Resuscitation of newborns: indications, types, stages, medications. Caring for premature newborns in the hospital: intensive care, nursing care for the child

Girls, I really need some sensible advice regarding breastfeeding. Pre-birth - I gave birth on October 5, at exactly 40 weeks. There was a misfortune during childbirth - after the water broke, the baby’s heartbeat during contractions began to drop to 0.... as it turned out later, he was wrapped in the umbilical cord and suffocated.... C-section It was too late to do this - the baby’s head was already inserted into the pelvis. They tried to give birth quickly - they pulled the son with a vacuum and two people squeezed him out at the same time. Since I was terribly exhausted by the contractions - and they began immediately with an interval of 1.5-2 minutes, and after 5 hours of the period of contractions I was no longer at ease - I could not catch my breath after one contraction, as the second was coming - and I really could not push.. ..in general they gave birth for a long time....the baby was born without breathing, without reflexes, blue-violet....there was only a heartbeat....2/3 Apgar....a state of severe asphyxia...after resuscitation in the delivery room , which did not give any results, he was taken to the children's intensive care unit, where they applied the method of cryocerebral hypothermia to him for 72 hours (I won’t describe this - if you are interested, you can google it), then for another week he was on a ventilator... then an oxygen tent.. .mask....the child’s condition until recently was assessed as extremely serious

about 4-5 days after his birth, I started feeding him milk... (I’m still amazed how, during the several weeks of that hell in which I lived, looking at the lifeless body of my son, all my nerves, tears, hysterics, the milk was preserved - what a blessing) obviously first through a tube, since he was actually in a coma. We started with a dose of 5 cubes of milk every 3 hours - he hardly absorbed it, out of 8 feedings, God forbid that the milk would be completely absorbed by 2 feedings....then we switched to 2 cubes every 2 hours - things went well....then 3 and etc. on the 19th day of his life we reached a dose of 50-60 cubic meters of milk per feeding every 3 hours, feeding through a tube. During this time, the child woke up, got stronger, began to breathe on his own, reflexes began to appear, he screamed... we were transferred from intensive care to another hospital - i.e. the acute period has passed. From the 20th day of his life, I started breastfeeding him. He took the breast right away, at first he really sucked for a minute or two, passed out to sleep, now (I’ve been breastfeeding for the 3rd day) he sucks longer.

Anyway, now the questions:

1) How to understand whether it is saturated or not? (I read a lot on the Internet on this topic, but I never formed my own opinion - some write that when a child is full, he stops sucking (in my opinion, this is the most logical opinion), others write that it happens that a child does not finish eating, and it is necessary weigh him before and after feeding, others something else....

2) The doctor told me that during feeding I should supplement him with 20 cubic meters from a syringe.... essentially this question follows from the first one - if the baby eats himself, then there is no point in cramming in these 20 cubic meters... especially since he started suck the breast, he tries to spit out the syringe.

3) While I was feeding him through a tube, I got used to pumping - every 3 hours, alternately from one breast to the other. About 50 cubic meters of milk came out from the breast at a time. Now I don’t know how much he sucks....so the question is: do I now need to express after each feeding? Because the fact that he doesn’t suck everything out is evident from the breasts - no matter how much he sucks, there is still milk left - it just drips from the nipples - and after pumping everything was dry. And the chest is swollen and hurts when pressed...

4) During these 3 days that he was on his chest, he did not gain weight. At birth he weighed 4170, now 3950... the child is 3 weeks old, I understand that he lay in a coma for almost two weeks of his life, and that such a weight in our case is not an indicator of something bad, but I still worry that he I haven’t gained it yet...or a couple of days on the chest and the lack of dynamics of weight gain - shouldn’t this be alarming?

5) At night he is capricious, whines, I give him the breast - he sucks for just a couple of minutes and falls asleep, but as soon as I transfer him to the crib, he starts to be capricious again - I put him to bed for two nights - everything was fine, he fell asleep well, woke up to suck the breast and fell asleep again . But this night there was a disaster in our department - one baby died - his mother took him to sleep with her, and accidentally passed out during feeding, crushed him with her breasts and suffocated him..... horror.... now I’m afraid to take him to sleep with me ( especially since you understand what hospital beds are - they are narrow), so the question is - how to try to calm him down at night? During the day he sleeps normally in his crib, but at night he asks... and he’s scared to take him in, and I feel sorry for him if he cries all night.....

I will be very glad to see your advice and comments, all this is very, very important to me!

Profound changes occur in the cardiovascular and respiratory systems at birth. Disruption of these changes can lead to death or damage to the central nervous system. Accordingly, a physician trained in neonatal resuscitation must be present at all births. Wasting time searching for someone who can resuscitate a newborn can have disastrous consequences for the baby. This article discusses the causes and consequences of cardiorespiratory failure at birth and resuscitation techniques. Whenever possible, American Academy of Pediatrics guidelines were followed.

Guidelines for neonatal resuscitation have been issued by many organizations, including the American Heart Association and the American Academy of Pediatrics. Recommendations are useful for remembering the sequence of resuscitation measures. Failure to follow the principles leads to poor results. However, mindlessly following recommendations can also lead to poor results. Understanding the physiology of labor and birth is the key to success.

Neonatal resuscitation requires training and practical experience. Unfortunately, most anesthesiologists have little opportunity to acquire and maintain neonatal resuscitation skills because few of their patients require resuscitation. Simulations can solve this problem. In the near future, those who perform neonatal resuscitation will be required to train in a simulator and repeat this training several times a year to maintain certification.

Identifying potential problems and preparing to address them before birth increases the likelihood of successful resuscitation of patients. Fetal heart rate monitoring is a very reliable and widely used method for early detection of serious fetal problems. Analysis of blood gases and fetal pH can be used to identify hypoxia and determine the need for urgent premature delivery of the fetus.

Asphyxia (i.e., decreased PaO 2 and pHa and increased PaCO 2 ) occurs when gas exchange through the placenta (fetus) and lungs (newborn) is inadequate or when there is a right-to-left shunt of blood in the heart or lungs after birth. This also occurs with myocardial dysfunction.

With fetal asphyxia, PaO 2 decreases from normal 25-40 mm Hg. Art. to less than 5 mm Hg. Art. for approximately 2 min, followed by anaerobic metabolism. After five minutes of asphyxia, the pH decreases to 6.90 or less, PaCO 2 increases to more than 100 mm Hg, and PaO 2 decreases to a level where it is undetectable. Blood flow to the liver, kidneys, intestines, skin and muscles is reduced, but blood flow to the heart, brain, adrenal glands and placenta is unchanged or increased. The consumption of oxygen from the blood increases significantly. Myocardial function is supported by myocardial glycogen and lactic acid metabolism. A heart rate of less than 100 beats/min significantly reduces cardiac output. Catecholamines are also important for survival after asphyxia. Asphyxia during childbirth can lead to hypervolemia or hypovolemia.

