NEWBORN RESUSCITATION

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NEWBORN RESUSCITATION

• Dr Ingrid Bucens

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Layout of talk

• What is newborn resuscitation?
• What does it do?
• Is it effective? (The impact of NBR on asphyxia)
• What can it not do?
• Relationship between NBR, asphyxia and CP.
• Take home messages.

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What is neonatal resuscitation?

• Newborn resuscitation is a series of actions
  which are used to assist newborn babies who have
  difficulty with making the physiological
  transition between the womb and the outside
  world.
• Newborn resuscitation assists babies who fail to
  initiate or sustain regular breathing at birth.

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What does it involve?

• Preparation at every birth
• Assessment of the babys condition at birth
• Interventions
• Dry / stimulate
• Clear airway
• Support breathing
• Ventilate (bag/mask)
• ?oxygen
• (Advanced support)
• Chest compressions
• Intubation / ventilation
• Medications
• Ongoing assessment

BASIC
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How many babies require resuscitation?
NOT POSSIBLE TO PREDICT WHICH BABIES NEED HELP.
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What does it do?

• Through EFFECTIVE VENTILATION (physical process
  of stretch biochemical process of improving gas
  exchange), resuscitation attempts to facilitate
  the baby to begin to breathe spontaneously and
  effectively.

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Why do some babies need help with breathing at
birth?

• Something is wrong with the drive to breath
• ASPHYXIA (Intrapartum asphyxia)
• Prematurity
• Sepsis
• Drugs administered to mother (GA)
• Congenital malformation, intracranial disease
• Too weak - Neuromuscular disease

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What is ASPHYXIA?

• Asphyxia is a disturbed physiological state due
  to deprivation of oxygen supply to the fetus /
  newborn.

• Oxygen compromise may be
• Acute or chronic
• Mild or severe
• Once off or repeated episodes

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When and why does asphyxia occur?

• Causes of asphyxia are many (direct / indirect)!
  Eg.
• MOTHER
• Pre-eclampsia
• Obstructed labour
• Hypotension
• PLACENTA/CORD
• Cord prolapse
• Antepartum haemorrhage
• BABY
• IUGR
• Postmature
• Malpresentation/breech

• Asphyxia may occur
• Antenatally
• During labour / perinatal
• After delivery
• Resuscitation not expedient

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Why does ASPHYXIA matter?

• Some babies with asphyxia recover fully
• the asphyxia was mild and occurred just before
  birth
• the asphyxia was quickly recognised
• the resuscitation was timely and effective.
• Other consequences of asphyxia include
• Stillbirth
• Neonatal encephalopathy
• Neonatal death
• Longterm disability.

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INTRAPARTUM HYPOXIA
Other
Postnatal hypoxia
STILLBIRTH
ASPHYXIATED BABY No breathing
RESUSCITATION
Unsuccessful DEATH intrapartum/neonatal Dependin
g on HR at birth?
Successful
Neonatal encephalopathy
Normal
Disability
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Burden of DEATH from asphyxia

• NEONATAL DEATHS
• 4 000 000 / year
• 1 000 000 intrapartum asphyxia

• STILLBIRTHS PLUS
• Number less certain
• 4 000 000
• ?1 000 000 from asphyxia
• ?Antenatal
• ?intrapartum

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The number and of neonatal deaths due to
intrapartum asphyxia increases as overall NMR
increases.
Lawn et al. Int J Gyn Obst (2009) 107 S5-19.
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Impact on child survival- the burden of
intrapartum asphyxia
INTRAPARTUM-RELATED DEATH IS THE 5TH COMMONEST
CAUSE OF UNDER-5 DEATH IN CHILDREN! -almost 10
BMC Pregnancy and Childbirth 2009, 9 (Suppl 1)S2
http//www.biomedcentral.com/1471-2393/9/S1/S2
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DISABILITY the other burden due of intrapartum
asphyxia.

Lawn JE, et al. PLoS 2011 8e1000389
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Burden of DISABILITY from asphyxia
-Intrapartum-related impairment.
TOTAL NMR / 1000 livebirths TOTAL NMR / 1000 livebirths TOTAL NMR / 1000 livebirths TOTAL NMR / 1000 livebirths TOTAL NMR / 1000 livebirths
lt/ 5 6-15 16-30 31-45 gt/45
DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births
Stillborn 1.2 3.8 6.1 10.1 11.4
NMR 0.5 1.9 4.5 8.7 11.8
NEONATAL ENCEPHALOPATHY NEONATAL ENCEPHALOPATHY NEONATAL ENCEPHALOPATHY NEONATAL ENCEPHALOPATHY NEONATAL ENCEPHALOPATHY NEONATAL ENCEPHALOPATHY
case fatality rate Median 21 12 (?) 19 31 NA
survivors w mod-severe impairment 29 27 30 25 NA
Lawn et al. Int J Gyn Obst (2009) 107 S5-19.
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Can we impact on the burden of asphyxia
(STILLBIRTH, NND, DISABILITY) and, if so, how?

