Relevance of the topic. According to WHO, approximately 5-10% of all newborns require medical care in the delivery room, and about 1% are in full intensive care. Providing adequate care to newborns in the first minutes of life can reduce their mortality and/or morbidity by 6-42%. The degree of knowledge of medical personnel present at childbirth in methods primary resuscitation Newborns have a positive effect not only on their survival, but also on their further development and level of health in subsequent age periods.

General goal: improve knowledge on assessing the condition of a newborn, determine indications for resuscitation measures and their volume. Be able to temporarily begin resuscitation, master the skills of resuscitation of a newborn.

Specific goal: based on perinatal history, data objective examination identify the main signs of an emergency condition, carry out differential diagnosis, provide the necessary assistance.

Theoretical issues

1. Preparation for providing resuscitation care to a newborn in the delivery room or operating room.

2. Assessing the condition of the newborn child, determining the need for intervention.

3. Activities after the birth of a child. Airway management, oxygen therapy, artificial ventilation lungs with a bag and mask, tracheal intubation, indirect massage hearts, etc.

4. Algorithm for providing emergency care to newborns with clean amniotic fluid.

5. Algorithm for providing emergency care to newborns in case of contamination of amniotic fluid with meconium.

6. Medicines for primary resuscitation of newborns.

7. Indications for stopping resuscitation.

Indicative basis of activity

When preparing for a lesson, you need to familiarize yourself with the basic theoretical issues through the treatment algorithm (Fig. 1), literature sources.

Preparing to provide resuscitation care to a newborn in the delivery room

Staffing: 1 person who can provide resuscitation assistance; 2 people with these skills during childbirth high risk when full resuscitation may be required. In case of multiple pregnancy, the presence of several resuscitation teams is necessary. Before each birth, you need to assess the temperature in the room (not lower than 25 ° C), the absence of drafts, select, install and check the functioning of resuscitation equipment:

1. Before birth, turn on the radiant heat source, warm the surface of the resuscitation table to 36-37 °C and prepare warmed diapers.

2. Check the oxygen supply system: presence of oxygen, pressure, flow rate, presence of connecting tubes.

3. Roll the diaper into a roll under the shoulders.

4. Prepare equipment for suctioning the contents of the upper respiratory tract (rubber balloon, adapter for connecting the endotracheal tube directly to the suction tube).

5. Prepare a gastric tube size 8F, a 20 ml syringe for aspiration of gastric contents, an adhesive plaster, scissors.

6. Prepare equipment for artificial pulmonary ventilation (ALV): resuscitation bag (volume no more than 75 ml) and mask. The oxygen flow rate must be at least 5 l/min. Check the functioning of the control valve, the integrity of the bag, the presence of oxygen in the tank, it is advisable to have a pressure gauge.

7. Prepare an intubation kit.

Urgent Care

Activities after the birth of a child

Immediately determine the need for resuscitation. Rate:

— presence of meconium contamination;

- breathing;

- muscle tone;

- skin color;

— determine gestational age (term, premature).

Term, active infants with adequate breathing, a loud cry and normal motor activity do not require resuscitation. They are placed on the mother's stomach, dried and covered with a dry diaper. Sanitation of the upper respiratory tract is carried out by wiping the mucous membranes of the child’s mouth and nose.

Indications for further assessment of the newborn's condition and determination of the need for intervention:

1. Contamination of amniotic fluid or skin of a newborn with meconium.

2. Absence or decrease in the child’s response to stimulation.

3. Persistent central (diffuse) cyanosis.

4. Premature birth.

If any of these signs are present, newborns require standard initial resuscitation steps and require constant monitoring.

If a newborn needs emergency care, and the amniotic fluid is clear and there is no meconium on the baby’s skin, you must:

1. Place the baby under a radiant heat source on a warm swaddle.

2. Ensure airway patency: position on the back with the head moderately tilted back (roll under the shoulders).

3. Suck out the contents from the mouth, then from the nasal passages. If there is a significant amount of secretion, turn the child's head to the side.