Fetal assessment at birth

The Apgar score, done properly, is a simple, useful guide to the condition and need for resuscitation of the newborn, but it is only a guide. The 1 minute score correlates well with acidosis and survival. The 5-minute assessment predicts neurological outcome, but not always. To obtain an overall score, each parameter must be assessed at 1 and 5 minutes. However, newborns with severe acidosis may have relatively normal indicators Apgar at 1 and 5 minutes due to peripheral vasoconstriction, which is manifested by pallor of the skin with normal heart rate and blood pressure.

Heart rate

In healthy fetuses and newborns, heart rate ranges from 120 to 160 beats/min. When the heart rate is less than 100 beats/min, cardiac output and tissue perfusion are reduced.

Breath

Breathing usually begins 30 seconds after birth and is maintained for 90 seconds. A few minutes after birth, the respiratory rate of healthy newborns is 30-60 per minute.

The absence of a pause between inhalation and exhalation helps develop and maintain FRC. Apnea and bradypnea prolong expiration, reduce FRC and cause hypoxia. The causes of apnea and bradypnea can be severe acidosis, asphyxia, drugs used by the mother, infections and damage to the central nervous system. Tachypnea (>60 breaths/min) occurs due to:

hypoxemia;

hypovolemia;

metabolic and respiratory acidosis;

hemorrhage of the central nervous system;

air leak syndrome;

pulmonary disease (eg, hyaline membrane disease, aspiration syndromes, infections);

pulmonary edema;

drugs used by the mother (eg, drugs, alcohol, magnesium, barbiturates).

Resuscitation with 100% oxygen can have detrimental effects. Resuscitation of newborns with room air is as successful as resuscitation with oxygen. Animals resuscitated with air had less hydrogen peroxide in their brain tissue than those resuscitated with oxygen. Polymorphonuclear cells were less activated by room air. Supplying oxygen in excess of what is available in room air increases the likelihood of an inflammatory reaction. Whenever possible, room air rather than oxygen should be used for neonatal resuscitation.

Muscle tone

Most newborns, including those born prematurely, are active immediately after birth and move their limbs in response to stimulation. Previous asphyxia, damage to the central nervous system, congenital amyotonia and myasthenia, as well as the prescription of medications to the mother can contribute to a decrease in muscle tone in the newborn. Flexion contractures and the absence of skin folds in the joint area are signs of intrauterine damage to the central nervous system.

Reflex activity

A newborn baby responds normally physical activity in response to stimulation, and when a catheter is inserted into the nasal passage, he cries or shows a crying grimace on his face. The newborn may not move in case of hypoxia and acidosis, as well as in the presence of damage to the central nervous system, congenital muscle diseases and when the mother is prescribed sedatives.

Color of the skin

In the first minutes after birth, all newborns have a bluish skin color. After 60 s, most children's skin becomes pink, with the exception of the hands and feet, which are still cyanotic. If central cyanosis persists for more than 90 s, especially during oxygen therapy and controlled ventilation, then suspect asphyxia, low cardiac output syndrome, pulmonary edema, methemoglobinemia, polycythemia, congenital diseases of the cardiovascular system, arrhythmia and pulmonary diseases (eg, respiratory distress syndrome, airway obstruction, pulmonary hypoplasia, diaphragmatic hernia).

Pale skin at birth is often observed in children in cases of asphyxia, hypovolemia, acidosis, or in the presence of a congenital malformation of the cardiovascular system. If a newborn pale color skin persists for more than 2 minutes, alcohol intoxication, hypermagnesemia or alkalosis (pH>7.50) should be suspected. Rubeosis of the skin is observed in polycythemia.

Resuscitation equipment

The resuscitation bed should be positioned so that the child's head is below the level of the lungs. This is necessary to ensure drainage of lung fluid and prevent aspiration of gastric contents. In the absence of asphyxia, it is necessary to maintain the newborn’s body temperature at 36-37°C. To do this, use an infrared heater with servo control. In case of asphyxia, to ensure protection of the brain, the child’s body temperature must be reduced to 34-35°C. The resuscitation area must be equipped with a suction device with adjustable suction pressure; It is unacceptable to use pressure less than 100 mmHg. Art.

To perform tracheal intubation, straight laryngoscope blades of sizes 00 and 0 are required; pencil type laryngoscope; endotracheal tubes with an internal diameter of 2.5, 3.0 and 3.5 mm; suction catheters of appropriate diameter.

The ventilator must provide ventilation at a rate of up to 150 breaths/min and maintain PEEP. Be aware of the potential for sticking of the breathing circuit valves, especially when performing high-frequency ventilation with high gas flow. If the specialist has the appropriate training, modified Jackon-Rees or Eyre circuits can be used for ventilation. Overinflation of the lungs during high tidal volume ventilation causes lung damage and activation of a systemic inflammatory response, which can lead to the development of chronic lung disease. Gentle ventilation of the lungs has less damaging effects. When providing assisted or controlled ventilation in the delivery room, peak inspiratory pressure should be monitored continuously and overpressure and high tidal volume ventilation should be avoided.

As in any critical situation, decision-making must be based on the information received. In this regard, monitoring of blood gas composition and pH level is mandatory, and test results must be obtained within 10 minutes from the moment of blood collection. It is convenient to use an umbilical arterial catheter to monitor blood pressure and collect blood for research. In case of emergency, an infusion can be performed through it.

Arterial blood saturation (SaO2) in the first minutes after birth can be determined by attaching a pulse oximeter sensor to the palm or foot of the newborn. A pulse oximeter allows you to quickly detect changes in oxygenation or FiO. Normally, in newborns, SaO 2 is 87-95%, which corresponds to PaO 2 55-70 mm Hg. Art.

Pulmonary resuscitation

If the heart rate is less than 80 beats/min and SaO 2 is less than 85%, the need for tracheal intubation should be considered and mechanical ventilation should be started at a rate of 30-60 breaths/min. During the first minutes, the duration of every fifth breath should be 2 seconds. This increase in inspiratory time allows the atelectatic lungs to open and lung fluid to be removed. PEER is maintained at 3-5 cmH 2 O. Excessive peak inspiratory pressure should be avoided. In an experiment on premature lambs, it was shown that giving just six artificial breaths with excess pressure significantly increases the damage to lung tissue and interferes with the response to surfactant. Excessive tidal volume is also associated with inflammation and chronic lung disease. Determination of airway pressure helps prevent ventilation with excessive pressure and tidal volume.

