Resuscitation of newborns algorithm of actions. Neonatal resuscitation kit: equipment and medications. Medicines for neonatal resuscitation in the delivery room

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 has no spontaneous breathing or it is superficial 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 meconium aspiration, amniotic fluid, mucus, blood, as well as with 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?

Various factors - maternal, placental, fetal and the effects of a number of external reasons- 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?

When fetal hypoxia occurs, a universal reaction is observed aimed at preserving vital important organs and systems. Oxygen deficiency is accompanied by the release of vasoactive substances that increase tone peripheral vessels 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, predominates anaerobic processes and metabolic disorders of glucose, proteins, fats, electrolytes and water.

Electrolyte imbalance in combination with hypoxia and metabolic acidosis has 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 ready to provide timely resuscitation care 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, high and low water levels, fetal growth retardation, post-term pregnancy, multiple pregnancy, mother's use of drugs, alcohol and some medicines(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 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 oral cavity With right side at the moment the vocal cords open during inhalation, carry it out to the mark indicating the required depth of insertion. 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 manifests as pallor skin, weak pulse, pale spot symptom lasting more than 3 seconds, low blood pressure and lack of effect of 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 ward for continued treatment intensive care. 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. WITH therapeutic purpose alkalis and dopamine are used.

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 may develop Bladder, 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.

Pulmonary complications include respiratory distress syndrome, hypertension, and impaired utilization fluids with 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 considered prognostic 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. At 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 premature birth, adequate protocol-appropriate primary resuscitation, stabilization of hemodynamics and blood volume, maintenance of normal arterial and intraventricular pressures, and neurosonographic monitoring of the expansion of the cerebral ventricles 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 head elevated shoulder girdle and 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 for 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 predominance of heart failure, provide the child with a positive nitrogen balance, use diuretics, digoxin and metabolic drugs. Cardiogenic shock develops with a complicated course of asphyxia, acidosis, hypoglycemia, congenital defects heart disease, myocardial dysfunction, 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 drug.

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

general information

Short description

Expert advice

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 massage hearts;

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 respiratory tract)

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 the treatment of 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:
- severe metabolic acidosis (in 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.).

Medical tourism

Get treatment in Korea, Israel, Germany, USA

Medical tourism

Get advice on medical tourism

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 premature 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 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 should be considered, such as airway abnormalities, pneumothorax, diaphragmatic hernia or congenital heart disease.

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

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 ventilation lungs

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.

Resuscitation of a newborn is carried out in the delivery room or in the operating room. The volume of resuscitation measures depends on the condition of the newborn, which is assessed immediately after birth based on 4 signs of live birth: breathing, heartbeat, umbilical cord pulsation, motor activity. If all these signs are absent, the child is considered stillborn. If at least one of these signs is present, the child requires resuscitation care.

The volume and sequence of resuscitation measures depend on the severity of three main signs characterizing the state of the vital functions of a newborn - spontaneous breathing, heart rate (HR) and skin color.

When providing resuscitation care to a child, the doctor must follow the principle of “therapy - step by step.”

Stage 1 of newborn resuscitation (step A, according to the first letter of the English word airways - respiratory tract) - restoration of free airway patency and tactile stimulation of breathing.

The duration of this step is 20-25 s.

The doctor’s actions at this stage are as follows:

Suctioning the contents of the oropharynx when the baby’s head appears in the birth canal or immediately after birth;

Separation of the child from the mother without waiting for the pulsation of the umbilical cord to stop;

Placing the child under a radiant heat source;

Drying the child with a warm sterile diaper;

Suction of the contents of the oropharynx, and if there is meconium in the amniotic fluid, sanitation of the child’s larynx and trachea under the control of direct laryngoscopy;

Tactile stimulation of breathing (1-2 clicks on the heel) in the absence of spontaneous breathing after sanitization of the child’s upper respiratory tract.

The doctor’s further tactics depend on the condition of the newborn. When the child has adequate breathing, a heart rate of more than 100 beats/min and pink skin, resuscitation measures are stopped, constant medical supervision is established for him, vitamin K is administered parenterally, and applied to the mother’s breast.

If resuscitation is ineffective (irregular, shallow breathing, heart rate less than 100 beats/min, cyanosis and pale skin), proceed to the 2nd stage of resuscitation.

Stage 2 of newborn resuscitation (step B, according to the first letter of the English word breath) - restoration of adequate breathing by performing assisted or artificial ventilation.

The duration of step B is 20-30 s.

The doctor begins his actions by supplying the newborn with a 60% oxygen-air mixture using a mask and a self-expanding bag (breathing rate 40 per minute - 10 breaths within 15 s). If mask ventilation is ineffective, endotracheal intubation is started.

In the presence of drug-induced cardiorespiratory depression, nalorphine (0.01 mg/kg body weight) or etimizol (1 mg/kg body weight) is injected into the umbilical cord vessels at the same time as mechanical ventilation to stimulate the child’s breathing.

The doctor’s further tactics depend on the effectiveness of this stage of resuscitation. When the heart rate is from 80 to 100 beats/min, mechanical ventilation is continued until a heart rate of 100 beats/min or more is achieved. For cyanosis, use 100% oxygen. If the heart rate is less than 80 beats/min, mechanical ventilation should be continued and the 3rd stage of resuscitation should be started.