4. Dry your skin and hair with a diaper using quick blotting movements.

5. Remove the wet diaper.

6. Again ensure the correct position of the child.

7. If there is no effective spontaneous breathing, perform one of the tactile stimulation techniques, which is repeated no more than two times (patting the soles, light blows on the heels, rubbing the skin along the spine)1.

8. If the skin of the body and mucous membranes remain cyanotic in the presence of spontaneous breathing, administer oxygen therapy. A free flow of 100% oxygen directed to the child's nose is provided through an anesthetic bag and mask, or through an oxygen tube and a hand funnel, or using an oxygen mask.

Once the cyanosis has resolved, oxygen support should be gradually withdrawn so that the baby remains pink when breathing room air. Saving pink color skin when the end of the tube is removed by 5 cm indicates that the child does not need high concentrations oxygen.

In case of any contamination of amniotic fluid with meconium:

- it is necessary to assess the activity of the newborn, clamp and cross the umbilical cord, inform the mother about the child’s breathing problems, without taking away the diaper and avoiding tactile stimulation;

- if the child is active - screams or breathes adequately, has satisfactory muscle tone and a heart rate (HR) of more than 100 beats per minute, he is placed on the mother’s stomach and observed for 15 minutes. A baby at risk of meconium aspiration may require subsequent tracheal intubation, even if active after birth;

- in the absence respiratory disorders provide standard medical care in accordance with clinical protocol medical supervision of a healthy newborn child (Order No. 152 of the Ministry of Health of Ukraine dated April 4, 2005);

- if the newborn has depressed breathing, decreased muscle tone, heart rate less than 100 beats per minute, immediately suck out meconium from the trachea through the endotracheal tube. Aspiration of meconium should be carried out under heart rate control. If bradycardia increases, stop repeated aspiration of meconium and begin mechanical ventilation with a resuscitation bag through an endotracheal tube.

All measures for the initial treatment of a newborn are completed in 30 seconds. The child's condition (breathing, heart rate and skin color) is then assessed to determine whether further resuscitation is necessary2.

Breathing assessment. Normally, the child has active chest excursions, and the frequency and depth of respiratory movements increases a few seconds after tactile stimulation. Convulsive breathing movements are ineffective, and their presence in a newborn requires a complex of resuscitation measures, as in the case of complete absence of breathing.

Heart rate assessment. The heart rate should exceed 100 beats per minute. Heart rate is calculated at the base of the umbilical cord, directly in the area where it joins the anterior abdominal wall. If the pulse on the umbilical cord is not detected, you need to listen with a stethoscope to the heartbeat over the left side of the chest. Heart rate is calculated for 6 seconds and the result is multiplied by 10.

Skin color assessment. The baby's lips and body should be pink. After normalization of heart rate and ventilation, the child should not have diffuse cyanosis. Acrocyanosis, as a rule, does not indicate low level oxygen in the blood. Only diffuse cyanosis requires intervention.

After eliminating heat loss, ensuring airway patency and stimulating spontaneous breathing next step resuscitation should be supported by ventilation.

Artificial ventilation with a bag and mask

Indications for mechanical ventilation:

- lack of breathing or its ineffectiveness (convulsive breathing movements, etc.);

- bradycardia (less than 100 beats per minute) regardless of the presence of spontaneous breathing;

- persistent central cyanosis with free flow of 100% oxygen in a child who is breathing independently and has a heart rate of more than 100 beats per minute.

The effectiveness of ventilation is determined: by chest excursion; auscultation data; increase in heart rate; color improvement skin.

The first 2-3 breaths are performed, creating an inhalation pressure of 30-40 cm of water column, after which ventilation is continued with an inhalation pressure of 15-20 cm of water column and a frequency of 40-60 per minute. In the presence of pulmonary pathology, ventilation is carried out with an inspiratory pressure of 20-40 cm of water column. Ventilation of newborns is carried out with 100% humidified and warmed oxygen.

After 30 s of positive pressure ventilation, the heart rate and the presence of spontaneous breathing are again determined. Next steps depend on the result obtained.

1. If heart rate is more than 100 beats per minute:

— if spontaneous breathing is present, mechanical ventilation is gradually stopped, reducing its pressure and frequency, and free flow oxygen and assess skin color;

— in the absence of spontaneous breathing, continue mechanical ventilation until it appears.

