Resuscitation of newborns: indications, types, stages, medications. Primary resuscitation of newborns

Resuscitation of newborns in the delivery room is based on a strictly defined sequence of actions, including predicting the occurrence of critical situations, assessing the condition of the child immediately after birth, and conducting resuscitation aimed at restoring and maintaining the function of respiration and circulation.

Predicting the probability of having a child in asphyxia or drug-induced depression is based on the analysis of antenatal and intranatal history.

Risk factors

Antenatal risk factors include maternal diseases such as diabetes, hypertension syndromes, infections, and maternal drug and alcohol use. Of the pathology of pregnancy, it should be noted a lot - or oligohydramnios, overdose, delay prenatal development fetus and presence multiple pregnancy.

Intranatal risk factors include: preterm or delayed labor, abnormal presentation or position of the fetus, placental abruption, prolapsed umbilical cord, use general anesthesia, anomalies labor activity, the presence of meconium in the amniotic fluid, etc.

Before the start of resuscitation, the child's condition is assessed according to the signs of live birth:

• spontaneous breathing,
• heartbeat,
• cord pulsations,
• voluntary muscle movements.

In the absence of all 4 signs, the child is considered stillborn and is not subject to resuscitation. The presence of at least one sign of live birth is an indication for the immediate start of resuscitation.

Resuscitation algorithm

The resuscitation care algorithm is determined by three main features:

• the presence of spontaneous breathing;
• heart rate;
• color skin.

The Apgar score is made, as was customary, at the 1st and 5th minutes to determine the severity of asphyxia, but its indicators do not have any effect on the volume and sequence of resuscitation.

Primary care for newborns in the maternity hospital

Initial events (duration 20-40 s).

In the absence of risk factors and light amniotic fluid, the umbilical cord is cut immediately after birth, the child is wiped dry with a warm diaper and placed under a source of radiant heat. If there is a large amount of mucus in the upper respiratory tract, then it is sucked out of oral cavity and nasal passages using a balloon or catheter connected to an electric suction. In the absence of breathing, light tactile stimulation is carried out by patting the feet 1-2 times.

In the presence of asphyxia factors and pathological impurities in the amniotic fluid (meconium, blood), aspiration of the contents of the oral cavity and nasal passages is performed immediately after the birth of the head (before the birth of the shoulders). After birth, pathological impurities are aspirated from the stomach and trachea.

I. First assessment of the state and action:

A. Breathing.

Absent (primary or secondary epnea) - start mechanical ventilation;

Independent, but inadequate (convulsive, superficial, irregular) - start mechanical ventilation;

Independent regular - to assess the heart rate (HR).

B. Heart rate.

Heart rate less than 100 beats per minute. - carry out mask ventilation with 100% oxygen until the heart rate normalizes;

B. Skin color.

Completely pink or pink with cyanosis of the hands and feet - observe;

Cyanotic - carry out inhalation of 100% oxygen through a face mask until cyanosis disappears.

Mechanical ventilation technique

artificial ventilation lung is carried out with a self-expanding bag (Ambu, Penlon, Laerdal, etc.) through a face mask or endotracheal tube. Before starting mechanical ventilation, the bag is connected to an oxygen source, preferably through a gas mixture humidifier. A roller is placed under the shoulders of the child and the head is slightly thrown back. The mask is placed on the face so that it top obturator lay on the bridge of the nose, and the bottom - on the chin. When pressing on the bag, an excursion of the chest should be clearly visible.

Indications for the use of an oral airway for mask ventilation are: bilateral choanal atresia, Pierre-Robin syndrome and the impossibility of ensuring free airway patency with proper positioning of the child.

Tracheal intubation and the transition to mechanical ventilation through an endotracheal tube is indicated for suspected diaphragmatic hernia, ineffective mask ventilation for 1 minute, and with apnea or inadequate breathing in a child with a gestational age of less than 28 weeks.

Artificial ventilation of the lungs is carried out with 90-100% oxygen-air mixture with a frequency of 40 breaths per 1 minute and the ratio of inhalation to exhalation time is 1:1.

After ventilation of the lungs, the heart rate is again monitored for 15-30 seconds.

If the heart rate is above 80 per minute, continue mechanical ventilation until adequate spontaneous breathing is restored.

If the heart rate is less than 80 beats per minute - continue ventilation, start indirect massage hearts.

Chest Compression Technique

The child is placed on hard surface. Two fingers (middle and index) of one hand or two thumbs of both hands produce pressure on the border of the lower and middle thirds of the sternum with a frequency of 120 per minute. The displacement of the sternum towards the spine should be 1.5-2 cm. Ventilation of the lungs and heart massage do not synchronize, i.e. each manipulation is carried out in its own rhythm.

30 seconds after the start of a closed heart massage, the heart rate is again controlled.

If the heart rate is above 80 beats per minute - stop the heart massage and continue mechanical ventilation until adequate spontaneous breathing is restored.

If the heart rate is below 80 per minute - continue chest compressions, mechanical ventilation and start drug therapy.

Medical therapy

With asystole or heart rate below 80 beats per minute, adrenaline is immediately injected at a concentration of 1:10,000. For this, 1 ml of an ampouled solution of adrenaline is diluted in 10 ml physiological saline. The solution prepared in this way is collected in an amount of 1 ml in a separate syringe and injected intravenously or endotracheally at a dose of 0.1-0.3 ml/kg of body weight.

Every 30 seconds, the heart rate is re-controlled.

If the heart rate recovers and exceeds 80 beats per minute, stop cardiac massage and the introduction of other medicines.

If asystole or heart rate is below 80 beats per minute - continue chest compressions, mechanical ventilation and drug therapy.

Repeat the administration of epinephrine in the same dose (if necessary, this can be done every 5 minutes).

If the patient has signs of acute hypovolemia, which is manifested by pallor, a weak, thready pulse, low blood pressure, then the child is shown the introduction of a 5% solution of albumin or saline at a dose of 10-15 ml / kg of body weight. Solutions are administered intravenously over 5-10 minutes. If signs of hypovolemia persist, repeated administration of these solutions at the same dose is acceptable.

