the chin. Check the tightness of the mask by squeezing the bag 2-3 times with the whole hand and watching the excursion chest. The tube should not be inserted into the stomach, since it will not be possible to achieve a tight seal in the breathing circuit.
c) Once you are satisfied that chest excursion is satisfactory, perform the initial stage of ventilation, while observing the following requirements:
respiratory rate - 40 per minute (10 breaths in 15 seconds),
the number of fingers involved in compressing the mark is minimal to ensure adequate excursion of the chest,

1. Gastric tube.
a) Insertion of a probe into the stomach is indicated only if mask ventilation takes more than 2 minutes.
b) Use a sterile gastric tube No. 8; a larger diameter probe will compromise the tightness of the breathing circuit. Insert the probe through the mouth to a depth equal to the distance from the bridge of the nose to the earlobe and further to xiphoid process(the length of the catheter is measured approximately without removing the face mask and without stopping the mechanical ventilation).
c) Attach a 20 ml syringe to the probe, quickly but smoothly suck out the contents of the stomach, then secure the probe on the child’s cheek with an adhesive plaster, leaving it open for the entire period of mask ventilation. If abdominal bloating persists after the end of mechanical ventilation, leave the tube in the stomach for more long time(until signs of flatulence disappear).
2. Oral air duct.
a) During mask ventilation, an oral airway may be required in three cases:
bilateral choanal atresia,
Pierre-Robin syndrome,
the impossibility of ensuring free patency of the upper respiratory tract when the child is positioned correctly.
b) The resuscitation kit must have two air ducts: one for full-term infants, the other for premature infants. When inserting the airway, it should fit freely above the tongue and reach the back wall of the pharynx: the cuff should remain on the child’s lips.

1. Ventilation through an endotracheal tube.
a) Indications for tracheal intubation:
suspicion of diaphragmatic hernia,
aspiration of amniotic fluid, requiring sanitation of the trachea,
ineffectiveness of mask ventilation within 1 minute,
apnea or inadequate spontaneous breathing in a baby less than 28 weeks gestational age.
b) Before tracheal intubation:
check that the breathing bag is working properly,
connect it to an oxygen source,
prepare a laryngoscope and endotracheal tube,
Place the child on his back with a bolster under his shoulders and his head slightly tilted back.
c) Perform tracheal intubation.
d) Once you are satisfied that chest excursion is satisfactory, perform the initial stage of ventilation, while observing the following requirements:
respiratory rate - 40 per 1 minute (10 breaths in 15 seconds) with a ratio of inhalation and exhalation time of 1:1 (inhalation time - 0.7 s),
oxygen concentration in the gas mixture - 90-100%,
the number of fingers involved in compressing the bag is minimal to ensure adequate excursion of the chest,
if during mechanical ventilation it is possible to control the pressure in respiratory tract using a pressure gauge, the first 2-3 breaths should be performed with a maximum end-inspiratory pressure (PIP) of 30-40 cmH2O. Art., and at subsequent times - maintain it within 15-20 cm of water. at healthy lungs and 20-40 cm water. Art. - with aspiration of meconium or RDS; Positive end expiratory pressure (PEEP) should be maintained at 2 cmH2O:
When using a volumetric respirator, the tidal volume must be set at the rate of 6 ml/kg.
duration initial stage ventilation - 15-30 seconds.
IN. Further actions.
After the initial stage of mechanical ventilation, assess the heart rate for 15-30 seconds (!), as indicated in paragraph 2.B.
1. If the heart rate is above 80 beats per minute, continue mechanical ventilation until adequate spontaneous breathing is restored, after which assess the color of the skin (see paragraph 2.B.).
2. If the heart rate is less than 80 beats per minute - while continuing mechanical ventilation, check its adequacy and start indirect massage hearts.

1. Indirect cardiac massage.
A. Indications for chest compressions.
Heart rate below 80 beats per minute after the initial stage of mechanical ventilation for 15-30 seconds.
B. Technique of indirect cardiac massage.
Indirect cardiac massage can be performed in one of two ways:
1. using two fingers (index and middle or middle and ring) of one hand;
2. using thumbs both hands, covering the chest.
In both cases, the child should be on a hard surface and pressure on the sternum should be carried out at the border of the middle and lower third (avoid pressure on the xiphoid process due to the risk of injury to the left lobe of the liver!) with an amplitude of 1.5 - 2.0 cm and a frequency of 120 per minute (2 compressions per second).
B. The frequency of mechanical ventilation during cardiac massage remains 40 per minute. In this case, compression of the sternum is carried out only during the exhalation phase with the ratio “inhalation:compression of the sternum” = 1:3. In the case of chest compressions against the background of mask ventilation, it is necessary to insert a gastric tube for decompression.
D. Further actions.
1. Assess your heart rate (HR). The first assessment of heart rate is carried out 30 seconds from the start of chest compressions. In this case, it is stopped for 6 seconds and the heart rate is assessed, as indicated in paragraph 2.B. In the future, for a child who responds well to resuscitation measures, it is necessary to determine the heart rate every 30 seconds in order to stop chest compressions as soon as it is established at a level above 80 beats per minute. If long-term resuscitation is necessary, heart rate can be determined less frequently.
2. If the heart rate is above 80 beats per minute, stop chest compressions and continue mechanical ventilation until adequate spontaneous breathing is restored.
3. If the heart rate is below 80 beats per minute, continue chest compressions against the background of mechanical ventilation (if mechanical ventilation was carried out through a face mask, perform tracheal intubation) and begin drug therapy.

1. Drug therapy.
A. Indications for drug therapy:
1. Heart rate below 80 beats per minute after 30 seconds of chest compressions during mechanical ventilation.
2. There are no heartbeats.
B. Drugs used for resuscitation of a newborn in the delivery room:
1. Adrenaline solution diluted 1:10,000.
2. Solutions to replenish the deficiency of circulating blood: albumin 5%, isotonic sodium chloride solution, Ringer-lactate solution.
3. 4% sodium bicarbonate solution.
B. Methods of drug administration.

1. Through a catheter in the umbilical vein:
a) for catheterization of the umbilical vein, it is necessary to use umbilical catheters of size 3.5-4Fr or 5-6Fr (domestic No. 6 or No. 8) with one hole at the end;
b) the catheter into the umbilical vein should be inserted only 1-2 cm below the skin level until free blood flow appears; with deep insertion of the catheter, the risk of damage to liver vessels by hyperosmolar solutions increases;
c) immediately after resuscitation measures, it is advisable to remove the catheter from the umbilical vein; only if it is impossible to carry out infusion therapy through the peripheral veins, the catheter in the umbilical vein can be left, advancing it to a depth equal to the distance from umbilical ring to the xiphoid process, plus 1 cm.

2. Through the endotracheal tube:
a) only adrenaline can be administered through the endotracheal tube; it is inserted either directly into the endotracheal tube connector or through a 5Fr catheter (no. 6) inserted into the tube, which is then flushed isotonic solution sodium chloride (0.5 ml per 40 cm of catheter length.
b) after endotracheal administration of adrenaline, it is necessary to continue mechanical ventilation for a more uniform distribution and absorption of the drug in the lungs.
D. Characteristics medicines, used in primary resuscitation of newborns in the delivery room.