2. If heart rate is from 60 to 100 beats per minute:

— continue mechanical ventilation;

- if mechanical ventilation was carried out with room air, anticipate the transition to the use of 100% oxygen, the need for tracheal intubation.

3. Heart rate is less than 60 beats per minute:

— begin chest compressions at a rate of 90 compressions per minute, continue mechanical ventilation with 100% oxygen at a rate of 30 breaths per minute, and determine the need for tracheal intubation.

Heart rate is monitored every 30 s until it exceeds 100 beats per minute and spontaneous breathing is established.

Carrying out mechanical ventilation for several minutes requires the introduction of an orogastric tube (8F) in order to prevent gastric distension with air and subsequent regurgitation of gastric contents.

Indirect cardiac massage indicated if heart rate is less than 60 beats per minute after 30 seconds of effective ventilation with 100% oxygen.

Perform indirect cardiac massage by pressing on the lower third of the sternum. It is located below the conditional line that connects the nipples. It is important not to press on the xiphoid process to avoid rupture of the liver.

Two indirect massage techniques are used, according to which pressure is applied to the sternum:

first - two thumbs, while the remaining fingers of both hands support the back;

the second - with the tips of two fingers of one hand: II and III or III and IV; while the second hand supports the back.

The depth of compression should be one third of the anteroposterior diameter of the chest.

The frequency of pressure is 90 per minute.

It is important to coordinate chest compressions with mechanical ventilation, avoiding performing both procedures simultaneously, and not removing your fingers from the surface of the chest during the pause between pressures. After every three pressures on the sternum, a pause is made for ventilation, after which the pressures are repeated, etc. In 2 seconds you need to make 3 pressures on the sternum (90 per 1 minute) and one ventilation (30 per 1 minute). Stop chest compressions if the heart rate is more than 60 beats per minute.

Tracheal intubation can be carried out at all stages of resuscitation, in particular:

- if necessary, suck out meconium from the trachea;

— if long-term ventilation is necessary to increase its effectiveness;

— to facilitate the coordination of chest compressions and ventilation;

- for the administration of adrenaline;

- if you suspect a diaphragmatic hernia;

- with deep prematurity.

Use of medications. Administration of drugs is indicated if, despite adequate ventilation of the lungs with 100% oxygen and chest compressions for 30 seconds, the heart rate remains less than 60 beats per minute.

During primary resuscitation of newborns, medications are used: adrenaline; means that normalize bcc; sodium bicarbonate, antagonists of narcotic drugs.

Adrenalin. Indications for use:

— Heart rate less than 60 beats per minute after at least 30 seconds of mechanical ventilation with 100% oxygen and chest compressions;

- absence of heart contractions (asystole) at any time during resuscitation.

Adrenaline is administered as quickly as possible intravenously or endotracheally at a dose of 0.1-0.3 ml/kg of solution at a concentration of 1: 10,000. The concentration of the solution is 1: 10,000 (to 0.1 ml of 0.1% solution of adrenaline hydrochloride or add 0.9 ml of isotonic sodium chloride solution to 0.1 ml of 0.18% adrenaline hydrogen tartrate solution).

Endotracheally, adrenaline is injected from a syringe directly into the tube or through a probe inserted into the tube. In this case, a solution of adrenaline at a concentration of 1: 10,000 can be further diluted with an isotonic solution to a final volume of 1 ml or the endotracheal tube (probe) can be washed with an isotonic sodium chloride solution (0.5-1.0 ml) after administering an undiluted dose. In case of endotracheal administration, it is recommended to always use a dose of 0.3-1.0 ml/kg. After injecting epinephrine into the trachea, it is important to immediately perform several effective positive pressure ventilations.

If there is no effect, the injection of adrenaline is repeated every 3-5 minutes, repeated administrations only i.v.

Large doses of intravenous epinephrine are not recommended for resuscitation of newborns, since their administration can cause damage to the baby's brain and heart.