The introduction of sodium bicarbonate is indicated for confirmed decompensated metabolic acidosis (pH 7.0; BE -12), as well as in the absence of the effect of mechanical ventilation, heart massage and drug therapy(suggested severe acidosis, preventing the restoration of cardiac activity). A solution of sodium bicarbonate (4%) is injected into the vein of the umbilical cord at the rate of 4 ml/kg of body weight (2 meq/kg). The rate of drug administration is 1 meq/kg/min.

If within 20 minutes after birth, despite the full resuscitation measures, the child does not recover cardiac activity (there are no heartbeats), resuscitation in the delivery room is stopped.

At positive effect from resuscitation, the child must be transferred to the intensive care unit (ward), where specialized treatment will be continued.

Primary neonatal resuscitation

Death is the death of body cells due to the cessation of their supply of blood, which carries oxygen and nutrients. Cells die after a sudden stop of the heart and breathing, although quickly, but not instantly. Most of all, the cells of the brain suffer from the cessation of oxygen supply, especially its cortex, that is, the department on the functioning of which consciousness, spiritual life, and the activity of a person as a person depend.

If oxygen does not enter the cells of the cerebral cortex within 4-5 minutes, then they are irreversibly damaged and die. Cells of other organs, including the heart, are more viable. Therefore, if breathing and blood circulation are quickly restored, then the vital activity of these cells will resume. However, this will be only the biological existence of the organism, consciousness, mental activity either will not recover at all, or will be profoundly changed. Therefore, the revival of a person must begin as early as possible.

That is why everyone needs to know the methods of primary resuscitation of children, that is, to learn a set of measures to provide assistance at the scene, prevent death and revive the body. Knowing how to do this is everyone's duty. Inactivity in anticipation of medical workers, no matter what it is motivated by - confusion, fear, inability - should be considered as a failure to fulfill a moral and civic duty in relation to a dying person. If it concerns your beloved crumbs, it is simply necessary to know the basics of resuscitation care!

Resuscitation of a newborn

How is primary resuscitation of children carried out?

Cardiopulmonary and cerebral resuscitation (LCCR) is a set of measures aimed at restoring basic vital important functions body (heart and respiration) to prevent brain death. Such resuscitation is aimed at reviving a person after stopping breathing.

Leading reasons terminal states, developed outside medical institutions, in childhood are the syndrome sudden death newborns, car accident, drowning, upper airway obstruction. The maximum number of deaths in children occurs under the age of 2 years.

Periods of cardiopulmonary and cerebral resuscitation:

• Period of elementary life support. In our country it is called the immediate stage;
• Life support period. It is often labeled as a specialized stage;
• The period of prolonged and prolonged life support, or post-resuscitation.

At the stage of elementary life support, techniques are performed to replace ("prosthetics") the vital functions of the body - the heart and respiration. At the same time, the events and their sequence are conventionally denoted by a well-remembered abbreviation of three English letters ABS:

- from English. airway, literally opening the airways, restoring airway patency;

- breath for victim, literally - breathing for the victim, mechanical ventilation;

- circulation his blood, literally - ensuring its blood flow, outdoor massage hearts.

Transportation of victims

Functionally justified for the transportation of children is:

• with severe hypotension - horizontal position with head end lowered by 15°;
• with damage to the chest, acute respiratory failure various etiologies- semi-sitting;
• in case of damage to the spine - horizontal on the shield;
• with fractures pelvic bones, organ damage abdominal cavity- legs bent at the knees and hips; joints and divorced to the sides (“the position of the frog”);
• in case of injuries of the skull and brain with lack of consciousness - horizontal on the side or on the back with a raised head end by 15 °, fixation of the head and cervical spine.

According to statistics, every tenth newborn child receives medical care in the delivery room, and 1% of all births need medical care. full complex resuscitation actions. The high level of training of medical personnel allows you to increase the chances of life and reduce possible development complications. Adequate and timely resuscitation of newborns is the first step to reduce the number of deaths and the development of diseases.

Basic concepts

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

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

Full-term babies do not require resuscitation. They are born active, scream loudly, pulse and heart rate are within normal limits, the skin has a pink color, 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.

Holding cardiopulmonary resuscitation considered an emergency. It is performed in case of respiratory and cardiac arrest. After such interference, in case of a favorable result, the basics of intensive care are applied. This treatment aims to eliminate possible complications stop work important organs.

If the patient cannot maintain homeostasis on his own, then resuscitation of the newborn includes either setting a pacemaker.

What is needed for resuscitation in the delivery room?

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

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

1. It is necessary to connect a heat source so that the resuscitation table and diapers are warmed up, roll up one diaper in the form of a roller.
2. Check if the oxygen supply system is properly installed. Must be enough oxygen, properly adjusted pressure and delivery rate.
3. The readiness of the equipment required for suctioning the contents of the respiratory tract should be checked.
4. Prepare instruments to eliminate gastric contents in case of aspiration (probe, syringe, scissors, fixing material), meconium aspirator.
5. Prepare and check the integrity of the resuscitation bag and mask, as well as the intubation kit.

The intubation set consists of endotracheal tubes with wire guides, laryngoscope with different blades and spare batteries, scissors and gloves.

What is the success of events?

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

• availability of the resuscitation team - resuscitators must be present at all births;
• coordinated work - the team must work harmoniously, complementing each other as one big mechanism;
• qualified employees - each resuscitator must have a high level of knowledge and practical skills;
• work taking into account the reaction of the patient - resuscitation should begin immediately when they are needed, further measures are taken depending on the reaction of the patient's body;
• serviceability of equipment - equipment for resuscitation must be serviceable and available at any time.

Reasons for the need for events

To etiological factors oppression of the heart, lungs and other vital organs of the newborn include the development of asphyxia, birth trauma, development congenital pathology, toxicosis of infectious origin and other cases of unexplained etiology.

Children's resuscitation of newborns and its need can be predicted even during the period of bearing a child. In such cases, the resuscitation team should be ready to immediately help the baby.

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

• a lot or a lack of water;
• overwearing;
• maternal diabetes;
• hypertonic disease;
• infectious diseases;
• fetal hypotrophy.

There are also a number of factors that already arise during childbirth. If they appear, you can expect the need for resuscitation. These factors include bradycardia in a child, C-section, premature and rapid delivery, placenta previa or abruption, uterine hypertonicity.

