Neonatal resuscitation, the golden life saver

 The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants (90 per cent), these changes are successfully completed at delivery without requiring any special assistance. However, about 10 per cent of infants will need some intervention, and 1 percent will require extensive resuscitative measures at birth.  Globally, about one quarter of all neonatal deaths are caused by birth asphyxia, according to the World Health Organisation. Birth asphyxia is the failure to initiate and sustain breathing at birth. Effective resuscitation at birth can prevent a large proportion of these deaths.
Dr Athanase (L) poses with nurses at Kibagabaga Hospital after training in neonatal resuscitation. Courtesy photo.
Dr Athanase (L) poses with nurses at Kibagabaga Hospital after training in neonatal resuscitation. Courtesy photo.

 The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants (90 per cent), these changes are successfully completed at delivery without requiring any special assistance.

However, about 10 per cent of infants will need some intervention, and 1 percent will require extensive resuscitative measures at birth. 

Globally, about one quarter of all neonatal deaths are caused by birth asphyxia, according to the World Health Organisation. Birth asphyxia is the failure to initiate and sustain breathing at birth. Effective resuscitation at birth can prevent a large proportion of these deaths.

Dr Osée Sebatunzi, the director of Kibagabaga Hospital, says there are different levels of care available on neonatal units, depending on a baby’s needs.

“If a baby doesn’t breathe within one minute of being born ,the  birth attendant should take immediate action to stimulate their breathing and this may involve use of a bag or mask,” Dr Sebatunzi says.

The ‘golden minute’

“A baby was born but he couldn’t cry; one of the nurses cleared the airways of the baby and stimulated him but he couldn’t breathe. I was overjoyed to see how the nurse applied the theory about neonatal resuscitation we talked about in the training. She started breathing immediately for the baby with a bag mask, and, three minutes later, the baby started crying and breathing on his own.

What would have happened to this baby if no one was there to breathe for him? What if this nurse haven’t attended the training and learnt resuscitation skills?”

Dr H. Athanase, a palliative care medical student at Kibagabaga Hospital had just been training nurses and midwives on neonatal resuscitation under the “Helping babies breathe” extension programme of the International Organisation for Women and Development (IOWD).

IOWD last year introduced the neonatal resuscitation programme among the many initiatives it undertakes in the country. With the base at Kibagabaga Hospital, doctors, midwives and nurses from across the country have been undergoing the training that Dr Athanase delicately dubs, “The Golden Minutes,” because of how crucial the first ticking minutes of a baby’s birth can be to saving its life. It is the most central moment of tender loving care (TLC).

Under the programme, Dr Michael Yaker, a paediatrician from Mount Sinai Hospital, Israel, who volunteers with IOWD, gave intensive training in paediatrics to local specialists, who are also expected to pass the skills to other healthcare givers in the country. It so happens that the baby in the aforementioned peg was born moments after midwives and nurses had been inducted on the procedure by Dr Athanase.

From Dr Athanase’s experience, published on the IOWD web site, www.iowd.org, failure to administer timely neonatal resuscitation could lead to death, and when it survives, a part of its brain risks damage (encephalopathy).

“In local health centres and hospitals, newborns die either because the nurses and midwives lack the practical skills of neonatal resuscitation or lack the bag masks for ventilation of the newborn. With the bag masks Dr Yaker brought and the knowledge he shared with me, the baby was saved and his family is overjoyed to have the baby,” Dr Athanase enthuses.

The guideline

The World Health Organisation says being prepared is the first and most important step in delivering effective neonatal resuscitation. Neonates requiring resuscitation are inevitably born in locations where resuscitation is uncommon because most newborns are healthy and do not require additional special assistance.

In these settings, the need for resuscitation is not anticipated in most infants who require resuscitation. As a result, at every birthing location, personnel who are adequately trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated.

In all instances, at least one healthcare provider is assigned primary responsibility for the newborn infant. This person should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures such as positive pressure ventilation and chest compressions. In addition, either this person or another who is immediately available should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications.

Equipment needed for resuscitation should be available at every delivery area and routinely checked to ensure they are functioning properly. 

About 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required. The decision to progress beyond the initial steps is determined by simultaneous assessment of two vital characteristics: respirations (apnea, gasping, or laboured or unlaboured breathing) and heart rate (whether greater than or less than 100 beats per minute), says the World Health Organisation in a manual. 

Assessment of heart rate should be done by intermittently auscultating the precordial pulse. When a pulse is detectable, palpation of the umbilical pulse can

also provide a rapid estimate of the pulse and is more accurate than palpation at other sites.

A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures, but the device takes one to two minutes to apply, and it may not function during states of very poor cardiac output or perfusion.

Once positive pressure ventilation or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of three vital characteristics: heart rate, respirations, and the state of oxygenation, the latter optimally determined by a pulse oximeter.

The most sensitive indicator of a successful response to each step is an increase in heart rate.

The manual says careful consideration of risk factors, the majority of newborns who will need resuscitation can be identified before birth. If the possible need for resuscitation is anticipated, additional skilled personnel should be recruited and the necessary equipment prepared. 

“If a preterm delivery (less than 37 weeks of gestation) is expected, special preparations will be required. Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation,” World Health Organisation says in a manual.

“Preterm babies also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock due to small blood volume.” 

 

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