Means that normalize bcc: 0.9% sodium chloride solution; lactated Ringer's solution; in order to correct significant blood loss (with clinical signs hemorrhagic shock) - transfusion of O(I) Rh(-) red blood cells. Indications for use:

- lack of response of the child to resuscitation measures;

- signs of blood loss (pallor, pulse weak filling, persistent tachycardia or bradycardia, no signs of improved circulation despite all resuscitation measures).

With the development of hypovolemia, children whose condition does not improve during resuscitation are administered intravenously slowly, over 5-10 minutes, up to 10 ml/kg of one of the indicated solutions (isotonic sodium chloride solution is recommended).3

Sodium bicarbonate indicated for the development of severe metabolic acidosis during prolonged and ineffective resuscitation against the background of adequate mechanical ventilation. A 4.2% solution at a dose of 4 ml/kg or 2 mEq/kg is injected into the umbilical cord vein slowly, no faster than 2 ml/kg/min. The drug should not be administered until the newborn's lungs are ventilated.

Antagonists of narcotic drugs (naloxone hydrochloride)

Indications for use: persistent severe respiratory depression during positive pressure ventilation, with normal heart rate and skin color in a child whose mother was administered narcotic drugs during the last 4 hours before birth. Naloxone hydrochloride is administered at a concentration of 1.0 mg/ml solution, at a dose of 0.1 mg/kg IV. When administered intramuscularly, the effect of naloxone is delayed; when administered endotracheally, it is ineffective.

Naloxone should not be prescribed to a child from a mother with suspected drug addiction or from a mother who is undergoing long-term drug treatment. This may cause severe cramping. The child's breathing can also be suppressed by other drugs administered to the mother (magnesium sulfate, non-narcotic analgesics, anesthetics), but their effect will not be blocked by the administration of naloxone.

If the child’s condition does not improve despite effective mechanical ventilation and chest compressions, administration of drugs, exclude abnormalities in the development of the respiratory tract, pneumothorax, diaphragmatic hernia, birth defects hearts.

Resuscitation of the newborn is stopped if, despite the correct and complete implementation of all resuscitation measures, there is no cardiac activity for 10 minutes.

1 It is prohibited to pour cold or hot water, direct a stream of oxygen into the face, squeeze the chest, hit the buttocks, and carry out any other activities whose safety for a newborn has not been proven.

2 The Apgar score characterizes general condition newborn and the effectiveness of resuscitation measures and is not used to determine the need for resuscitation, its volume or the timing of resuscitation measures. The Apgar score should be assessed at 1 and 5 minutes after the baby is born. If the assessment result at the 5th minute is less than 7 points, it should be additionally carried out every 5 minutes until the 20th minute of life.

Literature

1. Order of the Ministry of Health of Ukraine No. 437 dated 08/31/04 “On the approval of clinical protocols for the provision of medical assistance for difficult conditions in children at the hospital and pre-hospital stages.”

2. Order of the Ministry of Health of Ukraine No. 152 dated 04/04/2005 “On the approval of the clinical protocol for medical supervision of a healthy newborn baby.”

3. Order of the Ministry of Health of Ukraine No. 312 dated 06/08/2007 “On the approval of the clinical protocol for initial resuscitation and post-resuscitation care for newborns.”

4. Uncomplicated topics in pediatrics: Beg. pos_b. / Volosovets O.P., Marushko Yu.V., Tyazhka O.V. ta inshi / Ed. O.P. Volosovtsia and Yu.V. Marushko. - Kh.: Prapor, 2008. - 200 p.

5. Emergency conditions in children / Petrushina A.D., Malchenko L.A., Kretinina L.N. and others / Ed. HELL. Petrushina. - M.: Medical Information Agency LLC, 2007. - 216 p.

6. Peshiy M.M., Kryuchko T.O., Smiyan O.I. Uncomplicated assistance in pediatric practice. - Poltava; Sumi, 2004. - 234 p.

7. Emergency medical care for children prehospital stage/ G.I. Posternak, M.Yu. Tkacheva, L.M. Beletskaya, I.F. Volny / Ed. G.I. Belebezeva. - Lvov: Medicine for the World, 2004. - 186 p.