Asphyxia of newborns

The development of a violation of respiratory processes with hypoxia of the body causes the appearance of disorders from the circulatory system, metabolic processes and microcirculation. Then there is a disorder in the work of the kidneys, heart, adrenal glands, brain.

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

• hypoxia;
• violation of the airway (aspiration of blood, mucus, meconium);
• organic lesions of the brain and the work of the central nervous system;
• malformations;
• insufficient amount of surfactant.

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

A state 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.

Condition assessment sequence

1. 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. There is tactile stimulation.
2. Breathing is assessed. When normal rhythm and the presence of a loud cry, proceed to the next stage. At irregular breathing carry out mechanical ventilation with oxygen for 15-20 minutes.
3. Heart rate is assessed. If the pulse is above 100 beats per minute, go to the next stage of the examination. In the case of less than 100 strokes, IVL is performed. Then the effectiveness of the measures is evaluated.
   • Pulse below 60 - indirect heart massage + IVL.
   • Pulse from 60 to 100 - IVL.
   • Pulse above 100 - IVL in case of irregular breathing.
   • After 30 seconds, with the ineffectiveness of indirect massage with mechanical ventilation, it is necessary to carry out drug therapy.
4. The skin color is examined. Pink color testifies to normal condition child. With cyanosis or acrocyanosis, it is necessary to give oxygen and monitor the condition of the baby.

How is primary resuscitation performed?

Be sure to wash and treat hands with an antiseptic, put on sterile gloves. The time of birth of the child is fixed, after the necessary activities- is documented. The newborn is placed under a heat source, wrapped in a dry warm diaper.

To restore airway patency, you can lower the head end and put 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 aspirate the contents without resorting to deep insertion of the aspirator.

If such measures do not help, resuscitation of the newborn continues by sanitizing the trachea using a laryngoscope. After the appearance of breathing, but the absence of its rhythm, the child is transferred to a ventilator.

The neonatal resuscitation and intensive care unit accepts the child after primary resuscitation to provide further assistance and maintain vital functions.

Ventilation

The stages of resuscitation of newborns include carrying out ventilation:

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

This set of activities is carried out using a mask or bag. The head of the newborn is thrown back a little and a mask is applied to the face. It is held with index and thumb fingers. The rest is taken out the jaw of the child.

The mask should be on the chin, nose and mouth area. It is enough to ventilate the lungs with a frequency of 30 to 50 times in 1 minute. Bag ventilation can cause air to enter the stomach cavity. You can remove it from there using

To control the effectiveness of the conduction, it is necessary to pay attention to the rise of the chest and the change in heart rate. The child continues to be monitored until full recovery respiratory rate and heart rate.

Why and how is intubation performed?

Primary resuscitation of newborns also includes tracheal intubation, in case of ineffective mechanical ventilation for 1 minute. The correct choice of the tube for intubation is one of the important points. It is done depending on the body weight of the child and his gestational age.

Intubation is also performed in the following cases:

• the need to remove the aspiration of meconium from the trachea;
• continuous ventilation;
• facilitating the management of resuscitation;
• the introduction of adrenaline;
• deep prematurity.

On the laryngoscope, turn on the lighting and take in left hand. Right hand hold the newborn's head. The blade is inserted into the mouth and held 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 with right side into the oral cavity and passed through vocal cords at the time of their release. It happens on the inhale. The tube is held to the planned mark.

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

Indirect cardiac massage

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

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

It is imperative to ensure that inhalation and pressing on the chest are not carried out at the same time. In a pause between pressures, you can not remove your hands from the surface of the sternum. Pressing on the bag is done after every three pressures. For every 2 seconds, you need to carry out 3 pressures and 1 ventilation.

What to do if water is contaminated with meconium

Features of neonatal resuscitation include assistance with staining amniotic fluid with meconium and assessing the child on the Apgar scale less than 6 points.

1. During childbirth after the appearance of the head from birth canal aspirate nasal and oral contents immediately.
2. After birth and placing the baby under a heat source, before the first breath, it is desirable to intubate with the largest possible tube in order to extract the contents of the bronchi and trachea.
3. If it is possible to extract the contents and it has an admixture of meconium, then it is necessary to reintubate the newborn with another tube.
4. Ventilation is established only after all the contents have been removed.

Drug therapy

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

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

Mistakes that are not allowed

It is strictly forbidden to carry out activities, the safety of which has not been proven:

• pour water on the baby
• squeeze his chest;
• strike on the buttocks;
• direct an oxygen jet in the face, and the like.

Albumin solution should not be used to increase initial volume, as this increases the risk lethal outcome newborn.

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

methodical writing

Primary and resuscitation care for newborns

Chief editors: Academician of RAMS N.N.Volodin1 , Professor E.N.Baybarina2 , Academician of RAMS G.T.Sukhikh2 .

Team of authors: Professor A.G.Antonov2 , Professor D.N.Degtyarev2 , Ph.D. O.V.Ionov2 , Ph.D. D.S. Kryuchko2, Ph.D. A.A. Lenyushkina2, Ph.D. A.V. Mostovoy3 , M.E. Prutkin,4 Terekhova Yu.E.5 ,

Professor O.S.Filippov5 , Professor O.V.Chumakova5 .

The authors thank the members of the Russian Association of Perinatal Medicine Specialists, who took an active part in finalizing these recommendations - A.P. Averina (Chelyabinsk), A.P. Galunina (Moscow), A.L. Karpov (Yaroslavl), A.R. Kirtbaya (Moscow), F.G. Mukhametshina (Yekaterinburg), V.A. Romanenko (Chelyabinsk), K.V. Romanenko (Chelyabinsk).

Updated approach to neonatal primary resuscitation outlined in guidelines heard and endorsed at IV

them. N.I. Pirogov.

2. Leading institution: Federal State Institution “Scientific Center for Obstetrics, Gynecology and Perinatology named after A.I. Academician V.I. Kulakov.

3. GOU VPO St. Petersburg State Pediatric Medical Academy.

4. GUZ Regional children's clinical Hospital No. 1 in Yekaterinburg.

5. Ministry of Health and social development Russian Federation.

List of abbreviations:

HR - heart rate IVL - mechanical ventilation BCC - volume of circulating blood

CPAP - continuous positive airway pressure PEEP positive end expiratory pressure

PIP - Peak Inspiratory Pressure ETT - Endotracheal Tube

SpO2 - saturation (saturation) of hemoglobin with oxygen

Introduction

Severe ante- and intranatal fetal hypoxia is one of the main causes of high perinatal morbidity and mortality in the Russian Federation. Effective primary resuscitation of newborns in the delivery room can significantly reduce adverse effects perinatal hypoxia.