Tracheal intubation

When performing mask ventilation and tracheal intubation, the child’s head should be in the “sniffing” position. After visualizing the glottis, an endotracheal tube is inserted into the trachea to a depth of 1-2 cm below the level of the glottis, depending on the size of the child. Typically this corresponds to a depth of 7, 8, 9, 10 cm from the anterior margin of the gums in a newborn weighing 1, 2, 3 and 4 kg, respectively. When performing ventilation with a peak pressure of 15-25 cm H 2 O, a small air leak should be heard when auscultating the child's mouth. This is typically seen with 2.5 mm ID tubes in children weighing less than 1.5 kg, 3.0 mm ID tubes in children weighing 1.5-2.5 kg, and 3.0 mm ID tubes. 5 mm in children weighing more than 2.5 kg. Confirmation of successful tracheal intubation is visualization of the passage of the endotracheal tube beyond the vocal cords, the movement of both halves of the chest with each artificial inspiration, and the appearance of perspiration on the inner surface of the tube during each exhalation. Breath sounds should be louder when auscultating the lungs than when auscultating the abdomen. Once positive pressure ventilation is started, skin color should improve, as should heart rate and SaO2. At the moment of exhalation, carbon dioxide should be determined (capnometry).

However, the small tidal volume and low pulmonary blood flow velocity that characterize some infants at birth may make the effective use of capnography difficult.

Adequacy of ventilation

During inhalation, both halves of the chest should move simultaneously and symmetrically, however, the excursion of the chest during artificial ventilation should not exceed the excursion during normal spontaneous breathing of the newborn. The presence of breath sounds during auscultation is not a reliable sign of the adequacy of ventilation, due to the possibility of breath sounds from the other lung in newborns with a small chest. Asymmetry of breath sounds during auscultation of the lungs on both sides may indicate endobronchial intubation, pneumothorax, atelectasis, or congenital lung anomaly. The presence of loud respiratory sounds during auscultation in the epigastric region allows one to suspect esophageal intubation or tracheoesophageal fistula. If there is adequate ventilation, the child turns pink, begins to breathe spontaneously, and the heart rate normalizes.

Since most asphyxiated newborns do not have lung disease, they can be effectively ventilated with a peak pressure of less than 25 mmHg. Art., including during the first breaths. Neonates with hard lungs (eg, erythroblastosis fetalis, congenital pulmonary anomalies, pulmonary edema, severe meconium aspiration, diaphragmatic hernia) may require high peak inspiratory pressure ventilation, increasing the likelihood of air leak syndrome. It can be prevented by ventilation with a peak pressure of 15-20 cmH 2 O and a frequency of 150-200 breaths/min. If low pressure (low volume) high tidal volume ventilation does not improve oxygenation, high pressure (high tidal volume) ventilation may be necessary. Failure to effectively ventilate at birth can worsen hypoxemia and lead to central nervous system damage and even death. With an increase in PaO 2 more than 70-80 mm Hg. Art. or SaO 2 more than 94%, the concentration of inhaled oxygen (if a breathing mixture with a high oxygen content was previously used) should be brought to a level at which SaO 2 and PaO 2 will be maintained at normal age levels. In infants less than 34 weeks of gestation, oxygenation is maintained at the lower limit of normal to prevent the development of neonatal retinopathy. During tracheal intubation in a hypoxic newborn, there is a risk of arrhythmia, and therefore the heart rate should be constantly monitored.

Routine tracheal debridement

If there is an admixture of dense meconium in amniotic fluid, as well as in the case of massive vaginal bleeding, ventilation is started only after aspiration of the tracheal contents. Descriptions of meconium aspirators are widely available in the literature.

Particulate meconium must be removed from the lungs before ventilation is started. The mouth and throat must be sanitized immediately after the baby's head is born. After tracheal intubation, the endotracheal tube is connected to a special suction device and, at the time of aspiration, is removed from the trachea. The laryngoscope is not removed. After aspiration of meconium, the endotracheal tube is inserted into the trachea, after which repeated aspiration is performed. Gentle ventilation is then carried out. During laryngoscopy and aspiration, it is necessary to constantly monitor the heart rate and insufflate 100% oxygen near the newborn's face. Meconium should also be aspirated from the stomach to avoid regurgitation and aspiration. Newborns with an Apgar score of 9-10 do not require tracheal sanitation. Removing liquid meconium from the trachea of a newborn at the time of birth has no beneficial effect, while removing solid meconium particles is effective.

Other causes of respiratory failure

Pneumothorax

Pneumothorax occurs in 1% of cases during vaginal delivery, in 10% of cases in the presence of meconium in the amniotic fluid and in 2-3% of newborns who required artificial ventilation in the delivery room. In the presence of unilateral pneumothorax, overinflation of one half of the chest and limitation of its respiratory excursion are observed. The heartbeat is shifted to the healthy side. Heart sounds may be muffled.

In the presence of pneumothorax, the affected part of the chest glows when illuminated with a narrow beam of highly intense cold light. Elimination of pneumothorax is carried out by puncture or drainage of the pleural cavity.

Surfactant administration

Surfactant administration resulted in a significant reduction in the incidence of air leak syndrome, including interstitial emphysema, hyaline membrane disease, bronchopulmonary dysplasia (BPD), and mortality. Surfactant is administered intratracheally at a dose of 5 ml of solution per kilogram of body weight immediately at birth or within a short period of time after it. The administration of surfactant is accompanied by a short episode of desaturation. In most cases, SaO 2 subsequently increases rapidly due to increased pulmonary compliance, which, in turn, can lead to hyperinflation of the lungs with subsequent damage to lung tissue or the occurrence of air leak syndrome if inspiratory pressure is not reduced in a timely manner.

Premature infants often require nasal CPAP after birth, which reduces the likelihood of tracheal intubation and mechanical ventilation. However, this does not reduce the incidence of hemorrhage in the central nervous system and chronic lung disease. The duration of oxygen dependence and chronic lung disease does not change.

Vascular resuscitation

Vascular resuscitation is not a core aspect of neonatal resuscitation. If the newborn's condition does not improve with ventilation, oxygenation (if necessary), and tactile stimulation, it is necessary to catheterize the umbilical artery to collect blood for gas and pH testing, as well as to administer fluid therapy if necessary.