1. Adrenaline.
a) Indications:
Heart rate below 80 beats per minute after 30 seconds of chest compressions during mechanical ventilation;
no heartbeat; in this case, adrenaline is administered immediately, simultaneously with the start of mechanical ventilation and chest compressions.
b) The concentration of the injected solution is 1:10000.
c) Preparation of the syringe.
Dilute 1 ml from an adrenaline ampoule into 10 ml saline solution. Draw 1 ml of the prepared solution into a separate syringe.
d) Dose - 0.1-0.3 ml/kg of prepared solution.
e) Method of administration - into the umbilical cord vein or endotracheally.
e) Speed ​​of administration - jet.
g) Action:
increases the frequency and strength of heart contractions;
causes peripheral vasoconstriction leading to an increase in blood pressure.
h) Expected effect: 30 seconds from the moment of administration, the heart rate should reach 100 beats per minute.
i) Further actions:
1. if after 30 seconds the heart rate is restored and exceeds 80 beats per minute, do not administer other medications, stop chest compressions, continue mechanical ventilation until adequate spontaneous breathing is restored;
2. if after 30 seconds the heart rate remains below 80 beats per minute, continue chest compressions and mechanical ventilation, followed by one of the following:
repeat the injection of adrenaline (if necessary, this can be done every 5 minutes);
if there are signs acute blood loss or hypervolemia, administer one of the solutions to replenish the volume of blood volume;
for confirmed or suspected decompensated metabolic acidosis, administer sodium bicarbonate.

RCHR ( Republican Center healthcare development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2015

Unspecified birth asphyxia (P21.9), Moderate to moderate birth asphyxia (P21.1), Severe birth asphyxia (P21.0)

Neonatology, Pediatrics

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Short description

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RSE on REM "Republican Center for Health Development"

Ministry of Health and social development Republic of Kazakhstan

Protocol No. 10

I. INTRODUCTION PART

Protocol name: Resuscitation of premature babies.

Protocol code:

ICD-10 code(s):

P21.0 Severe asphyxia at birth

P21.1 Moderate and moderate asphyxia at birth

P21.9 Unspecified asphyxia at birth

Abbreviations used in the protocol:

HELL arterial pressure

IV IV

artificial ventilation ventilation

MTR birth weight

NMS indirect cardiac massage;

BCC volume of circulating blood

FOE functional residual capacity lungs

RR respiratory rate

Heart rate heart rate

ETT endotracheal tube

FiO2 concentration of oxygen in the inhaled gas mixture

ILCOR International Liaison Committee on Resuscitation

PIP positive inspiratory pressure

PEEP positive end expiratory pressure (positive end expiratory pressure)

SpO2 blood oxygen saturation

CPAP continuous positive airway pressure (continuous positive airway pressure)

Date of development of the protocol: 2015

Protocol users: neonatologists, resuscitators and obstetricians and gynecologists of obstetric organizations.

Assessing the level of evidence of the recommendations provided (Consensus European recommendations on treatment respiratory distress syndrome in premature newborns - updated version 2013).

Level of evidence scale:

Diagnostics

Diagnostic measures: are carried out in the post-resuscitation period to identify the causes of pulmonary-cardiac disorders at birth, i.e. to establish a clinical diagnosis.

Main events
To determine the severity of birth asphyxia, immediately after the birth of the child, blood is taken from the artery of the clamped umbilical cord to determine its gas composition.
. Markers of severe perinatal asphyxia (hypoxia) are:
- pronounced metabolic acidosis(V arterial blood umbilical cord pH<7,0 и дефицит оснований ВЕ ≥ 12 ммоль/л);
- Apgar score 0-3 points at 5 minutes;
- clinical neurological disorders that manifest themselves in the early stages after birth (convulsions, hypotension, coma ─ hypoxic-ischemic encephalopathy);
- signs of multiple organ damage in the early stages after birth [UD - A].

Additional Research:
. monitoring of WWTP to maintain normal values ​​within the range: pH 7.3-7.45; Ra O2 60-80 mmHg; SpO2 90-95%)); PaCO2 35-50 mm Hg;

. clinical blood test, platelet count to exclude or confirm the presence of a severe bacterial infection in the newborn (sepsis, pneumonia);

Heart rate, respiratory rate, body temperature, pulse oximetry, blood pressure monitoring to identify cardiopulmonary pathology, characterized by the development of hypotension, systemic secondary arterial hypoxemia against the background of increased pulmonary vascular resistance, leading to pathological shunting of blood through fetal communications (PDA, LLC);

Monitoring diuresis, taking into account fluid balance and electrolyte levels in the blood serum (pronounced low levels of sodium, potassium and chlorides in the blood serum with decreased diuresis and excessive weight gain together may indicate acute renal tubular necrosis or syndrome of inappropriate secretion of antidiuretic hormone, especially for the first time 2-3 days of life; increased urine output may indicate ongoing tubular damage and excess sodium excretion relative to water excretion);

The concentration of glucose in the blood serum (glucose is the main energy substrate necessary for postnatal adaptation and brain nutrition; hypoglycemia can lead to apnea and seizures).

Instrumental studies(preferably in the first days):
. Neurosonography to exclude/confirm IVH, ICH and other CNS pathologies;
. Ultrasound of the heart to exclude/confirm congenital heart disease, myocarditis;
. Echo CG to exclude/confirm congenital heart disease, PDA, LLC, etc.;
. Survey radiography to exclude/confirm respiratory pathology, UVB, NEC;
. Other studies according to indications.

Specialist consultations: are carried out as necessary in the post-resuscitation period to confirm the identified pathology (neurologist, cardiologist, ophthalmologist, neonatal surgeon, neurosurgeon, etc.).

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Treatment

II. MEDICAL REHABILITATION EVENTS

Purpose of resuscitation:
The goal of resuscitation is the complete restoration of vital body functions, the disruption of which is caused by perinatal hypoxia and asphyxia during childbirth.

Indications for medical rehabilitation: in accordance with international criteria in accordance with the Standard for organizing the provision of medical rehabilitation to the population of the Republic of Kazakhstan, approved by order of the Minister of Health of the Republic of Kazakhstan dated December 27, 2014 No. 759.

Indications for resuscitation:
. Premature newborns weighing 1000 - 1500 g require respiratory support immediately after birth in 25-50% of cases and those weighing less than 1000 g in 50-80% of cases (Class A).
. Such a frequent need for respiratory support is due to insufficient independent respiratory efforts in premature newborns and the inability to create and maintain functional residual capacity (FRC) of the lungs due to:
− immaturity of the lungs, surfactant deficiency;
− weakness of the chest muscles; −immaturity of the central nervous system, which does not provide adequate stimulation of breathing.
. Within the framework of the Newborn Resuscitation Program, a “Primary Assessment Block” has been allocated, which contains 3 questions that allow you to assess the condition of the child at the time of birth and identify the priority of actions:
− Is the baby full-term?
− Is he breathing or screaming?
− Is your muscle tone good?
. If the answer to at least one of the above questions is “no,” the child should be transferred to a heated table (open resuscitation system) for resuscitation measures.