According to various estimates, from 0.5 to 2% of full-term babies and from 10 to 20% of premature and post-term babies need primary resuscitation in the delivery room. At the same time, the need for primary resuscitation in children born weighing 1000-1500 g is from 25 to 50% of children, and in children weighing less than 1000 g - from 50 to 80% or more.

The basic principles of organization and algorithm for the provision of primary and resuscitation care to newborns, used to date in the activities of maternity hospitals and obstetric departments, were developed and approved by the 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 of December 28, 1995 No. 372). Over the past time, both in our country and abroad, a large clinical experience has been accumulated in the primary resuscitation of newborns of various gestational ages, the generalization of which made it possible to identify reserves for improving the efficiency of both individual medical events, and the entire complex of primary resuscitation as a whole.

The approaches to the primary resuscitation of very premature babies have changed most significantly. At the same time, in the previously approved algorithm for the actions of medical personnel in the delivery room, unjustified from the point of view of evidence-based medicine and even potentially dangerous medical practices. All this served as the basis for clarifying the principles of organization of primary

resuscitation care for newborns in the delivery room, revision and differentiated approach to the algorithm for primary resuscitation of full-term and very premature babies.

Thus, these recommendations set out modern, internationally recognized and proven principles and algorithms for conducting primary resuscitation of newborns. But for their full-scale implementation in medical practice and maintaining on high level quality medical care newborns need to be organized in each obstetric hospital for permanent basis training of medical workers. It is preferable that classes be conducted using special dummies, with video recording of training sessions and subsequent analysis of training results.

Rapid implementation of updated approaches to primary

and resuscitation care for newborns will reduce neonatal

and infant mortality and disability since childhood, to improve the quality of medical care for newborn children.

Principles of organizing primary resuscitation care for newborns

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

Primary and resuscitation care for newborns after birth should be provided in all facilities where childbirth can potentially occur, including the prehospital stage.

At every birth taking place in any division of any medical institution licensed to provide obstetric and gynecological care must always be present medical worker who has the special knowledge and skills necessary to provide a full range of primary resuscitation care to a newborn child.

For 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 where cardiopulmonary resuscitation begins, the employee who conducts 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 skills of primary resuscitation of the newborn should be owned by:

Doctors and paramedics of emergency and emergency medical care, transporting women in labor;

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

- staff of departments of newborns (neonatologists, anesthesiologists, resuscitators, pediatricians, children's nurses).

An obstetrician-gynecologist notifies a neonatologist or other medical worker who is fully familiar with the methods of primary resuscitation of newborns in advance of the birth of a child to prepare equipment. A specialist providing primary resuscitation care to newborns should be informed in advance by an obstetrician-gynecologist about the risk factors for the birth of a child in asphyxia.

Antenatal risk factors for neonatal asphyxia:

- diabetes;

- preeclampsia (preeclampsia);

- hypertensive syndromes;

- Rh sensitization;

- stillbirth in history;

- clinical signs of infection in the mother;

- bleeding in II or III trimesters pregnancy;

polyhydramnios;

oligohydramnios;

- multiple pregnancy;

- intrauterine growth retardation;

- mother's use of drugs and alcohol;

- the use by the mother of drugs that depress the breathing of the newborn;

- the presence of developmental anomalies identified during antenatal diagnosis;

- abnormal indicators of cardiotocography on the eve of childbirth.

Intranatal risk factors:

- preterm birth (less than 37 weeks);

- delayed delivery (more than 42 weeks);

- caesarean section operation;

- placental abruption;

- placenta previa;

- prolapse of umbilical cord loops;

- pathological position of the fetus;

- the use of general anesthesia;

- anomalies of labor activity;

- the presence of meconium in the amniotic fluid;

- violation of the fetal heart rhythm;

- shoulder dystocia;

- instrumental genera ( obstetric forceps, vacuum extraction). The neonatologist should also be informed of the indications for surgery.

caesarean section and features of anesthesia. When preparing for any childbirth, you should:

- provide optimal temperature regime for a newborn (the air temperature in the delivery room is not lower than + 24º C, no draft, the source of radiant heat is turned on, a warmed set of diapers);

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

- invite a doctor who knows the methods of resuscitation of a newborn in full to the birth. In multiple pregnancies, sufficient specialists and equipment should be available in advance to care for all newborns;

- when the birth of a child in asphyxia is predicted, the birth of a premature baby at 32 weeks of gestation or less, an intensive care team consisting of

of two people trained in all neonatal resuscitation techniques (preferably a neonatologist and a trained nurse). Care of the newborn should be the sole responsibility of the members of this team during the initial resuscitation.

After the birth of the child, it is necessary to record the time of his birth and, if indicated, proceed with resuscitation in accordance with the protocol outlined below. (The sequence of primary resuscitation measures is presented in the form of diagrams in Appendices No. 1-4).

Regardless of the initial state, nature and volume of resuscitation, 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 assessing the Apgar against the background of mechanical ventilation, only the presence of spontaneous respiratory efforts of the child is taken into account: if they are present, 1 point is set for breathing, if they are absent, 0, regardless of chest excursion in response to forced ventilation of the lungs.

Table 1.

Criteria for evaluating a newborn according to V. Apgar

Apgar score interpretation.

The sum of 8 points or more 1 min 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 is not so much diagnostic as prognostic value, and reflects the effectiveness (or ineffectiveness) of resuscitation measures. There is a strong inverse relationship 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 terminating primary resuscitation.

In all cases of live birth, the first and second Apgar scores are entered in the appropriate columns of the neonatal history.

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

1.1.Fix the time of the 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.) Amniotic fluid is clean, clear signs no 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 the close supervision of medical personnel. If the specialist answers “NO” to at least one of the above questions, he must transfer the child to a heated table (to an open resuscitation system) for an in-depth assessment of the child’s condition and, if necessary, for primary resuscitation.

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

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

Voluntary muscle movements.