Correction of acidosis

Correction of respiratory acidosis is carried out using artificial ventilation. To correct metabolic acidosis, a sodium bicarbonate solution is administered. Its osmolarity is 1800 mOsmol/L, so rapid administration of this solution (>1 mmol/kg/min) in premature infants can lead to intracranial bleeding. The interaction of hydrogen ions with 50 mmol of bicarbonate leads to the formation of 1250 ml of CO. If pulmonary ventilation is adequate, this does not lead to an increase in PaCO 2; with inadequate ventilation, a significant increase in PaCO 2 occurs, which can cause cardiac arrest and/or intracranial hemorrhage. Therefore, sodium bicarbonate solution can only be administered to newborns with metabolic acidosis, provided there is adequate pulmonary ventilation. In hypovolemic neonates, administration of sodium bicarbonate may cause hypotension by reversing peripheral vasoconstriction caused by acidosis. Trisamine (THAM) is an alternative drug. Its administration leads to a decrease in PaCO levels.

If, despite tactile stimulation and ventilation, the Apgar score is 2 or less at 2 minutes or 5 or less at 5 minutes, it may be necessary to administer sodium bicarbonate at a dose of 2 mmol/kg during ventilation. If pH is less than 7.0, PaCO 2 is less than 35 mm Hg. Art., and the blood volume is adequate, one-fourth of the base deficiency should be corrected. If the pH is more than 7.1, sodium bicarbonate is not administered, but pulmonary ventilation is continued. If the pH is more than 7.15, then only ventilation is performed. If, against this background, the pH decreases or remains at the same level, continue ventilation and correct one-fourth of the deficiency of buffer bases by administering sodium bicarbonate or trisamine. A significant increase in PaO 2 was not observed until the pH increased from 7.1 to 7.2, when Rudolph and Yuen found the most significant decrease in PVR.

Typically, metabolic acidosis develops as a result of decreased tissue perfusion as a consequence of hypovolemia or heart failure. Acidosis-induced heart failure usually occurs when the pH decreases less. When pH increases above 7.15, cardiac output improves. In case of heart failure due to congenital bradycardia, isoproterenol is prescribed (in an initial dose of 0.05 mcg/kg/min with a further increase if necessary) or a transvenous pacemaker is installed. Hypoglycemia may be the cause of heart failure. Therefore, when resuscitating a newborn, it is necessary to monitor blood glucose levels.

Intravascular volume expansion

If the umbilical cord is clamped early or if the umbilical cord is tightly wrapped around the fetus's neck and the umbilical cord must be cut to deliver the baby, the fetus may become hypovolemic. It is also observed with asphyxia during childbirth, abruption and placenta previa.

Diagnosis of hypovolemia

Hypovolemia is determined by measuring blood pressure and physical examination (ie, skin color, perfusion, capillary refill time, pulse refill, and extremity temperature). CVP measurements are useful in diagnosing hypovolemia and in determining the adequacy of fluid replacement. Venous pressure in healthy newborns is 2-8 cm H 2 O. If the central venous pressure is less than 2 cm H 2 O, hypovolemia should be suspected.

Therapy for hypovolemia

Treatment of hypovolemia requires intravascular volume replacement with blood and crystalloids. Albumin can also be used, but evidence of its effectiveness is limited. If it is suspected that the newborn will be hypovolemic at birth, then a bag of Rh negative type 0 blood should be available in the delivery room before the baby is born.

Sometimes, in order to raise blood pressure to normal, huge amounts of blood and solutions are required. At times, it is necessary to replace more than 50% of the blood volume (85 ml/kg in full-term newborns and 100 ml/kg in premature newborns), especially if abruption or placental injury occurs during childbirth. In most cases, up to 10-20 ml/kg of solutions are required to restore mean arterial pressure to normal.

Excessive increase in intravascular volume should be avoided because sudden systemic hypertension may rupture cerebral vessels, leading to intracranial hemorrhage, especially in premature infants.

Other causes of hypotension

Hypoglycemia, hypocalcemia, and hypermagnesemia cause hypotension in newborns. Hypotension caused by alcohol or magnesium intoxication usually responds well to blood volume replacement or dopamine, or both. Hypermagnesemia in newborns is usually treated with 100-200 mg/kg calcium gluconate administered over 5 minutes.

Heart massage

If, despite stimulation and ventilation, the heart rate in the 1st minute of life or earlier is less than 80 beats/min, it is necessary to intubate the trachea, perform mechanical ventilation with oxygen and begin closed cardiac massage. Place both thumbs on the sternum and use your other fingers to support the baby's back. Compress the sternum 2-2.5 cm with a frequency of 100-120 per minute. There is no need to interrupt ventilation during cardiac massage. The effectiveness of cardiac massage is assessed by measuring blood gases and pH, created by blood pressure and examining the pupils, which should be in the middle position or constricted. If the pupils are dilated and no atropine has been used, cerebral blood flow and oxygenation are inadequate.

Drugs for resuscitation

In severe acidosis (pH< 7,0) эффективность этих лекарств уменьшается. Т.е. необходимо как можно быстрее поднять рН выше. Все препараты необходимо вводить в минимальном объеме растворителя, чтобы снизить риск возникновения гиперволемии.

When to stop resuscitation

The decision to stop resuscitation is usually based on the physician's experience, the patient's condition, and the wishes of the parents. If the chances of living a productive, successful life are very low, you should consider stopping all revitalization efforts. Whether to resuscitate extremely premature babies is a big question, since the outcomes of nursing newborns born before the 26th week of gestation are very disastrous. If possible, the situation should be discussed openly with the family before the baby is born. If this is not done, then you need to start resuscitation and stop it after talking with the parents.

As a rule, in modern maternity hospitals, a mother and her child are kept together in the same room after childbirth. They are called "shared wards" or "mother and child" wards. The vast majority of modern maternity hospitals and departments operate on this principle. But it happens that for reasons beyond the control of a young mother, this principle has to be violated...

Staying together with the mother after birth makes the child’s adaptation to extrauterine life easier. The baby is not afraid next to his mother: he feels protected. Reacting to the baby’s anxiety, the mother can take him in her arms, caress him, and calm him down at any moment of the day or night. In addition to the benefits for the child, this helps strengthen the woman’s sense of motherhood.

Staying in the same room with a baby for several days, a woman acquires skills in caring for a newborn: she learns to swaddle and wash the baby. This helps mothers, especially first-time mothers, subsequently feel more confident at home. In the “mother and child” wards, the modern principle of free feeding of the child (not “by the clock”, but “on demand”) is most successfully implemented. Frequent feedings contribute to more successful lactation in a woman. There are fewer cases of shortage (or, conversely, stagnation) of milk in.

But some children may be separated from their mothers. The cause is usually situations related to the child's health. That is why, with the widespread introduction of the “mother and child” principle into the work of maternity hospitals, they still retain departments or simply wards for newborns who have any diseases or significant disorders of adaptation to extrauterine life that do not allow them to be next to moms.