Contraindications to medical rehabilitation:
Contraindications for resuscitation:
In Kazakhstan there is no law regulating the scope of provision

Resuscitation care for newborns in the delivery room. However, recommendations published by the International Consensus Committee on Resuscitation, based on the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 15: Neonatal Resuscitation: 2010, and the 6th edition of the textbook Neonatal Resuscitation, indicate conditions under which resuscitation is not indicated:
. If gestational age, birth weight, or congenital anomalies are associated with virtually certain death or unacceptably severe disability in surviving children, or:
. confirmed gestational age less than 23 weeks or birth weight less than 400 g;
. anencephaly;
. confirmed incompatible congenital malformations or genetic disease;
. the presence of data indicating an unacceptably high risk of death and disability.

Scope of medical rehabilitation

Main stages of resuscitation:
Resuscitation measures for premature newborns are carried out in the sequence recommended by the ILCOR (International Consensus Committee on Resuscitation) 2010 for all newborns [LE - A]:
A. Primary resuscitation measures (warming, clearing the airways, drying, tactile stimulation).
B. Positive pressure ventilation.
C. Indirect cardiac massage.
D. Administration of adrenaline and/or solution to replenish the volume of circulating blood (volume expander therapy).

After each step of resuscitation, its effectiveness is assessed, which is based on the child's heart rate, respiratory rate and oxygenation (which is preferably assessed using a pulse oximeter).
. If heart rate, respiration and oxygenation do not improve, proceed to the next step (block) of action.

Preparing for resuscitation
Assessment and intervention are simultaneous processes facilitated by the critical care team.
. The success and quality of resuscitation depends on the experience, readiness and skills of the staff, the availability of a full set of resuscitation equipment and medications, which should always be available in the delivery room. [UD -A]
. In case of premature birth, a team of doctors with experience in the neonatal intensive care unit is called to the delivery room, including employees who are well-versed in tracheal intubation and emergency umbilical vein catheterization. [UD A]
. If preterm birth is expected, the temperature in the delivery room should be increased to ≥26°C and a radiant heat source should be turned on first to ensure a comfortable ambient temperature for the preterm neonate. [UD -A]

Place an exothermic mattress under several layers of diapers located on the resuscitation table.
. If a baby is expected to be born with a gestational age of less than 28 weeks, it is necessary to prepare a heat-resistant plastic bag or plastic film for food or medical purposes and an exothermic mattress (warming mat). [UD - A]
. Warming and humidifying gases used to stabilize the condition may also help maintain the newborn's body temperature. [UD - V]
. A pulse oximeter and a mixer connected to a source of oxygen and compressed air should always be available. [UD - S]
. It is important to have a prepared, prewarmed transport incubator to maintain the neonate's body temperature when transported to the NICU after stabilization in the delivery room. [UD - A]

Block A.
Primary resuscitation measures ─ providing initial care to a newborn boils down to ensuring minimal heat loss, sanitation of the respiratory tract (if indicated), giving the child the correct position to ensure airway patency, tactile stimulation of breathing and re-positioning the newborn in the correct position, after which breathing and heart rate (HR) are assessed. [UD - V]

Prevention of heat loss:
. Premature newborns are especially at risk of hypothermia, which can increase oxygen consumption and interfere with effective resuscitation. This situation is most dangerous for newborns with extremely low (˂ 1000 g) and very low birth weight (˂ 1500 g). In order to prevent hypothermia, it is necessary to take additional actions that are not limited, as described above, to raising the air temperature in the delivery room to ≥26°C and in the area where resuscitation measures will be carried out, placing an exothermic mattress under several layers of diapers located on the resuscitation table. [EL B] When using an exothermic mattress, you should strictly follow the manufacturer's instructions for activation and place the child on the appropriate side of the exothermic mattress.

Premature newborns with a gestational age of 29 weeks or less are placed immediately after birth (without drying) in a plastic bag or under a plastic diaper up to the neck on pre-warmed diapers on a resuscitation table under a radiant heat source (Fig. 1). The surface of the child's head is additionally covered with film or a cap. The pulse oximeter sensor is attached to the child's right wrist before being placed in the bag. The bag or diaper should not be removed during resuscitation efforts. [UD - A]

Picture 1

The child's temperature should be carefully monitored because sometimes, the use of methods aimed at preventing heat loss can lead to hyperthermia. [UD - V]

All resuscitation measures, including tracheal intubation, chest compressions, and venous access, must be carried out while ensuring thermoregulation. [UD - S]

Sanitation of the respiratory tract:

It has been shown that airway clearance may precipitate bradycardia during resuscitation, and tracheal evacuation in the absence of obvious nasal discharge in intubated ventilated neonates may contribute to decreased lung tissue plasticity and oxygenation levels, as well as decreased cerebral blood flow.

Therefore, sanitation of the respiratory tract should be carried out only for those newborns who, during the first seconds of life, did not develop adequate spontaneous breathing due to obstruction by mucus and blood, as well as if forced ventilation under positive pressure is necessary. [UD - S]

Giving the newborn's head the correct position

A newborn requiring resuscitation should be gently placed on his back with his head slightly tilted back (correct position, Fig. 2). This position will allow the back of the pharynx, larynx and trachea to be positioned in one line, ensuring maximum opening of the airways and unlimited air flow. [UD - V]

Figure 2:

If the back of the head is very prominent, a 2cm thick blanket or towel placed under the shoulders can help maintain the correct position. [UD - A]

Tactile stimulation
. In many cases, giving the head the correct position and sanitizing the airways (if indicated) are a sufficient stimulus to start breathing. Drying the newborn's body and head also stimulates breathing while keeping the head in the correct position.
. If the child does not have adequate respiratory movements, then additional tactile stimulation can be performed to stimulate breathing:
- gentle stroking along the back, torso or limbs (1-2 times), after which assess the effectiveness of primary resuscitation measures. [UD - A]

Evaluating the effectiveness of Block A
. If a premature newborn is not breathing after initial care, or has gasping breathing, or a heart rate of less than 100 per minute, this is considered indication for starting positive pressure ventilation (go to Block B) .

Block B. Positive pressure ventilation

Providing ventilation
. Uncontrolled inspiratory volumes, either too much or too little, have a damaging effect on the immature lungs of premature newborns. That's why routine use of ventilation with a self-expanding Ambu bag and mask is inappropriate . [UD - A]
. Most premature newborns do not have apnea, because... due to the immaturity of the lungs and surfactant deficiency, natural ventilation of the lungs and the formation of functional residual lung capacity are difficult. Use of early CPAP in the presence of spontaneous breathing(including groaning accompanied by chest retraction) with the ability to provide controlled inflation, is now the main way to safely stabilize preterm infants immediately after birth, reducing the need for mechanical ventilation. [UD - A]
. To provide CPAP (constant positive pressure in the airways throughout the entire respiratory cycle, created by a continuous flow of the gas mixture), a resuscitation device with a T-connector (Fig. 3) or a flow-filling bag with a resuscitation mask (Fig. 4) is used. as well as special equipment (CPAP machine, or neonatal ventilator with nasal cannulas or mask). CPAP cannot be provided with a self-inflating bag. [UD - S].