1.5. In the absence of all signs of a live birth, the child is considered stillborn.

1. General principles

Immediately after the birth of the head, mucus is removed from the nasopharynx and oropharynx of the fetus using a rubber pear or a catheter connected to a special suction. When the baby is born completely, it is wiped dry with a sterile towel. After the appearance of spontaneous breathing or the cessation of pulsation of the umbilical cord, a clamp is applied to the umbilical cord and the newborn is placed in the incubator, giving it a position with a slightly lowered head end. With obvious asphyxia, the umbilical cord is immediately clamped and resuscitation begins. Normally, the newborn takes the first breath within 30 seconds after delivery, and steady spontaneous breathing is established within 90 seconds. The norm of respiratory rate is 30-60/mip, and heart rate is 120-160/min. Respiration is assessed by auscultation of the lungs, heart rate - by auscultation of the lungs or by palpation of the pulse at the base of the umbilical cord.

In addition to breathing and heart rate, it is necessary to assess the color of the skin, muscle tone and reflex excitability. The generally accepted method is to assess the child's condition on the Apgar scale (Table 43-4), produced at the 1st and 5th minute of life. The Apgar score at the 1st minute of life correlates with survival, at the 5th minute - with the risk of neurological disorders.

The norm is an Apgar score of 8-10 points. Such children need only mild stimulation (patting on the feet, rubbing the back, vigorous towel drying). The catheter is carefully passed through each nasal passage to rule out choanal atresia, and through the mouth into the stomach to rule out esophageal atresia.

2. Meconium admixture in amniotic fluid

The admixture of meconium in the 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 dense staining of amniotic fluid with meconium. With intrauterine hypoxia, the fetus develops 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. Meconium that is thick or contains solid particles can close the lumen of the small bronchi, which is the cause of severe respiratory failure, which occurs in 15% of cases with the admixture of meconium in the amniotic fluid. In addition, with this complication, the risk of persistence of the fetal circulation type is high (Chapter 42).

With light staining of amniotic fluid with meconium, sanitation of the respiratory tract is not required. If the amniotic fluid is heavily 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 contents of the trachea are sucked off. A special suction is connected directly to the endotracheal tube, which is slowly removed. If meconium is found in the trachea, intubation and aspiration of the contents continue 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 mouth of the newborn, through which humidified oxygen is supplied. It is also necessary to aspirate the contents of the stomach to prevent passive meconium regurgitation. Meconium aspiration is a risk factor for pneumothorax (the frequency 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 provides airway patency and conducts

TABLE 43-4. Apgar score

IVL, the second performs an indirect heart massage. The participation of a third person, who catheterizes the vessels, injects drugs and infusion solutions, is very useful.

The most common cause of neonatal asphyxia is intrauterine hypoxia, therefore key point resuscitation is the normalization of 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 of the umbilical cord, prematurity, bleeding in the mother, crossing the placenta during caesarean section, sepsis, cross-circulation in twins.

If the neonate does not improve despite adequate respiratory resuscitation, vascular access and gas analysis should be performed. arterial blood; pneumothorax should be ruled out (1% prevalence) and congenital anomalies respiratory tract, including tracheoesophageal fistula (1:3000-5000 newborns) and congenital hernia aperture (1:2000-4000).

Apgar score at the 1st minute of life allows to standardize the approach to resuscitation: (1) mild asphyxia (5-7 points): stimulation (wiping the body, patting on the feet, debridement 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 heart 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 weight of the child: 2 kg - 1 and 3.5 mm. If the tube is chosen correctly, then at an airway pressure 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: 6 is added to the child's weight in kilograms, the result is expressed in centimeters. It is advisable to carry out pulse oximetry using a handheld sensor. The use of a transcutaneous oxygen tension monitor is also quite informative, but it takes a lot of time to set it up.

External cardiac massage

External cardiac massage is indicated when, after 30 hours of adequate ventilation with 100% oxygen, the heart rate is
Heart massage is carried out simultaneously with IVL with 100 oxygen. The frequency of pressure on the sternum should be 90-120 / min (Fig. 43-4). Heart massage technique described for children younger age(chapter 48) may be used for neonates weighing > 3 kg. The ratio of the frequency of compressions and injections should be 3:1, so that within 1 minute 90 compressions and 30 injections are performed. Heart rate should be checked periodically. At heart rate > 80/min, chest compressions are stopped.

Rice. 43-3. Newborn intubation. The head is in a neutral position. The laryngoscope is held between the large and index finger left hand, holding the chin middle and nameless. The little finger of the left hand is pressed against the hyoid bone, which helps to see the vocal cords. Best Review provides a straight blade, e.g. a #0 or #1 Miller laryngoscope

Vascular access

Most best method vascular access is the placement of 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 level of the skin and the reverse flow of blood when the syringe plunger is pulled is free; with a deeper introduction transfused hypertonic solutions can go directly to the liver.

Catheterization of one of the two umbilical arteries, which allows monitoring blood pressure and facilitating the analysis of arterial blood gases, is technically more difficult. Special catheters for the umbilical artery have been developed, which allow not only to measure blood pressure, but also to conduct long-term monitoring of PaO2 and SaO2. Need to take necessary measures to prevent air from entering a vein or artery.

Infusion therapy

Of the newborns who require resuscitation, hypovolemia is present in some full-term and two-thirds of preterm infants. Hypovolemia is diagnosed with arterial hypotension and pallor of the skin, combined with a poor response to resuscitation. In newborns, BP correlates with BCC, so all newborns should have BP 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, an erythrocyte mass of group 0 (I) Rh (neg), combined with maternal blood, or a 5% solution of albumin or Ringer's solution with lactate at a dose of 10 ml / kg is used. More rare causes arterial hypotension include hypocalcemia, hypermagnesemia and hypoglycemia.

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

Medications

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

B. Naloxone: Indications: elimination of respiratory depression caused by the administration of opioids to the mother in the last 4 hours before delivery. Dose: 0.01 mg/kg IV or 0.02 mg/kg IM. If the mother has abused opioids, then naloxone can provoke a withdrawal syndrome in the fetus.

