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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

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Rate: 90/min
Ratio: three compressions to one ventilation/inhalation
Depth: one-third of the depth of the baby’s chest (1–2cm)
Action: well controlled, not jerky or erratic.
Allow for expansion after each compression to facilitate venous return.
²Emergency drugs are given if adequate ventilation and effective chest
compressions have failed to increase the heart rate above 60bpm. They are given to increase cardiac output and improve cardiac and cerebral perfusion. They are usually administered through an umbilical venous catheter.
CHAPTER 19
Emergencies
456
- Adrenaline:
  improves cerebral and cardiac perfusion.
  - Dose 10micrograms/kg; 0.1mL 1:10 000 solution can be given via an endotracheal tube but is less effective.
- Sodium bicarbonate:
  reverses acidosis, ‘kick starts’ the heart
  - Dose 1–2mmol/kg; 2–4mL 4.2% solution.
    If there is no response to adrenaline and sodium bicarbonate, use:
- Glucose:
  2.5mL/kg 10% solution.
  Occasionally volume expansion may help. Use:
- Plasma, whole blood or normal saline, 10mL/kg. In addition:
- Naloxone
  1.0mg/kg is given intramuscularly to reverse the effects of pethidine given during labour. Do not use this if the mother has been taking opiate drugs during pregnancy.
- Calcium
  2mL/kg 10% solution. Give when the heart rate remains below 80bpm, despite a minimum of 30s, of adequate ventilation with 100% oxygen, chest compressions, and the administration of adrenaline or if the heart rate is 0 and there is no response to ventilation despite the administration of adrenaline and cardiac compressions.
  ²
  Tracheal intubation
  Is indicated where there is:
- Ineffective face-mask ventilation
- The need for tracheal suction at the level or below the vocal cords due to thick meconium
- Extreme prematurity and surfactant administration (b see Respiratory distress syndrome in the newborn, p. 640)
- Prolonged ventilation
- During transfer from the labour ward/theatre to the neonatal unit
- Some congenital abnormalities, where the baby has abnormalities of the face and neck, for example a cystic hygroma which is large enough to obstruct the airway
- Lung pathology due to diaphragmatic hernia, pneumothorax, hypoplastic lungs, and hydrops.
  ²
  Meconium-stained liquor
- Meconium aspiration syndrome (MAS) is a problem associated with term babies.
- If peristalsis is stimulated by hypoxia
  in utero,
  the anal sphincter relaxes and the fetus will pass meconium into the amniotic fluid.
- The asphyxia also causes the fetus to make gasping movements, taking the meconium into the lungs.
- Aspiration can occur at any time, but the risk is greatest with intrauterine asphyxia.
  ³
  Thin meconium
  May be an ‘innocent’ finding due to fetal maturation processes. It is often associated with post-term deliveries.
  Thick meconium
- Is a marker of fetal hypoxia.
- Must be cleared from the oropharynx prior to delivery of the shoulders.
  NEONATAL RESUSCITATION
  457
Normal respiration should not be initiated until it has been cleared, otherwise it will be driven into the lungs, causing MAS.
Management of meconium-stained liquor
Thin meconium
A small amount of meconium with light staining and no particulate material presents minimal risk of aspiration.
The baby will be lively, have cried and breathed spontaneously.
Assess and treat as any other birth.
Some gentle suction to the mouth may well be sufficient.
Thick particulate meconium
Increases the risk of aspiration.
The infant will be depressed and not making any respiratory effort.
Attempt to remove the meconium before initiating normal respiration.
Do not stimulate or ventilate.
Place the infant under a radiant heater on the resuscitaire.
Examine the upper airway for residual meconium.
Suck out under direct vision using a large-sized catheter or a Yankauer
^®sucker.
Dry the baby and keep warm.
The trachea should be intubated and meconium suctioned from the lower airways.
This may require several attempts.
³
Post-resuscitation care
Babies who receive minimal or no resuscitation can normally be handed straight to the parents. Routine observations will be made.
Babies who receive prolonged resuscitation will need to be transferred to the neonatal intensive care unit. This will involve:
- Stabilization
- Safe transfer
- Identification and treatment of problems.
Babies with MAS will require antibiotics, physiotherapy, and suction to remove the meconium from the lungs. They are also at risk of a pneumothorax due to the meconium blocking the airways.
²
Communication and record keeping
An accurate written record detailing the resuscitation events is vital, as it can help to protect practitioners if defence of their actions is required.
All documentation should be legible, signed, dated, and timed.
Parents need a clear, detailed account of the baby’s problems and further treatments should the baby require specialized care and transfer to the NICU.
²
When to stop
Hospitals will have their own policies in place regarding when to stop resuscitation, usually based on the following factors:
No cardiac output after 15min.
No respiratory effort after 30min, despite effective ventilation and chest compressions.
CHAPTER 19
Emergencies
458
When all reversible factors have been eliminated, the decision to stop is made by the most senior clinician available.
²
1. Roberton NRC (1999). Resuscitation of the newborn. In: Rennie JM, Roberton NRC (eds)
  Textbook of Neonatology
  , 3rd edn. London: Churchill Livingstone, pp. 241–62.
2. Resuscitation Council (UK) (2001).
  Resuscitation at Birth
  .
  The Newborn Life Support Provider Course Manual
  . London: Resuscitation Council.
3. Greenhough A (1995). Meconium aspiration syndrome: prevention and treatment.
  Early Human Development
  41
  , 183–92.
PERINATAL MORTALITY
459‌‌
Perinatal mortality
Perinatal mortality is defined as the sum of all stillbirths and neonatal deaths in the first week of life. The rate is expressed as numbers of deaths per thousand births.
CEMACH (2004)
¹produced a report on stillbirth, neonatal, and post- neonatal mortality from 2000 to 2002.