Premature baby

The most common reason separation from mother - birth. But even here there may be options for the development of events. Premature baby- not necessarily sick. Indeed, children born before 37 weeks of pregnancy have a higher incidence of diseases and disorders of the adaptation period compared to full-term infants. Thus, due to the immaturity of the lungs, such children often cannot breathe on their own, and they need the help of special equipment. Premature babies (especially those with a small initial weight of the child - up to 1500 g) may experience spontaneous respiratory arrest and convulsions.

In children born ahead of schedule, not uncommon feeding problems. They often spit up, there may be bloating, and sometimes the food the child receives through the mouth is not digested at all. These cases force doctors to use an alternative method of feeding - intravenous administration of nutrient solutions. But if the condition of a child weighing more than 2000 g (and sometimes a little less) remains satisfactory or becomes so after several hours or days of observation in the neonatal ward, such a baby can remain in the maternal ward for the remainder of his stay in the maternity hospital.

Of course, comfortable conditions should be created for him in the maternity hospital - first of all, warm. All newborn babies (and premature babies especially) are very sensitive to cold. An infant who has experienced cold stress has a higher risk of adverse effects on the nervous system and is less active in fighting possible infection. Such a child has longer and more intense jaundice, and swelling does not disappear for a long time. Therefore, in the room where the low birth weight newborn is located, a heater, a radiant heat lamp, or a warm bed for the baby is installed. Some maternity hospitals practice installing a special incubator (incubator) directly in the mother’s room for a baby who is stable in condition but does not retain heat independently, so that the child has the opportunity to constantly be close to the mother.

If the child’s weight at birth is less than 2000 g, then, as a rule, such a baby requires observation, and often treatment in a neonatal department. This could be the intensive care unit or the neonatal intensive care unit of a maternity hospital. It cannot be understood literally from the name that such a newborn will necessarily undergo some kind of resuscitation. There is a category of small newborns who receive minimal treatment (for example, phototherapy for jaundice or short-term intravenous administration of necessary medications), but require round-the-clock monitoring by qualified medical personnel. So, nurses The color of the child’s skin, breathing rate, heartbeat are regularly noted, and many important parameters of the baby’s body are measured using special instruments, incl. arterial pressure. In some cases, such measurements have to be carried out on a child quite often. In the maternal ward, this can only be organized if there is an individual medical post.

Many maternity hospitals are now implementing kangaroo method when nursing premature newborns. Its essence is that, as soon as the baby’s condition allows, he is laid on his mother’s chest for a while. Mom sits comfortably in a chair. In this case, the baby is in direct contact with the mother’s skin, which is very important for preventing infection in the child, because his skin begins to be colonized by the mother’s bacteria that are already familiar to him. This is a powerful protection factor against aggressive microflora in intensive care units. During this procedure, the baby is unswaddled, but covered on the outside with a blanket to keep warm.

Besides others positive aspects The kangaroo method allows you to better prepare the child for subsequent breastfeeding, since it stimulates precisely those innate reflexes inherent in all newborn children that are aimed at receiving nutrition. In addition, the baby can touch the mother's breast with his palms, causing a rush of milk from the mother and strengthening his own hand-mouth reflex, necessary for subsequent feedings.

Premature babies from maternity hospitals are often not discharged home, but are transferred to multidisciplinary hospitals, where they can receive additional examination and treatment. In addition, during these extra few weeks they manage to learn to feed from the breast and gain weight.

Most often, the transfer of the baby occurs on the 6-7th day. Although, depending on the condition of the child, the availability of beds in the hospital, and the readiness for the simultaneous transfer of mother and baby, these terms may vary somewhat.

Most departments for caring for premature newborns in hospitals (except neonatal intensive care units) are adapted for the simultaneous stay of children and mothers in the wards. It is very important that the sick child and mother are not separated. And if in the maternity hospital such separation was forced due to the child’s condition, then in the hospital, as a rule, the baby’s health condition allows him to be with his mother.

Full term baby

A full-term baby may also be kept separately from the mother in the maternity hospital. This applies to cases where children are born in a serious condition or condition medium degree gravity. For example, after birth a baby may have problems with spontaneous breathing; it is frequent, superficial, irregular or absent altogether. The reasons may be the so-called asphyxia- the birth of a child with impaired breathing and heartbeat, an inflammatory process in the lungs of the fetus that began in utero, as well as birth trauma of the child and some others. Then the doctor helps the baby’s lungs expand and subsequently breathe using special equipment. Immediately after birth, after listening to the baby's lungs and heart, the doctor may detect warning signs of dysfunction (for example, suspect congenital pneumonia). This may be combined with a change in the child's skin color: he looks bluish or very pale.

There are many newborn diseases that appear immediately after birth. For example, a child born in conditions of obvious oxygen starvation may be lethargic, react poorly to examination, refuse to breastfeed, or, conversely, be loud and excitable. Approximately the same symptoms are observed in newborns and with birth injuries.

As a rule, immediately after birth it is not difficult to suspect congenital heart defects(the baby may be cyanotic, the doctor will listen for a rough heart murmur, the heart rhythm may be abnormal) or defects of some internal organs(for example, a lack of stool, a bloated abdomen, persistent regurgitation or vomiting in a baby may indicate a pathology of intestinal development).

Other diseases become available for diagnosis after some time, when the condition of a full-term baby worsens during the first hours and days of life. This, for example, occurs with hemorrhagic disease of the newborn, which most often manifests itself in the form of regurgitation mixed with blood, or some infections.

All these cases require careful monitoring of the baby’s condition, emergency or planned medical procedures. And of course, the child must be in the neonatal department, where there are conditions for the necessary observation and treatment. Such a baby may need full monitoring of the vital functions of his body with the help of modern monitors. Necessary medications may need to be administered. And the most acceptable method for newborns is the intravenous route of administration. Supporting adequate breathing of a child involves the use of special devices. The neonatal intensive care units (or wards) found in maternity hospitals are equipped with all this.

It is not uncommon for a baby, who was initially in the ward with his mother after birth, to be transferred to the neonatal department after some time. This happens, for example, if there is a need to give a child a course of special therapy for severe jaundice.

Faint jaundice, visible only on the baby’s face and torso, is a fairly common occurrence. Occurring on the 2-3rd day, it is called physiological jaundice. The main reason for its occurrence is the immaturity of the liver of a newborn child. A special liver protein (enzyme), due to its low activity in children of this age, does not have time to “process” the bilirubin pigment. Therefore, bilirubin begins to accumulate in the subcutaneous fat layer, causing visible jaundice. With physiological jaundice, the child’s condition does not suffer. Such jaundice does not require treatment, disappearing on its own, as a rule, on the 8-10th day.