B. Other drugs: In some cases, other drugs are used. Sodium bicarbonate (dose 2 meq/kg body weight, 1 ml solution contains 0.5 meq) is indicated only for severe metabolic acidosis verified by arterial blood gas analysis. Sodium bicarbonate is also used in prolonged resuscitation (> 5 min), especially if arterial blood gas analysis is not technically possible. The infusion rate should not exceed 1 meq/kg/min to avoid hyperosmolarity and intracranial hemorrhage. In addition, to avoid hyperosmolarity-induced damage to hepatocytes, the distal tip of the catheter should not be located in the liver. Calcium gluconate 100 mg/kg (or calcium chloride 30 mg/kg) is only indicated 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, a 10% solution is used) is only indicated for documented hypoglycemia, as hyperglycemia exacerbates neurological deficits. Surfactant is indicated for respiratory distress syndrome in preterm infants, it can be injected into the trachea through an endotracheal tube.

approved by order of the Minister of Health and Medical Industry of the Russian Federation of December 28, 1995 No. 372

I. The sequence of primary and resuscitation care for a newborn in the delivery room.
A. When providing resuscitation care to a newborn in the delivery room, a certain sequence of actions must be strictly observed.
1. forecasting the need for resuscitation and preparation for their implementation;
2. assessment of the child's condition immediately after birth;
3. restoration of free airway patency;
4. restoration of adequate breathing;
5. restoration of adequate cardiac activity;
6. the introduction of medicines.
B. In the process of performing all of the above activities, it is necessary to strictly adhere to the rule - under any circumstances, the newborn must be provided with optimal temperature conditions.
C. The main factors for quick and effective resuscitation of a newborn in the delivery room are:
1. predicting the need for resuscitation;
2. readiness of personnel and equipment for resuscitation.

II. Predicting the need for resuscitation.
A. The delivery room staff must be prepared to provide resuscitation care to the newborn much more often than he actually has to do.
B. In most cases, the birth of a child in asphyxia or drug-induced depression can be predicted in advance based on an analysis of the antenatal and intranatal history.
Antenatal risk factors:
late preeclampsia;
diabetes;
hypertensive syndromes;
Rh sensitization;
stillborn in history;
maternal infection;
bleeding in the II or III trimesters of pregnancy;
polyhydramnios;
oligohydramnios;
prolongation of pregnancy;
multiple pregnancy;
intrauterine growth retardation;
mother's use of drugs and alcohol;
the use of certain drugs in a pregnant woman (magnesium sulfate, adrsnoblockers, reserpine), etc.

Intranatal risk factors:
premature birth;
belated birth;
C-section;
pathological presentation and position of the fetus;
placental abruption;
placenta previa;
prolapse of umbilical cord loops;
violation heart rate in the fetus;
the use of general anesthesia;
anomalies of labor activity (discoordination, prolonged, rapid and rapid labor);
the presence of meconium in the amniotic fluid;
infection during childbirth, etc.

Readiness of personnel and equipment for resuscitation.
A. Sometimes, despite a careful study of the anamnesis and observation of childbirth, the child is still born in asphyxia. In this regard, the process of preparing for each birth should include:
1. creating an optimal temperature environment for a newborn child (maintaining the air temperature in the delivery room at least 24 degrees Celsius + installing a pre-heated radiant heat source);
2. preparation of all resuscitation equipment located in the delivery room and operating room, available on demand for use;
3. ensuring the presence at the birth of at least one person who owns the methods of resuscitation of the newborn in full; one or two other trained members of the duty team should be on standby in case of an emergency.
B. When the birth of a child in asphyxia is predicted, a resuscitation team should be present in the delivery room, consisting of two people trained in all newborn resuscitation techniques (preferably a neonatologist and a trained nurse). Care of the newborn should be the sole responsibility of the members of this team.
With multiple pregnancies, one must bear in mind the need for the presence of an expanded team at the birth.

Cycle "assessment - decision - action".
A. Extremely important aspect resuscitation is an assessment of the condition of the child immediately after birth, on the basis of which a decision is made on the necessary actions, and then the actions themselves are performed. Further assessment of the child's condition will be the basis for subsequent decisions and follow-up actions. Effective resuscitation care for a newborn in the delivery room can only be provided when a series of "assessment - decision - action" cycles is carried out.
B. When deciding whether to start medical measures should rely on the severity of signs of live birth: spontaneous breathing, heartbeat (heart rate), umbilical cord pulsation, voluntary muscle movements. In the absence of all 4 signs of a live birth, the child is considered stillborn and is not subject to resuscitation. If the child has at least one of the signs of a live birth, the child must be provided with primary and resuscitation care. The volume and sequence of resuscitation measures depend on the severity of 3 main signs characterizing the state of the vital functions of a newborn child: spontaneous breathing, heart rate and skin color. In other words, if the child requires intervention in terms of breathing and cardiac activity, such an intervention should be carried out immediately. It should not be delayed until after 1 minute of life, when the first Apgar score is made. Such a delay can be too costly, especially if the child has severe asphyxia.
C. An Apgar score should be performed at the end of 1 and 5 minutes of life to determine the severity of asphyxia and the effectiveness of resuscitation, including cases where the child is being mechanically ventilated at the time of the assessment. Thereafter, if continued resuscitation is required, this assessment should be repeated every 5 minutes up to 20 minutes of life.

III. Stages of primary and resuscitation care for a newborn in the delivery room.
Main steps primary care and resuscitation of a newborn born in asphyxia or drug-induced depression are listed below:
1. Initial activities. Holding initial activities shown to all children who at birth have at least one of the signs of live birth.
A. Initial measures in the absence of risk factors for the development of asphyxia and light amniotic fluid.
1. At the birth of a child, fix the time (turn on the clock on the table or look at the wall clock).
2. Immediately after cutting the umbilical cord, place the baby under a source of radiant heat.
3. Wipe it dry with a warm diaper.
4. Remove the wet diaper from the table.
5. Give the child a position with a slightly thrown back head on the back with a cushion under the shoulders or on the right side.
6. When separating a large number mucus from the upper respiratory tract (URT), first suck out the contents of the oral cavity, then the nasal passages using a balloon, a De Lee catheter or a special catheter for sanitation of the upper respiratory tract, connected through a tee to an electric suction, with a discharge of no more than 100 mm Hg. Art. (0.1 atm). (When sanitizing the upper respiratory tract with a catheter, do not touch rear wall throats!).
7. If after sanitation URT child does not breathe, produce light tactile stimulation by 1-2 times (but no more!) patting on the feet.