Additional

1. Aryaev M.L. Neonatology. - K.: ADEF - Ukraine, 2006. - 754 p.

2. Handbook of neonatology: Trans. from English / For ed. Jonah Cleorti, Anne Stark. - K.: Fund for Helping Children of Chornobyl, 2002. - 722 p.

3. Shabalov N.P. Neonatology: Textbook for students and residents of pediatric faculties medical institutes. — Second edition, corrected and expanded. - St. Petersburg: Special Literature, 1997. - T. 1. - 496 p.

4. Reanimation of newborns: Pidruchnik / Ed. J. Cavintela: Translation from English. - Lviv: Spolom, 2004. - 268 p.

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

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

Stage A includes:

Warming the baby;

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

Drying the skin and stimulating the baby's breathing;

Assessment of breathing, heart rate and skin color;

Supply oxygen if necessary.

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

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

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

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

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

Skin color (pink or cyanotic).

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

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

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

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

Resuscitation principle A

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

1. Ensuring the correct position of the child.

2. Clearing the airways.

3. Tactile stimulation of breathing.

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

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

Wrong

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

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

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

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

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

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

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

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

Safe and correct methods tactile stimulation include:

Patting or tapping the soles;

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

Rice. 4. Methods of tactile stimulation of breathing

Resuscitation principle B

Principle B - ensuring adequate breathing using oxygenation.

Oxygen starvation vital tissues is one of the main causes of distant clinical consequences related to perinatal pathology Therefore, it is necessary to ensure adequate breathing in a timely manner. Ventilation of the lungs is the most important and the most effective way cardiopulmonary resuscitation newborn

For ventilation used:

Resuscitation bag;

Oxygen tube;

Oxygen mask.

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

Rice. 5. Ventilation support

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

A bag that fills with a flow (fills only when oxygen comes to it from additional source compressed gas), - anesthesia bag;

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

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

Correct Incorrect

A b c

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

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

nose and mouth (too small)

The visible rise and fall of the chest is best signs that the mask fits tightly and the lungs are oxygenated.

Although the lungs must be ventilated at a minimum pressure to ensure adequate chest excursions, the newborn baby's first few breaths often require high blood pressure(more than 30 cm of water column), so that the fluid is displaced from the fetal lungs and they are filled with air. Subsequent ventilations require lower pressure.

Ventilation frequency per initial stages resuscitation - 40–60 per minute, i.e. approximately 1 time per second.

Improvement in the newborn's condition is characterized by the following signs:

Increase in heart rate;

Improving skin color;

Restoring spontaneous breathing.

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

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

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

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

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

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

Rice. 7. Correct positioning gastric tube

Indications intubation:

Birth of a child with asphyxia;

Deep prematurity;

Surfactant administration is intratracheal;

Suspicion of diaphragmatic hernia;

Ineffective mask ventilation.

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

1. Laryngoscope (Fig. 8, A).

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

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

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

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

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

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

8. Scissors (Fig. 8, h).

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

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

11. Stethoscope (Fig. 8, l).

Rice. 8. Required equipment for tracheal intubation

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

Rice. 9. Endotracheal tube

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

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

Table 1

Related information.

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

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

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

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

The duration of this step is 20-25 s.

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

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

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

Placing the child under a radiant heat source;

Drying the child with a warm sterile diaper;

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

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

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

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

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

The duration of step B is 20-30 s.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Gray V N Strizhakov A N, Markin S A Practical obstetrics: A guide for doctors. M.. 1989.

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

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

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

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

Yakovlev I.I. Urgent Care in obstetric pathology. - L., 1965.

Interpretation of the Apgar score.

A total of 8 points or more 1 minute after birth indicates the absence of asphyxia of the newborn, 4–7 points indicates mild and moderate asphyxia, 1–3 points - about severe asphyxia. The Apgar score 5 minutes after birth has not so much a diagnostic as a prognostic value, and reflects the effectiveness (or ineffectiveness) of the resuscitation measures being taken. There is a strong inverse association between the second Apgar score and the incidence of adverse neurological outcomes. A score of 0 10 minutes after birth is one of the grounds for stopping primary resuscitation.