Another thing - pathological jaundice. There are quite a few reasons for its occurrence. It differs from physiological in that it often occurs early (on the first day of a child’s life) and does not go away for a long time. The child’s skin takes on an intense yellow color, even the sclera of the eyes are stained. The child's condition may worsen against the background of such jaundice. High levels of bilirubin can cause undesirable effects on the baby's nervous system.

Most effective method The treatment of pathological jaundice is called phototherapy. It involves exposing the child’s yellowed skin to the light of special lamps, and few maternity hospitals have the opportunity to equip maternal wards with such lamps. For some newborns, several phototherapy sessions of 2-3 hours are sufficient, while others must receive treatment over several days. As a result, the bilirubin that has accumulated in subcutaneous fat is eliminated from the body faster. Accordingly, its level in the blood also decreases, and jaundice disappears faster.

Another one of possible reasons temporary separation of a full-term baby from his mother - difficulties experienced by the baby at birth (in other words, suspected or proven birth injury child). In this case, the baby may be restless, he screams, any manipulation with him can increase this restlessness. During the first 1-2 days, such a child can be monitored in the neonatal department, receiving treatment (painkillers, intravenous administration of medicinal solutions). If the child’s condition clearly improves, he can continue to stay in the ward with his mother.

Often in maternity hospitals, in relation to premature newborns and full-term children, who are immediately after birth due to their health status, separated from their mothers, they practice staying in the maternal ward during the day, and at night in the neonatal department under the supervision of a nurse and doctor. This does not exclude night feeding of the baby (directly from the mother's breast or with expressed milk).

Children after surgical birth

A separate question is where the children should be, born as a result of caesarean section. On the 1st-2nd day (while the mother is in the intensive care unit after the operation), nurses take care of the child. They also help the mother put the baby to the breast. Such a child spends most of his time in the neonatal unit, but is brought to his mother for feeding. Currently, in some maternity hospitals, a healthy child is kept with the mother during the day for 1-2 days after a cesarean section. As soon as the woman is transferred to the postpartum ward and can independently care for her baby, it is better to leave him with his mother during the day and night. If it is possible to provide the mother with round-the-clock assistance from relatives or medical personnel, it is better for the baby to remain with the mother immediately after the woman is transferred to the postpartum ward (48 hours after the operation).

Contact is important!

In all cases of forced separation of mother and child in a maternity hospital, no one has the right to prohibit or limit contact between mother and child. It means that a mother should be able to see her child as often as she wants. Moreover, doctors explain how important it is that both parents can communicate with the child. After all, dad worries no less than mom, and if they visit their baby together in the intensive care ward in the intensive care unit, it will be easier for them to bear the weight of fears for the life and health of the child.

It is sometimes difficult for parents to see their one-kilogram baby or a child with a serious illness. Mom and dad do not dare to touch the child, they are afraid of hurting him, they do not dare to talk to him. They are frightened by the equipment with which the baby is surrounded. If this situation arises, do not be afraid to ask nurses and doctors about anything that is not clear. They will explain to parents why this or that device is needed, what the role of each wiring connected to the child is - most often in intensive care units it is necessary to monitor the baby’s breathing rate, pulse, blood pressure, and temperature. Various monitors can do this. Parents become medical assistants - this is surprising, but their love gives the child additional strength for recovery. Mom and dad can stroke their baby, just hold his hand, tell him tender words. Don't be afraid to do this. If there are any fears or doubts, the medical staff will definitely tell you what to do to make the child feel more comfortable.

Another important task is lactation support for women, whose children are various reasons temporarily separated from them. Cases when a child cannot receive breast milk are very rare: for example, contraindications may include the mother taking a number of medications that are incompatible with breastfeeding, and some other circumstances. Most children need mother's milk. This is especially important for premature, low birth weight, and sick full-term newborns. Every drop of breast milk will help grow and heal a baby who, immediately after birth, is sent to the intensive care unit (or intensive care unit) of a maternity hospital or hospital for health reasons. After all, only breast milk optimal in composition for a baby. In addition to nutrients, it contains protective anti-infective factors, as well as components that promote proper development child's nervous system.

If the baby is separated from the mother, no later than 2 hours after birth, the mother, with the help of a nurse or doctor, begins to express drops of colostrum. Such stimulation of the mammary glands is mandatory in the feeding regimen of healthy children, i.e. at least 8 times a day. These actions help maintain lactation and, in addition, get the right amount of milk to feed the baby. If a premature baby requires 12 feedings per day, you can ask the mother to change the pumping regimen. Sometimes mothers express milk right next to the cribs or incubators with their babies in intensive care units. It was noted that milk flows out better and, accordingly, the volume of expressed milk is greater.

Mothers, under the supervision of a nurse, can participate in feeding their premature babies by giving them freshly expressed milk. In this case, the mother realizes her involvement in the child’s recovery process.

It is important to understand that separation from the mother is justified only if there are truly significant reasons. Any interruption of contact between the newborn and the mother and transfer to various departments of the medical institution increases the risk of infection of the baby. Sometimes it is difficult for parents to understand why full-term and apparent healthy child can no longer be with his mother and must be transferred to the department. But this really happens, because we are talking about a baby who is only a few hours (or days) from birth and who still finds it very difficult to fight a disease or dangerous condition without the help of specialists. The condition of newborns sometimes deteriorates very quickly. That is why doctors and nurses carefully monitor the health of babies and are extremely careful when making any predictions.

Anna Usynina, neonatologist,
Associate Professor of the Department of Neonatology and Perinatology
Northern State Medical University,
Arkhangelsk

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 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 slightly 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 and administers medications and infusion solutions, is very useful.

The most common cause of newborn asphyxia is intrauterine hypoxia, therefore key point 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 us 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). Cardiac massage technique described for children younger age(Chapter 48), can be used for newborns weighing > 3 kg. The ratio of the frequency of pressure and blowing should be 3:1, so that 90 pressures and 30 blows are performed within 1 minute. It is necessary to periodically check your heart rate. When heart rate > 80/min, indirect cardiac massage is stopped.

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

Vascular access

The most optimal method of 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; with deeper administration, transfused hypertonic solutions can enter directly into 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. Necessary measures must be taken 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. Rarer causes of hypotension include hypocalcemia, hypermagnesemia, and hypoglycemia.

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

Medications

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

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

B. Other medications: 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 and can be administered into the trachea through an endotracheal tube.

According to statistics, every tenth newborn child receives medical care in the delivery room, and 1% of all births require a full range of resuscitation actions. The high level of training of medical personnel makes it possible to increase life chances and reduce possible development complications. Adequate and timely resuscitation of newborns is the first step towards reducing mortality and disease development.