Figure 3

Figure 4. Flow-fill bag:

Continuous positive airway pressure (CPAP) is created by sealing a resuscitation mask attached to a T-system or flow-fill bag with the child's face. [UD - A].

Before applying the mask to the child’s face, it is necessary to adjust the CPAP value by firmly pressing the mask to the resuscitator’s hand (Fig. 3). Check the pressure gauge and adjust using the T-System PEEP valve or Flow Control Valve until the gauge reading corresponds to the required initial pressure of 5 cmH2O [LE - A]

Then you should place the mask tightly on the child's face and make sure that the pressure remains at the selected level. If the pressure decreases, the mask may not fit tightly to the child's face.

While CPAP is provided, the newborn's lungs are kept slightly inflated at all times, and he or she does not have to exert much effort to refill the lungs with air during each exhalation. [UD - A]

Sealed contact between the mask and the child's face is the most important prerequisite for creating positive pressure in the airways. . [UD A]

When using the T-system, signs of adequate mask position will be an audible exhalation sound and positive pressure as indicated by the pressure gauge (Fig. 5). [UD - A]

Figure 5.

If CPAP must be provided for a long time, then instead of a mask it is more convenient to use special nasal cannulas, since they are easier to secure in the desired position. [UD - A]

While CPAP is being provided, the child must breathe independently, without additional mandatory breaths provided by a resuscitation bag or T-piece resuscitation device (that is, this is not mandatory positive pressure ventilation!). [UD - A]

What concentration of oxygen in the breathing mixture should be used?

Tissue damage during childbirth and the early neonatal period of adaptation can be caused by inadequate blood circulation and limited oxygen delivery to body tissues. Restoring these processes is an important task of resuscitation.

To begin to stabilize the condition of a premature newborn, an oxygen concentration of 21-30% is advisable, and its increase or decrease is carried out based on the readings of a pulse oximeter attached to the right wrist from the moment of birth to obtain information about heart rate and saturation (SpO2). [UD - A]

After birth, saturation should increase gradually from approximately 60% to 80% over 5 minutes, reaching 85% or higher by approximately 10 minutes. [UD - A]

Oximetry can identify newborns who are outside this range and help monitor the oxygen concentration in the inhaled mixture. Recommended target preductal saturation levels after birth are given below:

Target SpO2 norms after birth:

Initial CPAP settings[UD - A]:
. It is advisable to start CPAP with a pressure of 5 cmH2O. Art. at FiO2 = 0.21-0.30 under saturation control. If there is no improvement in oxygenation, the pressure is gradually increased to 6 cm aq. Art.
. The optimal recommended pressure is 6 cmH2O. Art. Using higher pressures with CPAP can cause serious complications (pneumothorax).
. FiO2 should be increased only after the pressure has increased.
. The pressure is provided by the flow rate (Flow), which is regulated by the device. The flow-pressure nomogram shows the relationship between flow rate and generated pressure (Fig. 6).

Figure 6. Flow-pressure nomogram (CPAP).

Indications for stopping CPAP:
. First of all, FiO2 is reduced, gradually to a level of 0.21 under the control of SaO2 88%. Then, slowly, 1-2 cm aq. Art. reduce pressure in the respiratory tract. When it is possible to bring the pressure to 4 cm aq. Art. at Flow-7 l/min, FiO2-0.21, SpO2 -88% CPAP is stopped [UD - C]
. If spontaneous breathing is ineffective in a child, mandatory ventilation should be performed instead of CPAP.
. In this case, the optimal inspiratory pressure (PIP) during the first forced breaths is selected individually for a particular newborn until the heart rhythm is restored and chest excursion occurs.
. An initial inspiratory pressure (PIP) of 20 cm H2O is adequate for most preterm infants.
. Forced ventilation should be carried out at a frequency of 40-60 breaths per minute to restore and maintain heart rate ˃ 100 beats/min:
‒ monitor blood oxygen saturation and adjust oxygen concentration to achieve the target SpO2 value in the ranges specified in the table “Target Preductal SpO2 Values ​​after Birth”;
- insert an orogastric tube while ventilation continues;
- reduce inhalation pressure if filling the lungs with air seems excessive;
- during the entire period of forced ventilation, evaluate attempts at spontaneous breathing, heart rate and blood oxygen saturation continuously or every 30 seconds.

If there is no rapid increase in heart rate, you should check to see if there is visible chest excursion. If there is no chest excursion, you should check the tightness of the mask on the child’s face and the patency of the airway. If after these measures there is still no chest excursion, it is necessary to carefully increase the inspiratory pressure (every few forced breaths) until breath sounds begin to be heard over both lung fields and chest excursions appear with each forced breath. With the advent of chest excursion, heart rate and blood oxygen saturation will begin to increase. [UD - V]

Tracheal intubation in premature newborns
. Only a small number of preterm neonates require tracheal intubation in the delivery room. It is used in infants who have not responded to positive pressure ventilation through a face mask, during chest compressions, as well as in preterm infants less than 26 weeks gestational age for the administration of surfactant for replacement purposes, and in children with congenital diaphragmatic hernia. [UD - V]
. If intubation is necessary, proper endotracheal tube (ETT) placement can be quickly verified using a CO2 colorimetric device (capnograph) before surfactant is administered and mechanical ventilation is initiated. If the ETT is inserted into the trachea, the capnograph indicator will show the presence of CO2 in the exhaled air. However, it should be noted that with a sharp decrease or absence of blood flow in the vessels of the lungs, the test results may be false negative, that is, CO2 is not detected, despite the correct administration of the ETT. [UD - V]

Therefore, along with a CO2 detector, clinical methods for correct placement of the ETT should be used: fogging the tube, having chest excursions, listening to breath sounds on both sides of the chest, and increasing heart rate in response to positive pressure ventilation. [UD - S]

Surfactant therapy:
. Administration of surfactant replacement directly in the delivery room is recommended for preterm neonates <26 weeks' gestational age, as well as in cases where the mother did not receive antenatal steroids to prevent RDS in her newborn or when intubation is necessary to stabilize the condition of the preterm infant. [UD - A]

In most clinical studies, the INtubate - SURfactant - Extubate to CPAP technique is recommended as the standard method for surfactant administration. This technique has been shown in randomized trials to reduce the need for mechanical ventilation and the incidence of subsequent bronchopulmonary dysplasia (BPD) [LE -A]

Early therapeutic administration of surfactant is recommended when CPAP is ineffective, when oxygen demand increases in newborns with a gestational age of less than 26 weeks, when FiO2 is ˃ 0.30, and for preterm infants with a gestational age of more than 26 weeks, when FiO2 is ˃ 0.40. [UD - A]