• There are 3 possible intervention points.
• PRIMARY INTERVENTION prevention of asphyxia
• Maternal health and reproductive health
• Health facility birth
• Risk factor identification (intrapartum)
• Early obstetric intervention (SBA, EMOC, referral
  services)
• Recognise and manage complications
• SECONDARY INTERVENTION NEONATAL RESUSCITATION
• TERTIARY PREVENTION
• Care of neonatal encephalopathy - NICU (referral
  services)

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INTRAPARTUM HYPOXIA
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STILLBIRTH
ASPHYXIATED BABY No breathing
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2
RESUSCITATION
Unsuccessful DEATH stillbirth/neonatal Depending
on HR at birth?
Successful
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Neonatal encephalopathy
Normal
Disabled
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NBR is an important evidence based intervention
for neonatal survival.
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Assumption that the NBR is universally
ACCESSIBLE and EFFECTIVE.

• Pre-requisites for EFFECTIVE newborn
  resuscitation
• Human resources
• SKILLED BIRTH ATTENDANT
• Other trained in NBR
• Physical resources
• Equipment / supplies

• ACCESSIBLE
• Available at point of birth
• Health facilities
• Communities!!!!!!!

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The reality .
Lawn et al. Int J Gyn Obst (2009) 107 S5-19.
Wall et al. Int J Gyn Obst (2009)
107 S47-64.
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Physical resources equipment/supplies

• Essential equipment required for basic
  resuscitation is minimal
• Self-inflating bag (no need for gas supply)
• Mask
• Suction device /- catheters
• Warming device (electricity)
• Towels
• Functional equipment issue
• Immediately available
• Good working order
• Correct size HEALTH SYSTEMS
• Sufficient supplies (multiple births)
• Clean Infection prevention

OXYGEN MAY NOT BE NECESSARY.
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Adaptations for low resource contexts

• Bag
• Tube/mask
• Mouth/mask
• ?Equally effective
• Less user-friendly
• Tiring to use
• More difficult to observe baby

• Suction devices
• Electric
• Manual
• One-way valve hand-held
• Infection risk (HIV)

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HUMAN RESOURCES

• Effective newborn resuscitation requires
  personnel to be
• Trained according to accepted standard of care
• Available at point of care
• Competently continuing to implement what they
  have learnt
• Supervision
• Resource availability
• CASE LOAD

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Availability at point of care- Cadres of
resuscitators
Adapted from Lancet (2005) 365. Newborn Survival
Series I
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Training courses
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Does training in NBR work?SBA in health
facilities

• Improvements in provider competency and
  intrapartum-related outcomes.
• Averts 30 of intra-partum related NND
  (asphyxia).
• Also 5-10 deaths due to preterm birth.

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Does training in NBR work?SBA in the community

• Community MW meta-analysis. Low grade evidence
  (trial design)
• PNMR 12, EaNNMR 13
• 22-47 mortality of non-breathing baby
• Community birthing centres /resident SBA
• Reductions in PNMR, asphyxia deaths
• Established community midwives Indonesia
  specific NBR training
• PATH competency-based NBR program tubes/masks
• Intensive supervision and follow-up 3mthly
• Total NMR by 40 EaNMR 29
• Not many countries have the luxury of so
  many midwives.
• Supervision issues isolated midwives.

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Does training in NBR work?Community - tTBAs

• Bit more controversial were out - ?back in
• Early studies methodology weak. ?11 asphyxia
  mortality
• Now mounting evidence of benefit. 1 impressive
  RCT so far.
• Primary prevention
• Increase referrals less babies born NEEDING
  resuscitation
• RCT Pakistan tTBA increased referrals and 30
  SBR, PNMR, NNMR
• And secondary
• Multicentre ENC(R) 6 countries
• SBR 31, 22 PMR
• Case loads vary, supervision needed.