NB! THE ENTIRE GETTING STARTED PROCESS SHOULD TAKE NO MORE THAN 20 SECONDS.
B. Initial measures in the presence of risk factors for asphyxia and pathological impurities in the amniotic fluid (meconium, blood, cloudy).
1. At the birth of the head (before the birth of the shoulders!) suck out the contents of the oral cavity and nasal passages with a catheter of at least 10 Fr (No. 10).
2. Immediately after the birth of the child, fix the time (turn on the clock on the table or look at the wall clock).
3. In the first seconds after birth, apply clamps to the umbilical cord and cut it without waiting for the pulsation to stop.
4. Place the child under a source of radiant heat.
5. Give the child a position on the back with a cushion under the shoulders with the head slightly thrown back and the head end lowered by 15-30 degrees.
6. Suction the contents of the oral cavity and nasal passages using a De Lee catheter or a special catheter for sanitation of the upper respiratory tract. Suction of the contents of the stomach should be performed no earlier than 5 minutes after birth in order to reduce the likelihood of apnea and bradycardia.
7. Under the control of direct laryngoscopy, sanitize the trachea with an endotracheal tube (not a catheter!) of the appropriate diameter, connected through a tee to an electric pump, with a discharge of no more than 100 mm Hg. Art. (0.1 atm).
8. Wipe the child dry with a warm diaper.
9. Remove the wet diaper from the table.

NB! THE ENTIRE INITIAL PROCESS IN THIS CASE SHOULD NOT TAKE MORE THAN 40 SECONDS.
1. The first assessment of the condition of the child after birth.
A. Breathing assessment.
1. absent (primary or secondary apnea) - start artificial lung ventilation (ALV);
2. independent, but inadequate (convulsive, "gasping" type, or irregular, superficial) - start mechanical ventilation;
3. self-regular - assess the heart rate.

Assessment of heart rate (HR).
Determine your heart rate in 6 seconds using one of three methods:
auscultation of heart sounds
palpation of the apex beat,
palpation of the pulse on the carotid, femoral or umbilical arteries (according to the pulsation of the umbilical cord).
Multiplying the heart rate for 6 seconds by 10 gives you a heart rate of 1 minute.
Possible options assessments and next steps:
1. Heart rate less than 100 beats per 1 minute - carry out mask ventilation with 100% oxygen until normal heart rate is restored;
2. Heart rate more than 100 beats per 1 minute - evaluate the color of the skin.
B. Evaluation of the color of the skin.
Possible evaluation options and next steps:
1. completely pink or pink with cyanosis of the hands and feet - observe. If everything is fine - attach to the mother's chest;
2. cyanotic skin and visible mucous membranes - carry out inhalation of 100% oxygen through a face mask until cyanosis disappears.

1. Artificial ventilation of the lungs.
A. Indications for mechanical ventilation.
IVL should be started if, after the initial measures, the child:
spontaneous breathing is absent (apnea);
independent breathing is inadequate (such as "gasping", irregular, shallow).
B. Ventilation technique.
IVL is carried out with a self-expanding bag (Ambu, Penlon Laerdal, Blue Cross, etc.) either through a face mask or through an endotracheal tube. Although mechanical ventilation through an endotracheal tube is usually more effective, it requires tracheal intubation, which can waste precious time. And if intubation is performed clumsily and not on the first attempt, the risk of complications is high.
In most cases, timely and effective result provides mask ventilation. The only contraindication to mask ventilation is the suspicion of diaphragmatic hernia.

1. Ventilation through a face mask.
a) Before starting IVL:
connect it to an oxygen source, optimally - through a humidifier / heater of the air-oxygen mixture,
select face mask required size depending on the expected body weight of the fetus (it is better to use a mask with a soft obturator),
b) Place the mask on the child's face so that the upper part of the obturator rests on the bridge of the nose and the lower part rests on the chin. Check the tightness of the application of the mask by squeezing the bag 2-3 times with the whole brush while observing the excursion of the chest. The probe should not be inserted into the stomach, since the tightness of the breathing circuit will not be achieved in this case.
c) After confirming that the chest excursion is satisfactory, perform the initial phase of ventilation, while observing the following requirements:
respiratory rate - 40 per 1 minute (10 breaths in 15 seconds),
the number of fingers involved in the compression of the mark is the minimum to ensure adequate chest excursion,

1. Gastric tube.
a) The introduction of a probe into the stomach is indicated only if the mask ventilation is delayed for more than 2 minutes.
b) Use a sterile gastric tube No. 8; a larger diameter probe will break the tightness of the breathing circuit. Insert the probe through the mouth to a depth equal to the distance from the bridge of the nose to the earlobe and further to the xiphoid process (the length of the catheter is measured approximately without removing the face mask and without stopping mechanical ventilation).
c) Attach a 20 ml syringe to the probe, quickly but smoothly suck out the contents of the stomach, then fix the probe on the child’s cheek with adhesive tape, leaving it open for the entire period of mask ventilation. If bloating persists after the end of mechanical ventilation, leave the probe in the stomach for a longer time (until the signs of flatulence disappear).
2. Oral duct.
a) During mask ventilation, an oral airway may be required in three cases:
bilateral choanal atresia,
Pierre Robin syndrome
the impossibility of ensuring free patency of the upper respiratory tract with the correct laying of the child.
b) C resuscitation kit there should be two air ducts: one for full-term babies, the other for premature babies. When the air duct is inserted, it should fit freely over the tongue and reach the posterior pharyngeal wall: the cuff should remain on the child's lips.