Evaluation of the effectiveness of block “B”:
. The most important sign of effective mandatory positive pressure ventilation and indication for its cessation is an increase in heart rate to 100 beats/min or more, an increase in blood oxygen saturation (SpO2 corresponds to the target value in minutes) and the appearance of spontaneous breathing. [UD - A]
. If after 30 seconds of mandatory positive pressure ventilation:
− heart rate less than 100 beats/min in the absence of spontaneous breathing, continue mechanical ventilation until it appears and provide for the need for tracheal intubation;
− heart rate is 60-99 per minute, mechanical ventilation is continued and the need for tracheal intubation is considered; [UD - A]
− Heart rate ˂60 per minute, begin chest compressions, continue mechanical ventilation and consider the need for tracheal intubation. [UD -A]

Block “C” Supporting blood circulation using chest compressions

Indications for starting chest compressions(NMS) is a heart rate less than 60 beats/min, despite adequate mandatory ventilation using supplemental oxygen for 30 seconds. [UD - A]
. NMS should be performed only against the background of adequate ventilation with 100% oxygen. [UD - A]

Indirect cardiac massage is performed by pressing on the lower third of the sternum. It is located under the conditional line connecting the nipples. It is important not to put pressure on the xiphoid process to prevent liver rupture. Two indirect massage techniques are used, according to which compression of the sternum is performed:
1) with the pads of two thumbs - while the remaining fingers of both hands support the back (thumb method);
2) with the tips of two fingers of one hand (second and third or third and fourth) - while the second hand supports the back (two-finger method)

The depth of compressions should be one third of the anteroposterior diameter of the chest, and the frequency should be 90 per minute. After every three pressures on the sternum, ventilation is carried out, after which the pressures are repeated. In 2 sec. it is necessary to perform 3 compressions on the sternum (90 per 1 min) and one ventilation (30 per 1 min). [UD - S]

Well-coordinated chest compressions and forced ventilation are performed for at least 45-60 seconds. A pulse oximeter and heart rate monitor will help determine heart rate without interrupting NMS [LE - C]

Evaluation of the effectiveness of block C:
− When heart rate reaches more than 60 beats/min. NMS should be stopped, but forced positive pressure ventilation should be continued at a rate of 40-60 forced breaths per minute.
− As soon as the heart rate becomes more than 100 beats/min. and the child begins to breathe independently, you should gradually reduce the frequency of forced breaths and reduce the ventilation pressure, and then transfer the child to the intensive care unit for post-resuscitation measures.
- If the heart rate remains less than 60 beats/min, despite ongoing chest compressions, coordinated with positive pressure ventilation for 45-60 seconds, proceed to block D. [EL - C].

Block “D” Administration of adrenaline and/or solution to replenish circulating blood volume

Adrenaline administration while continuing positive pressure ventilation and chest compressions
. The recommended dose of adrenaline for intravenous (preferable) administration to newborns is 0.01-0.03 mg/kg. The intravenous dose should not be increased as this may lead to hypertension, myocardial dysfunction and neurological impairment.

. When administering the 1st dose of adrenaline endotracheally, while the venous access is being prepared, it is recommended to always use a larger dose of 0.05 to 0.1 mg/kg. However, the effectiveness and safety of this practice have not been determined. Regardless of the route of administration, the concentration of adrenaline should be 1:10,000 (0.1 mg/ml). [UD - S]

Immediately after endotracheal administration of epinephrine, forced ventilation of the lungs with 100% oxygen should be continued for better distribution and absorption of the drug in the lungs. If adrenaline is administered intravenously through a catheter, then it must be followed by a bolus of 0.5-1.0 ml of saline to ensure that the entire volume of the drug enters the bloodstream. [UD - V]

60 seconds after the administration of adrenaline (with endotracheal administration - after a longer period of time), the child’s heart rate should be assessed:
─ If after the administration of the 1st dose of adrenaline the heart rate remains less than 60 beats/min, you can repeat the administration of the drug at the same dose after 3-5 minutes, but only if the minimum permissible dose was administered during the first administration of the drug, then when subsequent administrations should increase the dose to the maximum allowable. Any repeated administration of epinephrine should be administered intravenously. [UD - V]

You must additionally ensure that:
- there is good air exchange, as evidenced by adequate chest excursion and listening to breath sounds over both lung fields; if tracheal intubation has not yet been performed, it should be performed;
- the ETT did not move during resuscitation;
- compressions are carried out to a depth of 1/3 of the anteroposterior diameter of the chest; they are well coordinated with forced ventilation.

Replenishment of circulating blood volume
. If the child does not respond to resuscitation measures and has signs of hypovolemic shock (pallor, weak pulse, dull heart sounds, positive white spot sign), or there are indications of placenta previa, vaginal bleeding or blood loss from the umbilical cord vessels, you should consider about replenishment of circulating blood volume (CBV). [UD - C] ●The drugs of choice that normalize blood volume are 0.9% sodium chloride solution or lactated Ringer's solution. To urgently replace significant blood loss, emergency blood transfusion may be necessary.

In premature infants with a gestational age of less than 32 weeks, one should remember the structural features of the capillary network of the germinal matrix of the immature brain. Rapid administration of large volumes of fluid can lead to intraventricular hemorrhage. Therefore, the primary volume of fluid required to replenish the bcc is injected into the umbilical vein at a dose of 10 ml/kg in a slow stream over ≥10 minutes. If, after the first dose, the child’s condition does not improve, a second dose of the solution may be required in the same volume (10 ml/kg). [UD - S]

After replenishing the blood volume, it is necessary to evaluate the resulting clinical effect. The disappearance of pallor, normalization of capillary refill time (the “white spot” symptom is less than 2 seconds), an increase in heart rate of more than 60 beats/min, and normalization of the pulse may indicate sufficient replenishment of blood volume. In this case, the administration of drugs and NMS should be stopped, while mandatory positive pressure ventilation is continued. [UD - S]
. As soon as the heart rate becomes more than 100 beats/min. and the child begins to breathe independently, the frequency of forced breaths should be gradually reduced and the ventilation pressure should be reduced, and then the child should be transferred to the intensive care unit for post-resuscitation care. [UD - S]
. If the measures taken are ineffective and there is confidence that effective ventilation, chest compressions and drug therapy are adequate, mechanical reasons for the failure of resuscitation, such as airway abnormalities, pneumothorax, diaphragmatic hernia or congenital heart disease, should be considered.

Termination of resuscitation measures
Resuscitation measures should be stopped if heartbeats are not detected within 10 minutes.
The decision to continue resuscitation after 10 minutes of absence of a heartbeat should be based on the etiological factors of cardiac arrest, gestational age, presence or absence of complications and parental decision.
Available evidence suggests that resuscitation of a newborn after 10 minutes of complete asystole usually results in the child's death or survival with severe disability. [UD - S].