In all cases of live birth, the first and second Apgar scores are entered into the corresponding columns in the developmental history of the newborn.

In cases of primary resuscitation, a completed insert card for primary resuscitation of newborns (Appendix No. 5) is additionally pasted into the developmental history of the newborn.

The equipment sheet for primary resuscitation is presented in Appendix No. 6.

Protocol for primary resuscitation of newborns Algorithm for making a decision on the initiation of primary resuscitation measures:

1.1.Record the time of birth of the child.

1.2.Assess the need to move the child to the resuscitation table by answering 4 questions:

1.) Is the baby full term?

2.) The amniotic fluid is clean, obvious signs are there any infections?

3.) Is the newborn breathing and crying?

4.) Does the child have good muscle tone?

1.3. If the health worker caring for the newborn can answer “YES” to all 4 questions, the baby should be covered with a dry, warm diaper and placed on the mother’s chest. However, it should be remembered that during the entire period of stay in the delivery room, the child must remain under close supervision of medical personnel. If the specialist answers “NO” to at least one of the above questions, he should transfer the child to a heated table (in an open resuscitation system) for an in-depth assessment of the child’s condition and, if necessary, to carry out initial resuscitation measures.

1.4. Primary resuscitation measures are carried out if the child has indications, provided there is at least one sign of a live birth:

Spontaneous breathing; - heartbeat (heart rate); - pulsation of the umbilical cord;

Voluntary muscle movements.

1.5. If all signs of a live birth are absent, the child is considered stillborn.

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

METHODOLOGICAL LETTER

PRIMARY AND RESUSCITATIVE CARE FOR NEWBORN CHILDREN

List of abbreviations:

HR - heart rate

IVL - artificial lung ventilation

BCC - circulating blood volume

CPAP - continuous positive airway pressure

PEER - positive end expiratory pressure

P1P - peak inspiratory pressure

ETT- endotracheal tube

Zp02 - saturation (saturation) of hemoglobin with oxygen.

Introduction

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

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

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

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

Principles of organizing primary resuscitation care for newborns

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

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

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

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

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

The following must have skills in primary neonatal resuscitation:

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

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

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

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

Antenatal risk factors for the development of newborn asphyxia:

diabetes mellitus;

gestosis (preeclampsia);

hypertensive syndromes;

Rh sensitization;

history of stillbirth;

clinical signs of infection in the mother;

bleeding in the second or third trimesters of pregnancy;

polyhydramnios;

oligohydramnios;

multiple pregnancy;

intrauterine growth restriction:

maternal drug and alcohol use:

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

the presence of developmental anomalies identified during antenatal diagnosis;

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

premature birth (less than 37 weeks);

late birth (more than 42 weeks);

Caesarean section operation;

placental abruption;

placenta previa;

loss of umbilical cord loops;

pathological position of the fetus;

use of general anesthesia;

anomalies of labor;

presence of meconium in amniotic fluid;

fetal heart rhythm disturbances;

shoulder dystocia;

instrumental birth (obstetric forceps, vacuum extraction).

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

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

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

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

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

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

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



		Less than 100/min	More than 100/min
	Absent	Faint scream	Strong scream
		(hypoventilation)	(adequate breathing)
Muscle tone	Low (child	Moderately reduced	High (active
		(weak movements)	movement)
Reflexes	Not defined		Screaming or active
			movement
Skin color	Blue or white	Expressed	Fully pink
		acrocyanosis

vbordo.ru

Methods of resuscitation of newborns. Indications for emergency measures. Methodological letter_2010_on primary neonatal resuscitation

Theoretical issues

Indicative basis of activity

Preparing to provide resuscitation care to a newborn in the delivery room

Urgent Care

Artificial ventilation with a bag and mask

Antagonists of narcotic drugs (naloxone hydrochloride)

Literature

More on the topic RESUSCITATIVE CARE FOR A NEWBORN:

Interpretation of the Apgar score.

In all cases of live birth, the first and second Apgar scores are entered into the corresponding columns in the developmental history of the newborn.

In cases of primary resuscitation, a completed insert card for primary resuscitation of newborns (Appendix No. 5) is additionally pasted into the developmental history of the newborn.

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