Basic Concepts

What is neonatal intensive care? This is a series of activities that are aimed at revitalizing the child’s body and restoring lost functions. It includes:

intensive care methods;
use of artificial lung ventilation;
installation of a pacemaker, etc.

Full-term babies do not require resuscitation measures. They are born active, scream loudly, pulse and heart rate are within normal limits, the skin is pink, and the child responds well to external stimuli. Such children are immediately placed on the mother's stomach and covered with a dry, warm diaper. Mucous contents are aspirated from the respiratory tract to restore their patency.

Carrying out cardiopulmonary resuscitation is considered an emergency response. It is performed in case of respiratory and cardiac arrest. After such an intervention, in case of a favorable result, the basics of intensive care are applied. This treatment is aimed at eliminating possible complications stopping the work of important organs.

If the patient cannot independently maintain homeostasis, then resuscitation of the newborn includes either inserting a pacemaker.

What is needed to perform resuscitation in the delivery room?

If the need for such activities is small, then one person will be required to carry them out. In case of a difficult pregnancy and waiting for a full range of resuscitation actions, there are two specialists in the maternity room.

Resuscitation of a newborn in the delivery room requires careful preparation. Before the birth process, you should check that everything you need is available and make sure that the equipment is in working condition.

You need to connect a heat source so that the resuscitation table and diapers are warmed up, roll one diaper into a roll.
Check whether the oxygen supply system is installed correctly. There must be a sufficient amount of oxygen, correctly adjusted pressure and flow rate.
The readiness of the equipment required for suctioning the contents of the respiratory tract should be checked.
Prepare instruments to remove gastric contents in case of aspiration (probe, syringe, scissors, fixing material), meconium aspirator.
Prepare and check the integrity of the resuscitation bag and mask, as well as the intubation kit.

The intubation kit consists of guides, a laryngoscope with different blades and spare batteries, scissors and gloves.

What makes events successful?

Neonatal resuscitation in the delivery room is based on the following principles of success:

availability of resuscitation team - resuscitators must be present at all births;
coordinated work - the team must work harmoniously, complementing each other as one big mechanism;
qualified staff - every resuscitator must have a high level of knowledge and practical skills;
work taking into account the patient’s reaction - resuscitation actions should begin immediately when the need arises, further measures are carried out depending on the reaction of the patient’s body;
serviceability of equipment - equipment for resuscitation must be in working order and accessible at all times.

Reasons for the need for events

Etiological factors that inhibit the functioning of the heart, lungs and other vital organs of a newborn include the development of asphyxia, birth injuries, development congenital pathology, toxicosis of infectious origin and other cases of unknown etiology.

Pediatric neonatal resuscitation and its need can be predicted even during the period of pregnancy. In such cases, a team of resuscitators must be ready to immediately provide assistance to the baby.

The need for such measures may arise in the following conditions:

high or low water levels;
post-maturity;
maternal diabetes;
hypertonic disease;
infectious diseases;
fetal malnutrition.

There are also a number of factors that already arise during childbirth. If they occur, you can expect the need for resuscitation measures. Such factors include bradycardia in the child, cesarean section, premature and rapid labor, placenta previa or abruption, and uterine hypertonicity.

Asphyxia of newborns

The development of impaired breathing processes with hypoxia of the body causes the appearance of disorders in the circulatory system, metabolic processes and microcirculation. Next, a disorder in the functioning of the kidneys, heart, adrenal glands, and brain appears.

Asphyxia requires immediate intervention to reduce the possibility of complications. Causes of breathing disorders:

hypoxia;
airway obstruction (aspiration of blood, mucus, meconium);
organic damage to the brain and central nervous system;
developmental defects;
insufficient amount of surfactant.

Diagnosis of the need for resuscitation is carried out after assessing the child’s condition using the Apgar scale.

What is being assessed	0 points	1 point	2 points
Breathing status	Absent	Pathological, irregular	Loud scream, rhythmic
Heart rate	Absent	Less than 100 beats per minute	More than 100 beats per minute
Skin color	Cyanosis	Pink skin, bluish limbs	Pink
State of muscle tone	Absent	Limbs are slightly bent, tone is weak	Active movements, good tone
Reaction to irritant factors	Absent	Weakly expressed	Well expressed

A condition score of up to 3 points indicates the development of severe asphyxia, from 4 to 6 - asphyxia of moderate severity. Resuscitation of a newborn with asphyxia is carried out immediately after assessing his general condition.

Sequence of condition assessment

The child is placed under a heat source, his skin is dried with a warm diaper. The contents are aspirated from the nasal cavity and mouth. Tactile stimulation is provided.
A breathing assessment is performed. If the rhythm is normal and there is a loud cry, move on to the next stage. In case of irregular breathing, mechanical ventilation is performed with oxygen for 15-20 minutes.
Heart rate is assessed. If the pulse is above 100 beats per minute, proceed to the next stage of examination. In case of less than 100 beats, mechanical ventilation is performed. Then the effectiveness of the measures is assessed.
- Pulse below 60 - indirect cardiac massage + mechanical ventilation.
- Pulse from 60 to 100 - mechanical ventilation.
- Pulse above 100 - mechanical ventilation in case of irregular breathing.
- After 30 seconds, if indirect massage with mechanical ventilation is ineffective, it is necessary to carry out drug therapy.
Skin color is examined. Pink color indicates the normal condition of the child. In case of cyanosis or acrocyanosis, it is necessary to give oxygen and monitor the baby’s condition.

How is primary resuscitation performed?

Be sure to wash and treat your hands with antiseptic and wear sterile gloves. The time of birth of the child is recorded after necessary measures- is documented. The newborn is placed under a heat source and wrapped in a dry, warm diaper.

To restore airway patency, you can lower the head end and place the child on his left side. This will stop the aspiration process and allow the contents of the mouth and nose to be removed. Carefully suck out the contents without resorting to deep insertion of the aspirator.

If such measures do not help, resuscitation of the newborn continues by sanitation of the trachea using a laryngoscope. After breathing appears, but there is no rhythm, the child is transferred to mechanical ventilation.

The neonatal intensive care unit admits the child after initial resuscitation measures to provide further assistance and maintain vital functions.

Ventilation

The stages of neonatal resuscitation include ventilation:

lack of breathing or the appearance of convulsive respiratory movements;
pulse less than 100 times per minute, regardless of breathing status;
persistent cyanosis during normal functioning of the respiratory and cardiovascular systems.

This set of measures is carried out using a mask or bag. The newborn's head is tilted back slightly and a mask is placed on the face. It is held with the index fingers and thumbs. The rest is used to remove the child's jaw.