Post-resuscitation period:
. After adequate ventilation has been established and the heart rate has been restored, the newborn should be transferred in a pre-warmed transport incubator to the intensive care unit, where he will be examined and treated.

A premature baby has very small glycogen stores. During resuscitation, his energy reserves are depleted, which can result in hypoglycemia. Hypoglycemia is a risk factor for brain damage and adverse outcomes in the presence of hypoxia or ischemia.

The level of glucose at which the risk of an adverse outcome increases is not defined, nor is its normal level. Therefore, to prevent the development of hypoglycemia, intravenous glucose should be administered in the first 12 hours of the post-resuscitation period with monitoring of its level every 3 hours. [UD - S].

. Premature babies may have short pauses between breaths. Prolonged apnea and severe bradycardia in the post-resuscitation period may be the first clinical signs of disturbances in temperature balance, blood oxygen saturation, decreased levels of electrolytes and blood glucose, the presence of acidosis, and infection.

To prevent metabolic disorders, it is necessary to monitor and maintain within the following limits: − glucose level 2.6 - 5.5 mmol/l; − total calcium 1.75 - 2.73 mmol/l; − sodium 134 - 146 mEq/l; − potassium 3.0 - 7.0 mEq/l.

To ensure adequate ventilation of the lungs and adequate oxygen concentration, SpO2 should be monitored until the child's body can maintain normal oxygenation when breathing air.

If the child continues to require positive pressure ventilation or supplemental oxygen, blood gases should be measured regularly at intervals that optimize the amount of care required.

If the medical organization where the child was born does not specialize in providing care to premature newborns requiring long-term forced ventilation, the child should be transferred to a medical institution of the appropriate profile (3rd level of perinatal care).

Caffeine should be used in infants with apnea and to facilitate cessation of mechanical ventilation (MV). [LE A] Caffeine should also be considered in all infants at high risk of requiring CF, such as those weighing less than 1250 g, who are receiving non-invasive mechanical ventilation [LE B].

To facilitate extubation in infants who remain on CF after 1–2 weeks, a short course of low or very low dose dexamethasone therapy should be considered, with a gradual dose reduction [LEA]

Parenteral nutrition should be started on the first day to avoid growth retardation and increased rapidly, starting at 3.5 g/kg/day protein and 3.0 g/kg/day lipids as tolerated [LE - C].

Minimal enteral nutrition should also be started on the first day [LOE -B].

Low systemic blood flow and treatment of hypotension are important predictors of poor long-term outcome.

Decreased systemic blood flow and hypotension may be associated with hypovolemia, left-to-right shunting through the ductus arteriosus or foramen ovale, or myocardial dysfunction. Establishing the cause will help you choose the most appropriate treatment tactics. Early hypovolemia can be minimized by delaying cord ligation. [UD - S].

If hypovolemia is confirmed by echocardiogram, and also if the cause is not clearly established, the possibility of increasing blood volume by administering 10-20 ml/kg of saline, but not colloid, should be considered.

In the treatment of hypotension in preterm infants, dopamine is superior to dobutamine in influencing short-term outcomes, but dobutamine may be a better choice for myocardial dysfunction and low systemic blood flow. In case of ineffectiveness of traditional treatment of arterial hypotension, hydrocortisone may also be used.
Drugs used to treat arterial hypotension in premature infants

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 is worth noting polyhydramnios or oligohydramnios, post-maturity, intrauterine growth retardation and the presence of multiple pregnancies.

Intrapartum risk factors include: premature or delayed birth, pathological presentation or fetal position, placental abruption, prolapse of umbilical cord loops, use of general anesthesia, labor anomalies, 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 for 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 sucked out from the mouth 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 is indicated for suspected diaphragmatic hernia, ineffectiveness of mask ventilation within 1 minute, as well as for 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 of physiological 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 thread-like 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.

The 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 (supposed severe acidosis that prevents the restoration of cardiac activity). 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.

If there is a 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 a sudden stop of heart and breathing, although quickly, but not instantly. 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, while consciousness and mental activity will either not be restored at all or will be deeply 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 death and revive 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 of medical institutions in childhood are sudden neonatal death syndrome, automobile injury, drowning, and 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. At the same time, 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 its blood flow, external massage of the heart.

Transportation of victims

Functionally justified for transporting children is:

• in case of 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 of the pelvic bones, injuries to the abdominal organs - the legs are 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.

The Ministry of Health and Social Development of the Russian Federation is sending a methodological letter “Primary and resuscitation care for newborn children” for use in the work of medical institutions providing medical care to newborns.

METHODOLOGICAL LETTER

PRIMARY AND RESUSCITATIVE CARE FOR NEWBORN CHILDREN

List of abbreviations:

HR - heart rate

IVL - artificial lung ventilation

BCC - circulating blood volume

CPAP - continuous positive airway pressure

PEER - positive end expiratory pressure

P1P - peak inspiratory pressure

ETT- endotracheal tube

Zp02 - saturation (saturation) of hemoglobin with oxygen.

Introduction

Severe ante- and intrapartum fetal hypoxia is one of the main causes of high perinatal morbidity and mortality in the Russian Federation. Effective primary resuscitation of newborns in the delivery room can significantly reduce the adverse consequences of perinatal hypoxia.

According to various estimates, from 0.5 to 2% of full-term children and from 10 to 20% of premature and post-term children need to carry out primary resuscitation measures in the delivery room. At the same time, the need for primary resuscitation measures in children born with a body weight of 1000-1500 g ranges from 25 to 50% of children, and in children weighing less than 1000 g - from 50 to 80% or more.

The basic principles of organization and algorithm for providing primary and resuscitation care to newborns, used to date in the activities of maternity hospitals and obstetric departments, were developed and approved by order of the Ministry of Health and Medical Industry of Russia 15 years ago (Order of the Ministry of Health and Medical Industry of the Russian Federation dated December 28, 1995 N 372) . Over the past time, both in our country and abroad, extensive clinical experience has been accumulated in the primary resuscitation of newborns of various gestational ages, the generalization of which has made it possible to identify reserves for increasing the effectiveness of both individual medical measures and the entire complex of primary resuscitation as a whole.

The approaches to primary resuscitation of extremely premature infants have changed most significantly. At the same time, in the previously approved algorithm of actions of medical personnel in the delivery room, medical practices that were unjustified from the point of view of evidence-based medicine and even potentially dangerous were discovered. All this served as the basis for clarifying the principles of organizing primary resuscitation care for newborns in the maternity ward, approved by Order of the Ministry of Health and Medical Industry of Russia dated December 28, 1995 N 372, reviewing and differentiated approach to the algorithm of primary resuscitation of full-term and very premature infants.

Thus, these recommendations outline modern, internationally recognized and practice-tested principles and algorithms for primary neonatal resuscitation. But for their full-scale introduction into medical practice and maintaining the quality of medical care for newborns at a high level, it is necessary to organize on an ongoing basis the training of medical workers in every obstetric hospital. It is preferable that classes are conducted using special mannequins, with video recording of training sessions and subsequent analysis of training results.