The 3rd stage of newborn resuscitation (step C, according to the first letter of the English word cor - heart) - restoration and maintenance of cardiac activity and hemodynamics. The doctor continues mechanical ventilation using 100% oxygen and simultaneously performs external cardiac massage for 20-30 s.

The technique of external cardiac massage consists of rhythmic pressure with the fingers (index and middle or thumbs, clasping the child’s chest) on the lower third of the sternum (just below the level of the nipples) to a depth of 1.5-2 cm with an average frequency of 120 compressions per minute (2 compression per second).

The doctor’s further tactics depend on the results of the measures taken. If the child’s heart rate increases to 80 beats/min or more, cardiac massage is stopped, but mechanical ventilation is continued until adequate spontaneous breathing is restored.

If the newborn's heart rate remains less than 80 beats/min or there is no heartbeat in combination with cyanosis or pallor of the skin, mechanical ventilation and cardiac massage are continued for 60 s and drug stimulation of cardiac activity is started (0.1 ml per 1 kg of body weight 0.01% adrenaline solution endotracheally or into the umbilical cord vein).

If, 30 s after the administration of adrenaline, the heart rate increases to 100 beats/min, cardiac massage is stopped, and mechanical ventilation is continued until the newborn recovers adequate independent breathing.

If the effect of adrenaline is ineffective (heart rate less than 80 beats/min), mechanical ventilation and cardiac massage are continued, and adrenaline is reintroduced (if necessary, every 5 minutes). If the newborn’s condition improves (heart rate more than 80 beats/min), then cardiac massage is stopped, mechanical ventilation is continued until adequate spontaneous breathing is restored, and if it does not improve (heart rate less than 80 beats/min), then mechanical ventilation and cardiac massage are continued, adrenaline is reintroduced and according to indications - one of the solutions to replenish the volume of circulating blood.

Resuscitation measures are stopped after the child has restored adequate breathing and stable hemodynamics. If the child’s cardiac activity does not recover within 20 minutes after birth, against the background of adequate therapy, no further resuscitation is performed.

Abramchenko V.V., Kiselev A.G., Orlova O.O., Abdulaev D.N. Management of high-risk pregnancy and childbirth. - St. Petersburg, 1995.

Ailamazyan E.K. Obstetrics: Textbook. - St. Petersburg, 1997. - 496 p.

Obstetrics and gynecology: A guide for doctors and students / Trans. from English - M.: Medicine. 1997.

Arias F. High-risk pregnancy and childbirth. - M.: Medicine, 1989.

Zilber A.P., Shifman E.M. Obstetrics through the eyes of an anesthesiologist. Petrozavodsk. 1997. - 396 p.

Malinovsky M.S. Operative obstetrics. - M.. 1974.

Savelyeva G.M., Fedorova M.V., Klimenko P.A., Sichinova N.G./ Placental insufficiency. - M.: Medicine, 1991. - 276 p.

Seroe VN Strizhakov A N, Markin S A Practical obstetrics: A guide for doctors. M.. 1989.

Solsky Ya.P., Ivchenko VN, Bogdanova G Yu Infectious-toxic shock in obstetric and gynecological practice. - Kyiv Health, 1990. - 272 p.

Repina M.A. Uterine rupture. - L.: Medicine, 1984. 203 p.

Repina M.A. Errors in obstetric practice. - L Medicine, 1988. - 248 p.

Chernukha E A Generic block. - M.. 1991.

Yakovlev I.I. Emergency care for obstetric pathology. - L., 1965.

More on the topic RESUSCITATIVE CARE FOR A NEWBORN:

1. INSTRUCTIONS FOR COMPLETING A PRIMARY AND RESUSCITATION CARE CARD FOR A NEWBORN IN THE MATERNITY ROOM
2. Primary and resuscitation care for newborn asphyxia
3. STAGES OF PROVIDING PRIMARY AND RESUSCITATIVE CARE TO A NEWBORN IN THE MATERNITY ROOM
4. PRIMARY STABILIZATION OF CONDITION AND FEATURES OF PROVIDING RESUSCITATIVE CARE TO NEWBORN WITH EXTREMELY LOW BODY WEIGHT

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 the amniotic fluid is thickly stained with meconium (pea soup), then immediately after the birth of the head, before the shoulders are removed, 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

Resuscitation of a newborn requires at least two people: one to maintain the airway and

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. Another important cause of 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 cesarean section, sepsis, cross-circulation in twins.

If the neonate's condition does not improve despite adequate respiratory resuscitation, vascular access and arterial blood gas analysis should be performed; Pneumothorax (prevalence 1%) and congenital anomalies of the respiratory tract should be excluded, including tracheoesophageal fistula (1:3000-5000 newborns) and congenital hiatal 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 of 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). The cardiac massage technique described for young children (Chapter 48) can be used for neonates 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. Best Review provides a straight blade, for example, Miller laryngoscope No. 0 or No. 1

Vascular access

Most optimal method vascular access is to install 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 thumbs were located on the sternum immediately below the line connecting both nipples, and the remaining fingers 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 arterial 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, it can be inserted into the trachea through an endotracheal tube.