1. IVL through an endotracheal tube.
a) Indications for tracheal intubation:
suspected diaphragmatic hernia
aspiration of amniotic fluid, which required sanitation of the trachea,
inefficiency of mask ventilation for 1 minute,
Apnea or inadequate spontaneous breathing in a baby less than 28 weeks gestational age.
b) Before tracheal intubation:
check the condition of the breathing bag,
connect it to an oxygen source,
prepare the laryngoscope and endotracheal tube,
lay the child on his back with a cushion under his shoulders with his head slightly thrown back.
c) Perform tracheal intubation.
d) After confirming that the chest excursion is satisfactory, perform the initial phase of ventilation, while observing the following requirements:
respiratory rate - 40 per 1 minute (10 breaths in 15 seconds) with a ratio of inhalation and exhalation time 1: 1 (inhalation time - 0.7 s),
oxygen concentration in the gas mixture - 90-100%,
the number of fingers involved in the compression of the bag is the minimum to ensure adequate chest excursion,
if during mechanical ventilation it is possible to control airway pressure using a manometer, the first 2-3 breaths should be performed with a maximum end-inspiratory pressure (PIP) of 30-40 cm of water. Art., and in subsequent - to maintain it within 15-20 cm of water. at healthy lungs and 20-40 cm of water. Art. - with aspiration of meconium or RDS; positive end-expiratory pressure (PEEP) should be maintained at 2 cmH2O:
when using a volumetric respirator, the tidal volume must be set at the rate of 6 ml / kg.
duration initial stage ventilation - 15-30 seconds.
AT. Further actions.
After the initial stage of mechanical ventilation for 15-30 seconds (!) Evaluate the heart rate, as indicated and p.2.B.
1. If the heart rate is above 80 beats per minute - continue mechanical ventilation until adequate spontaneous breathing is restored, then evaluate the color of the skin (see paragraph 2.C.).
2. If the heart rate is less than 80 beats per minute - continuing mechanical ventilation, check its adequacy and start chest compressions.

1. Indirect cardiac massage.
A. Indications for chest compressions.
Heart rate below 80 beats per minute after the initial stage of mechanical ventilation for 15-30 seconds.
B. Technique of chest compressions.
An indirect heart massage can be performed in one of two ways:
1. with the help of two fingers (index and middle or middle and ring) of one brush;
2. using thumbs both hands, covering the chest with them.
In both cases, the child should be on a hard surface and pressure on the sternum should be carried out at the border of the middle and lower thirds (avoid pressure on the xiphoid process due to the risk of injury to the left lobe of the liver!) with an amplitude of 1.5 - 2.0 cm and a frequency of 120 per minute (2 compressions per second).
B. The frequency of ventilation during the heart massage is maintained at 40 per minute. In this case, the compression of the sternum is carried out only in the exhalation phase at a ratio of "inspiration:compression of the sternum" = 1:3. In the case of indirect heart massage against the background of mask ventilation, the introduction of a gastric tube for decompression is mandatory.
D. Next steps.
1. Perform a heart rate (HR) assessment. The first assessment of heart rate is carried out 30 seconds after the start of chest compressions. At the same time, it is stopped for 6 seconds and the heart rate is assessed, as indicated in paragraph 2.B. In the future, a child who responds well to resuscitation should determine the heart rate every 30 seconds to stop chest compressions as soon as it is above 80 beats per minute. If long-term resuscitation is necessary, heart rate can be determined less frequently.
2. If the heart rate is above 80 beats per minute - stop chest compressions and continue mechanical ventilation until adequate spontaneous breathing is restored.
3. If the heart rate is below 80 beats per minute - continue indirect heart massage on the background of mechanical ventilation (if mechanical ventilation was carried out through a face mask, perform tracheal intubation) and start drug therapy.

1. Drug therapy.
A. Indications for drug therapy:
1. Heart rate below 80 beats per minute after 30 seconds of chest compressions on the background of mechanical ventilation.
2. There are no heartbeats.
B. Drugs used in resuscitation of a newborn in the delivery room:
1. A solution of adrenaline in a dilution of 1:10,000.
2. Solutions to compensate for the deficiency of circulating blood: albumin 5%, isotonic sodium chloride solution, Ringer-lactate solution.
3. 4% sodium bicarbonate solution.
B. Methods of administering drugs.

1. Through a catheter in the umbilical vein:
a) for catheterization of the umbilical vein, it is necessary to use umbilical catheters of size 3.5-4Fr or 5-6Fr (domestic No. 6 or No. 8) with one hole at the end;
b) the catheter into the umbilical vein should be inserted only 1-2 cm below the level of the skin until free blood flow appears; with deep insertion of the catheter, the risk of damage to the liver vessels by hyperosmolar solutions increases;
c) immediately after resuscitation, it is advisable to remove the catheter from the umbilical vein; only if it is impossible to carry out infusion therapy through peripheral veins the catheter in the umbilical vein can be left by advancing it to a depth equal to the distance from the umbilical ring to the xiphoid process, plus 1 cm.

2. Through the endotracheal tube:
a) only adrenaline can be administered through the endotracheal tube; it is injected either directly into the endotracheal tube connector or through a 5Fr catheter (No. 6) inserted into the tube, which is then flushed with isotonic sodium chloride solution (0.5 ml per 40 cm of catheter length.
b) after endotracheal administration of adrenaline, it is necessary to continue mechanical ventilation for a more uniform distribution and absorption of the drug in the lungs.
D. Characteristics of drugs used in the primary resuscitation of newborns in the delivery room.

1. Adrenaline.
a) Indications:
Heart rate below 80 beats per minute after 30 seconds of chest compressions on the background of mechanical ventilation;
there are no heartbeats; in this case, adrenaline is administered immediately, simultaneously with the start of mechanical ventilation and chest compressions.
b) The concentration of the injected solution is 1:10000.
c) Preparation of the syringe.
Dilute 1 ml from an ampoule with adrenaline in 10 ml of saline. Draw up 1 ml of the prepared solution into a separate syringe.
d) Dose - 0.1-0.3 ml/kg of the prepared solution.
e) Method of administration - into the vein of the umbilical cord or endotracheally.
e) The rate of administration - jet.
g) Action:
increases the frequency and strength of heart contractions;
causes peripheral vasoconstriction leading to an increase in blood pressure.
h) Expected effect: after 30 seconds from the moment of administration, the heart rate should reach 100 beats per minute.
i) Next steps:
1. if after 30 seconds the heart rate is restored and exceeds 80 beats per minute, do not administer other medications, stop chest compressions, continue ventilation until adequate spontaneous breathing is restored;
2. If after 30 seconds the heart rate remains below 80 beats per minute, continue chest compressions and mechanical ventilation, against which do one of the following activities:
repeat the administration of adrenaline (if necessary, this can be done every 5 minutes);
if there are signs of acute blood loss or hypervolemia, enter one of the solutions to replenish the BCC;
for confirmed or suspected decompensated metabolic acidosis, administer sodium bicarbonate.