The rapid introduction into practice of updated approaches to primary and resuscitation care for newborns will reduce neonatal and infant mortality and disability from childhood, and improve the quality of medical care for newborns.

Principles of organizing primary resuscitation care for newborns

The basic principles of providing primary resuscitation care are the readiness of medical personnel of a medical institution of any functional level to immediately provide resuscitation measures to a newborn and a clear algorithm of actions in the delivery room.

Primary and postnatal resuscitation care for newborns should be provided in all settings where birth may potentially occur, including the pre-hospital stage.

At each birth taking place in any unit of any medical institution licensed to provide obstetric and gynecological care, a medical professional with the special knowledge and skills necessary to provide the full scope of primary resuscitation care to a newborn child must always be present.

To provide effective primary resuscitation care, obstetric institutions must be equipped with appropriate medical equipment.

Work in the maternity ward should be organized in such a way that in cases of cardiopulmonary resuscitation, the employee who carries it out can be assisted from the first minute by at least two other medical workers (obstetrician-gynecologist, anesthesiologist-resuscitator, nurse anesthetist , midwife, pediatric nurse).

The following must have skills in primary neonatal resuscitation:

Doctors and paramedics of ambulance and emergency medical care who transport women in labor;

all medical personnel present in the delivery room during childbirth (obstetrician-gynecologist, anesthesiologist-resuscitator, nurse anesthetist, nurse, midwife);

staff of neonatal departments (neonatologists, anesthesiologists-resuscitators, pediatricians, pediatric nurses).

The obstetrician-gynecologist notifies in advance of the birth of the child a neonatologist or other medical worker who is fully proficient in the methods of primary neonatal resuscitation in order to prepare equipment. The specialist providing primary resuscitation care to newborns must be informed in advance by the obstetrician-gynecologist about the risk factors for the birth of a child with asphyxia.

Antenatal risk factors for the development of newborn asphyxia:

diabetes;

gestosis (preeclampsia);

hypertensive syndromes;

Rh sensitization;

history of stillbirth;

clinical signs of infection in the mother;

bleeding in the second or third trimesters of pregnancy;

polyhydramnios;

oligohydramnios;

multiple pregnancy;

intrauterine growth restriction:

maternal drug and alcohol use:

maternal use of medications that depress the newborn's breathing;

the presence of developmental anomalies identified during antenatal diagnosis;

Abnormal cardiotocography readings on the eve of birth. Intrapartumrisk factors:

premature birth (less than 37 weeks);

late birth (more than 42 weeks);

Caesarean section operation;

placental abruption;

placenta previa;

loss of umbilical cord loops;

pathological position of the fetus;

use of general anesthesia;

anomalies of labor;

presence of meconium in amniotic fluid;

fetal heart rhythm disturbances;

shoulder dystocia;

instrumental birth (obstetric forceps, vacuum extraction).

The neonatologist should also be informed about the indications for cesarean section and the characteristics of anesthesia. When preparing for any childbirth you should:

ensure optimal temperature conditions for the newborn (the air temperature in the delivery room is not lower than +24 ° C, no draft, radiant heat source turned on, a warm set of diapers);

check the availability and readiness for operation of the necessary resuscitation equipment;

invite to the birth a doctor who is fully proficient in newborn resuscitation techniques. In case of multiple pregnancies, a sufficient number of specialists and equipment should be provided in advance to provide care to all newborns;

when the birth of a child with asphyxia or the birth of a premature baby at 32 weeks of gestation or less is predicted, a resuscitation team consisting of two people trained in all techniques for resuscitating newborns (preferably a neonatologist and a trained pediatric nurse) should be present in the delivery room. Providing care to the newborn should be the sole responsibility of the members of this team during the initial resuscitation.

After the birth of the child, it is necessary to record the time of his birth and, if indicated, begin resuscitation measures in accordance with the protocol outlined below. (The sequence of primary resuscitation measures is presented in the form of diagrams in Appendices NN 1 - 4.)

--“Regardless of the initial condition, nature and volume of resuscitation measures performed, 1 and 5 minutes after birth, the child’s condition should be assessed by Apgar (Table 1). If resuscitation continues beyond 5 minutes of life, a third Apgar assessment should be performed 10 minutes after birth. When performing an Apgar assessment

against the background of mechanical ventilation, only the presence of spontaneous respiratory efforts of the child is taken into account: if present, breathing is scored 1 point, if absent - 0, regardless of the excursion of the chest in response to forced ventilation.

During labor, the need for resuscitation may arise suddenly, so each birth should have at least one physician present who is trained in neonatal resuscitation and will be responsible for caring for the newborn. Additional staff (two health workers) are needed for high-risk deliveries.

The developed principles of ABC resuscitation make it possible to competently and consistently carry out all the required stages of intensive care and resuscitation for a newborn born with asphyxia.

Stage A includes:

Warming the baby;

Ensuring correct head position and clearing the airway if necessary (provide for the possibility of tracheal intubation at this moment);

Drying the skin and stimulating the baby's breathing;

Assessment of breathing, heart rate and skin color;

Supply oxygen if necessary.

Stage B consists of providing assisted ventilation under positive pressure using a resuscitation bag and 100% oxygen (provide for the possibility of tracheal intubation at this moment).

On stage C perform chest compressions while continuing auxiliary ventilation (provide for the possibility of tracheal intubation at this point).

On stage D administer adrenaline while continuing auxiliary ventilation and chest compressions (provide for the possibility of tracheal intubation at this point).

In order for primary resuscitation to be timely, effective and non-redundant, the neonatologist-resuscitator needs to assess:

Child's breathing (crying, breathing or not breathing);

Skin color (pink or cyanotic).

The presence of spontaneous breathing can be detected by observing the movements of the chest. A loud cry indicates the presence of breathing. However, sometimes an inexperienced neonatologist may mistakenly mistake gasping breathing for effective respiratory efforts. Gaspings are a series of deep individual or serial convulsive breaths that appear during hypoxia and/or ischemia. This type of breathing indicates severe neurological or respiratory depression.

Gasping in a newborn usually indicates a serious problem and requires the same intervention as a complete absence of breathing (apnea).

Skin color, which changes from blue to pink in the first few seconds after birth, can be a quick visual indicator of efficient breathing and circulation. It is best to determine the color of a child's skin by examining the central parts of the body. If there is a significant lack of oxygen in the blood, a blue tint to the lips, tongue and torso will be observed (cyanosis).

Sometimes central cyanosis can be detected in healthy newborns. However, their color should quickly change to pink within a few seconds after birth. Acrocyanosis, which refers to a blue tint only on the hands and feet, may persist longer. Acrocyanosis without central cyanosis does not usually indicate low oxygen levels in the child's blood. Only central cyanosis requires intervention.

Resuscitation principle A

The principle of resuscitation A (airway) - ensuring airway patency - consists of the following stages:

1. Ensuring the correct position of the child.

2. Clearing the airways.

3. Tactile stimulation of breathing.

Ensuring the correct position of the child. The newborn should be placed on his back, with his neck moderately extended and his head thrown back, in a position that will bring the back wall of the pharynx, larynx and trachea in line and promote free access of air (Fig. 3, A).