The mask should be on the chin, nose and mouth. It is enough to ventilate the lungs at a frequency of 30 to 50 times per minute. Ventilating with a bag may cause air to enter the stomach cavity. You can remove it from there using

To monitor the effectiveness of the exercise, you need to pay attention to the rise of the chest and changes in heart rate. The child continues to be monitored until full recovery rhythm of breathing and heart contractions.

Why and how is intubation performed?

Primary resuscitation of newborns also includes tracheal intubation, if mechanical ventilation is ineffective for 1 minute. Right choice intubation tubes - one of important points. It is done depending on the baby’s body weight and gestational age.

Intubation is also performed in the following cases:

the need to remove meconium aspiration from the trachea;
carrying out prolonged ventilation;
facilitating the management of resuscitation measures;
injection of adrenaline;
deep prematurity.

The laryngoscope is illuminated and held in the left hand. Right hand holding the newborn's head. The blade is inserted into the mouth and passed to the base of the tongue. Raising the blade towards the handle of the laryngoscope, the resuscitator sees the glottis. The intubation tube is inserted from the right side into the oral cavity and passed through the vocal cords at the moment they open. This happens while inhaling. The tube is carried out to the planned mark.

The laryngoscope is removed, then the guidewire. The correct insertion of the tube is checked by squeezing the breathing bag. Air enters the lungs and causes chest excursion. Next, the oxygen supply system is connected.

Indirect cardiac massage

Resuscitation of a newborn in the delivery room includes that indicated when the heart rate is less than 80 beats per minute.

There are two ways to perform indirect massage. When using the first, pressure on the chest is carried out using the index and middle finger of one hand. In another version, the massage is carried out with the thumbs of both hands, and the remaining fingers are involved in supporting the back. The resuscitator-neonatologist applies pressure at the border of the middle and lower third of the sternum so that the chest sag by 1.5 cm. The frequency of pressure is 90 per minute.

It is imperative to ensure that inhalation and pressing on the chest are not carried out simultaneously. During the pause between pressures, you cannot remove your hands from the surface of the sternum. Pressing the bag is done after every three pressures. For every 2 seconds you need to perform 3 pressures and 1 ventilation.

Actions in case of water contamination with meconium

Features of neonatal resuscitation include assistance with meconium staining of amniotic fluid and an Apgar score of less than 6 points for the child.

During childbirth, after the head appears from the birth canal, immediately aspirate the contents of the nasal and oral cavity.
After birth and placing the baby under a heat source, before the first breath, it is advisable to perform intubation with a tube of the largest possible size in order to extract the contents of the bronchi and trachea.
If it is possible to extract the contents and it contains an admixture of meconium, then it is necessary to reintubate the newborn with another tube.
Ventilation is established only after all contents have been removed.

Drug therapy

Pediatric neonatal resuscitation is based not only on manual or hardware interventions, but also on the use of medications. In the case of mechanical ventilation and indirect massage, when the measures are ineffective for more than 30 seconds, medications are used.

Resuscitation of newborns involves the use of adrenaline, means to restore circulating blood volume, sodium bicarbonate, naloxone, and dopamine.

Adrenaline is injected through an endotracheal tube into the trachea or into a vein. The concentration of the drug is 1:10,000. The drug is used to increase the force of heart contraction and accelerate the heart rate. After endotracheal administration, mechanical ventilation is continued so that the drug can be evenly distributed. If necessary, the product is administered after 5 minutes.

Calculation of the drug dose depending on the child’s weight:

1 kg - 0.1-0.3 ml;
2 kg - 0.2-0.6 ml;
3 kg - 0.3-0.9 ml;
4 kg - 0.4-1.2 ml.

If blood loss or need to be replaced, albumin, saline sodium chloride solution or Ringer's solution are used. The drugs are injected into the umbilical cord vein in a stream (10 ml per 1 kg of the child’s body weight) slowly over 10 minutes. The introduction of BCC replenishers allows you to increase blood pressure, reduce the level of acidosis, normalize the pulse rate and improve tissue metabolism.

Resuscitation of newborns with effective ventilation requires administration of sodium bicarbonate into the umbilical vein to reduce signs of acidosis. The drug should not be used until adequate ventilation of the child’s lungs has been established.

Dopamine is used to increase cardiac index and glomerular filtration rate. The drug dilates renal vessels and increases sodium clearance when using infusion therapy. It is administered intravenously via a micro-jet under constant monitoring of blood pressure and heart rate.

Naloxone is administered intravenously at the rate of 0.1 ml of the drug per 1 kg of the child’s body weight. The drug is used when skin color and pulse are normal, but there are signs of respiratory depression. A newborn should not be given naloxone when the mother is using narcotic drugs or undergoing treatment with narcotic analgesics.

When to stop resuscitation?

Ventilation continues until the child scores 6 Apgar points. This assessment is carried out every 5 minutes and lasts up to half an hour. If after this time the newborn has an indicator of less than 6, then he is transferred to the ICU of the maternity hospital, where further resuscitation and intensive care of newborns are carried out.

If the effectiveness of resuscitation measures is completely absent and asystole and cyanosis are observed, then the measures continue for up to 20 minutes. When even the slightest signs of effectiveness appear, their duration is increased for as long as the measures provide a positive result.

Neonatal intensive care unit

After successful restoration of lung and heart function, the newborn is transferred to the intensive care unit. There, the work of doctors is aimed at preventing possible complications.

A newborn after resuscitation needs to prevent the occurrence of brain swelling or other central nervous system disorders, restore kidney function and excretory function of the body, and normalize blood circulation.

The child may develop metabolic disorders in the form of acidosis, lactic acidosis, which is caused by disturbances in peripheral microcirculation. From the side of the brain, the appearance of convulsive attacks, hemorrhage, cerebral infarction, edema, development may also appear. Violations of the function of the ventricles of the heart, acute kidney failure, atony may also appear. Bladder, insufficiency of the adrenal glands and other endocrine organs.

Depending on the baby’s condition, he is placed in an incubator or an oxygen tent. Specialists monitor the functioning of all organs and systems. The child is allowed to feed only after 12 hours, in most cases - after

Mistakes that are prohibited

It is strictly prohibited to carry out activities whose safety has not been proven:

pour water over the baby;
squeeze his chest;
strike the buttocks;
direct a stream of oxygen into the face and the like.

Albumin solution should not be used to increase the initial volume of blood volume, as this increases the risk of death in the newborn.

Carrying out resuscitation measures does not mean that the baby will have any abnormalities or complications. Many parents expect pathological manifestations after the newborn has been in intensive care. Reviews of such cases show that in the future children have the same development as their peers.