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Does training in NBR work?Community CHWs

• Less controversial, significant results
• Mostly intervention packages.
• SEARCH Gadchioroli India
• Decade of work with close supervision
• 3 phases of asphyxia management
• Mouth/mouth, tube/mask, bag/mask
• BIG difference in SBR (50) and asphyxia
  mortality (65)
• Insignificant results from mouth to mouth
• Bag/mask slightly better results than tube/mask
• Other big trials India, Pakistan have shown CHW
  intervention packages aiming at improving care in
  pregnancy, SBA andENBC have shown big reductions
  in SBR, PNMR, NNMR 30-60.
• SUPERVISION very importnat

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What NBR can do - summary

• Improve the outcomes of babies with asphyxia
  reduce the impact of the injury.
• Decreases death
• Training assorted cadres of HW in basic NBR can /
  does reduce asphyxia deaths (SBR, eaNNMR) in both
  community and health facility settings.
• SBR is reduced because of coincident effects of
  primary prevention and / or because of
  resuscitation of babies who were not really
  stillborn.

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BUT!- the big question!Does it prevent
disability burden????

• Does reduction in asphyxia related deaths
  (stillbirths and neonatal deaths) mean an
  increase in the number of surviving severely
  disabled children?
• Particularly a risk where sophisticated after
  care for the successfully resuscitated babies
  is not an option.
• OR DOES IT DECREASE DISABILITY BECAUSE BABIES ARE
  BETTER RESUSCITATED???

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What newborn resuscitation cannot do.

• NBR (basic) can only hope to affect recently
  asphyxiated babies. NBR cannot bring back to
  life truly stillborn babies.
• Successful NBR does not guarantee a normal
  neurological outcome, or even survival.
• Some babies with severe neonatal encephalopathy
  due to asphyxia will have permanent neurological
  consequences disability.

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Can disability be predicted from condition
at/after resuscitation?

• Only to a limited extent.
• (APGAR SCORES)
• NEONATAL ENCEPHALOPATHY
• (BRAIN IMAGING, EEG)
• If you can, then can triage into high-risk
  follow-up or early intervention.

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Clinical prognostic predictors

• Apgar
• Score 0 at 10 minutes is almost universally poor.
• Neonatal encephalopathy
• Abnormal neurological function- difficulty
  initiating or sustaining respirations, depressed
  tone or reflexes, abnormal consciousness and
  often seizures.
• Across all NMR country categories 25-30 neonatal
  encephalopathy survivors may have a moderate or
  severe impairment!!!!
• Grade III, seizures, duration of abnormality
  BAD (80 die and other 20 severe disability)

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What about cerebral palsy? looking back...

• When is a case of CP due to birth asphyxia?
• ASPHYXIA is only one cause of CP
• Developmental abnormalities, infections, trauma.
• Intrapartum asphyxia is ONE cause of cerebral
  palsy. Only specific types of CP are caused by
  intrapartum hypoxia - (spastic 4plegia and
  dyskinetic).
• CP may result from asphyxia at any stage during
  pregnancy, delivery or after birth.
• In the West most cases are due to antenatal and
  postnatal causes.

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When is CP due to birth asphyxia?

• Criteria to attribute possible intrapartum
  causation-
• pHlt7 or BE lt -12
• severe or moderate neonatal encephalopathy
  (Ggt34wk)
• CP spastic 4p or dyskinetic.
• Sentinel hypoxic signal occurring before or
  during labour
• Sudden rapid sustained deceleration FHR after the
  event
• Apgar 0-6 for gt 5 mins
• Early evidence multisystem injury
• Early imaging evidence
• ?Is this relevant in low resource contexts
• Greater likelihood of intra-partum / perinatal
  asphyxia
• Cannot satisfy these diagnostic criteria
• Less litigation

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Take home messages

• NBR is an important evidence based intervention
  for child survival.
• It can be successfully performed by HW of all
  cadres, both at home and in health facilities.
• In HF reductions MR 30, communities similar.
• Asphyxial mortality 30
• Decreases stillbirths
• However, for NBR to be effective it needs to have
  high coverage and be of high quality. In
  communities supervision is essential.
• Challenge is bringing skilled hands to point of
  care before the babies are born. Intervention/s
  which will have impact beyond improving outcomes
  of asphyxiated babies.

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• Key interventions for maternal care
• focussed ANC
• skilled attendance at birth for risk detection
  and appropriate interventions including referral
  to EMOC centres
• Less certain is the impact of NBR on disability
  prevention because of
• Current inadequacy of data
• Multi-causal nature of CP

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