This alignment is also best for effective bag-mask ventilation and/or endotracheal tube insertion. To maintain the correct position of the head, you need to place a folded diaper under the baby’s shoulders (Fig. 3, b). Care should be taken to avoid excessive stretching (Fig. 3, V) or neck flexion (Fig. 3, G), which limits the flow of air into the respiratory tract.

Wrong

Rice. 3. Correct and incorrect positions of the child for ventilation:

A- the neck is moderately extended; b- a diaper is placed under the shoulders; V- the neck is overextended; G- neck is bent excessively

Clearing the airways. If the amniotic fluid was stained with meconium, then after the birth of the baby's shoulders, it is necessary to suction out the contents of the oropharynx and nose using a catheter or a rubber bulb.

The method of further airway management after birth will depend on the presence of meconium and the baby's activity level.

Secretions and mucus can be removed from the airways by clearing the nose and mouth with a diaper or suctioning the contents with a bulb or catheter. If a newborn has a lot of secretions coming from his mouth, his head should be turned to the side.

To remove fluid that blocks the airways, you need to use a bulb or catheter that is connected to mechanical suction. First, the oral cavity is sanitized, then the nose, so that the newborn does not aspirate the contents if he takes a convulsive breath while suctioning from the nose.

Tactile stimulation of breathing. Correct positioning of the child and suction of mucus often stimulate spontaneous breathing. Wiping and drying the body and head partially perform the same function (first, the child can be placed on one hygroscopic diaper prepared before resuscitation, which will absorb the bulk of the liquid, then other warm diapers should be used to continue drying and stimulation).

For most children, completing these steps is sufficient to achieve spontaneous breathing. If the newborn is still not breathing effectively, short-term additional tactile stimulation of breathing can be performed.

Safe and appropriate tactile stimulation methods include:

Patting or tapping the soles;

Lightly rubbing the newborn's back, torso, or limbs (Fig. 4).

Rice. 4. Methods of tactile stimulation of breathing

Resuscitation principle B

Principle B - ensuring adequate breathing using oxygenation.

Oxygen starvation of vital tissues is one of the main causes of long-term clinical consequences associated with perinatal pathology, therefore it is necessary to ensure adequate breathing in a timely manner. Ventilation is the most important and effective method of cardiopulmonary resuscitation of a newborn.

For ventilation are used:

Resuscitation bag;

Oxygen tube;

Oxygen mask.

To achieve the highest possible oxygen concentration, it is necessary to apply a mask or hold the tube as close to the child's nose as possible (Figure 5).

Rice. 5. Ventilation support

For ventilating the lungs of newborns, the following are available:
types of resuscitation bags:

A bag that is filled with a flow (fills only when oxygen from an additional source of compressed gas approaches it) is an anesthesia bag;

A bag that fills itself (after each compression it fills spontaneously, sucking in oxygen or air).

It is very important that the size of the mask is selected correctly (Fig. 6).

Right wrong

A B C

Rice. 6. Correct and incorrect application of a ventilation mask:

A- the mask covers the mouth, nose and chin, but not the eyes; b- the mask covers the bridge of the nose and protrudes beyond the chin (very large); V- the mask does not cover enough

nose and mouth (too small)

Visible rise and fall of the chest is the best indication that the mask is sealing tightly and the lungs are being oxygenated.

Although the lungs must be ventilated at minimal pressure to ensure adequate chest excursions, the newborn baby's first few breaths often require high pressure (more than 30 cm H2O) to expel fluid from the fetal lungs and fill them with air. Subsequent ventilations require lower pressure.

The ventilation rate in the initial stages of resuscitation is 40–60 per minute, i.e. approximately 1 time per second.

Improvement in the condition of the newborn is characterized by the following signs:

Increase in heart rate;

Improving skin color;

Restoring spontaneous breathing.

The duration of mask ventilation is determined by the specific clinical situation. If the child is breathing spontaneously and the heart rate is adequate, assisted ventilation can be discontinued as soon as the rate and depth of spontaneous breathing are adequate. If cyanosis appears after ventilation is stopped, oxygen therapy should be continued.

If ventilation with a bag and mask lasts longer than a few minutes, an additional gastric tube must be inserted into the stomach and left in it. This is a mandatory requirement, because during ventilation with a bag and mask, gas enters the oropharynx, from where it freely reaches not only the trachea and lungs, but also the esophagus. Even with the correct position of the head, some of the gas can enter the esophagus and stomach. And the stomach, stretched by gas, puts pressure on the diaphragm, preventing the lungs from fully expanding. Also, gas in the stomach can cause regurgitation of gastric contents, which the child may later aspirate during bag and mask ventilation.

To insert a gastric tube, an 8 F feeding tube and a 20 ml syringe are required. The length of the inserted probe should be equal to the distance from the bridge of the nose to the earlobe and from the earlobe to the xiphoid process. This length should be marked on the probe.

It is better to insert the probe through the mouth rather than through the nose. The nose should be free for ventilation (Fig. 7).

In general, bag and mask ventilation is less effective than ventilation through an endotracheal tube, because when using a mask, some of the air passes through the esophagus into the stomach.

If mask ventilation is ineffective, tracheal intubation would be advisable.

Rice. 7. Correct placement of the gastric tube

Indications intubation:

Birth of a child with asphyxia;

Deep prematurity;

Surfactant administration is intratracheal;

Suspicion of diaphragmatic hernia;

Ineffective mask ventilation.

The equipment and materials required for tracheal intubation are as follows:

1. Laryngoscope (Fig. 8, A).

2. Blades (Fig. 8, b): No. 1 (for full-term newborns), No. 0 (for premature newborns), No. 00 (preferably for extremely premature newborns).

3. Endotracheal tubes with an internal diameter of 2.5; 3; 3.5 and 4 mm (Fig. 8, V).

4. Stiletto (conductor) - preferably (Fig. 8, G).

5. CO 2 monitor or detector - optional (Fig. 8, d).

6. Suction with a 10 F or large bore catheter and 5 F or 6 F catheters for suctioning the endotracheal tube (Fig. 8, e).

7. Adhesive plaster or endotracheal tube fixation (Fig. 8, and).

8. Scissors (Fig. 8, h).

9. Air duct (Fig. 8, And).

10. Meconium aspirator (Fig. 8, To).

11. Stethoscope (Fig. 8, l).

Rice. 8. Necessary equipment for tracheal intubation

Sterile disposable endotracheal tubes must be used. They should have the same diameter along their entire length and not taper at the end (Fig. 9).

Rice. 9. Endotracheal tube

Most neonatal endotracheal tubes have a line nigra near their endotracheal end, called the glottis mark. After inserting the tube, the mark should be at the level of the vocal cords. This usually allows the end of the tube to be placed over the tracheal bifurcation.

The size of the endotracheal tube is determined according to the child’s body weight (Table 1).

Table 1

Related information.