Dr Ingrid Bucens

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

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

1.
Preparation at every birth
2.
Assessment of the baby’s condition at birth
3.
Interventions
1.
Dry / stimulate
2.
Clear airway
3.
Support breathing
• Ventilate (bag/mask)
• ?oxygen
4.
(Advanced support)
• Chest compressions
• Intubation / ventilation
• Medications
4.
Ongoing assessment
BASIC

How many babies require resuscitation?
NOT POSSIBLE
TO PREDICT
WHICH BABIES
NEED HELP.

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

Why do some babies need help with breathing at birth?
Something is wrong with the ‘drive to breath’
– ASPHYXIA (Intrapartum asphyxia)
– Prematurity
– Sepsis
– Drugs administered to mother (GA)
– Congenital malformation, intracranial disease
Too weak - Neuromuscular disease

What is ASPHYXIA?
• Asphyxia is a disturbed physiological state due to deprivation of oxygen supply to the fetus / newborn.
• Oxygen compromise may be
– Acute or chronic
– Mild or severe
– Once off or repeated episodes

When and why does asphyxia occur?
• Asphyxia may occur
– Antenatally
– During labour / perinatal
• Causes of asphyxia are many
(direct / indirect)!
Eg.
– MOTHER
• Pre-eclampsia
• Obstructed labour
• Hypotension
– After delivery
• Resuscitation not expedient
– PLACENTA/CORD
• Cord prolapse
• Antepartum haemorrhage
– BABY
• IUGR
• Postmature
• Malpresentation/breech

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

Other
STILLBIRTH
Unsuccessful
INTRAPARTUM HYPOXIA
DEATH – intrapartum/neonatal
Depending on HR at birth?
Postnatal hypoxia
ASPHYXIATED
BABY
No breathing
RESUSCITATION
Normal
‘Successful’
Neonatal encephalopathy
Disability

• STILLBIRTHS PLUS
– Number less certain
– ~ 4 000 000
– ?1 000 000 from asphyxia
• ?Antenatal
• ?intrapartum
• NEONATAL DEATHS
– 4 000 000 / year
– ~1 000 000 intrapartum asphyxia

The number and % of neonatal deaths due to intrapartum asphyxia increases as overall NMR increases.
Lawn et al. Int J Gyn Obst (2009) 107: S5-19.

Impact on child survival
- the burden of intrapartum asphyxia
INTRAPARTUM-RELATED DEATH IS THE 5 TH COMMONEST
CAUSE OF UNDER-5 DEATH IN CHILDREN! -almost 10%
BMC Pregnancy and Childbirth 2009, 9 (Suppl 1):S2 http://www.biomedcentral.com/1471-2393/9/S1/S2

DISABILITY – the other burden due of intrapartum asphyxia.
Lawn JE, et al. PLoS 2011; 8:e1000389

Burden of DISABILITY from asphyxia -
‘Intrapartum-related impairment’.
</= 5
TOTAL NMR / 1000 livebirths
6-15 16-30
DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births
31-45
Stillborn
NMR
1.2
0.5
3.8
1.9
6.1
4.5
10.1
8.7
NEONATAL ENCEPHALOPATHY
% case fatality rate
Median
% survivors w modsevere impairment
21
29
12 (?)
27
19
30
31
25
>/=45
11.4
11.8
NA
NA
Lawn et al. Int J Gyn Obst (2009) 107: S5-19.

Can we impact on the burden of asphyxia
(STILLBIRTH, NND, DISABILITY) and, if so, how?
• There are 3 possible intervention points.
– PRIMARY INTERVENTION – prevention of asphyxia
• Maternal health and reproductive health
• Health facility birth
• Risk factor identification (intrapartum)
• Early obstetric intervention (SBA, EMOC, referral services)
– Recognise and manage complications
– SECONDARY INTERVENTION – NEONATAL RESUSCITATION
– TERTIARY PREVENTION
• Care of neonatal encephalopathy - NICU (referral services)

1
INTRAPARTUM HYPOXIA
STILLBIRTH
Unsuccessful
DEATH – stillbirth/neonatal
Depending on HR at birth?
ASPHYXIATED
BABY
No breathing
RESUSCITATION
Normal
2
‘Successful’
Neonatal encephalopathy
Disabled

NBR is an important evidence based intervention for neonatal survival.

Assumption that the NBR is universally ACCESSIBLE and EFFECTIVE.
Pre-requisites for EFFECTIVE newborn resuscitation
ACCESSIBLE
• Human resources
– SKILLED BIRTH ATTENDANT
– Other trained in NBR
• Available at point of birth
– Health facilities
– Communities!!!!!!!
• Physical resources
– Equipment / supplies

Lawn et al. Int J Gyn Obst (2009) 107: S5-19. Wall et al. Int J Gyn Obst (2009) 107: S47-64.

Physical resources – equipment/supplies
• Essential equipment required for basic resuscitation is minimal
– Self-inflating bag (no need for gas supply)
– Mask
– Suction device +/- catheters
– Warming device (electricity)
– Towels
OXYGEN MAY NOT BE
NECESSARY.
• Functional equipment issue
– Immediately available
– Good working order
– Correct size
– Sufficient supplies (multiple births)
– Clean: Infection prevention
HEALTH SYSTEMS

Adaptations for low resource contexts
• ‘Bag’
– Tube/mask
– Mouth/mask
• Suction devices
– Electric
– Manual
– One-way valve hand-held
• Infection risk (HIV) • ?Equally effective
• Less ‘user-friendly’
– Tiring to use
– More difficult to observe baby

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

Availability at point of care
- Cadres of resuscitators
I
Adapted from Lancet (2005); 365. Newborn Survival Series

Training courses

Does training in NBR work?
SBA in health facilities
• Improvements in provider competency and intrapartum-related outcomes.
• Averts ~ 30% of intrapartum related NND
(asphyxia).
• Also 5-10% deaths due to preterm birth.

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

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

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

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

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

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

Can disability be predicted from condition at/after resuscitation?
Only to a limited extent.
• (APGAR SCORES)
• NEONATAL ENCEPHALOPATHY
• (BRAIN IMAGING, EEG)
If you can, then can triage into high-risk followup or early intervention.

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

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

When is CP due to ‘birth asphyxia’?
• Criteria to attribute possible intrapartum causation:-
• pH<7 or BE < -12
• severe or moderate neonatal encephalopathy (G>34wk)
• CP = spastic 4p or dyskinetic.
• Sentinel hypoxic signal occurring before or during labour
• Sudden rapid sustained deceleration FHR after the event
• Apgar 0-6 for > 5 mins
• Early evidence multisystem injury
• Early imaging evidence
• ?Is this relevant in low resource contexts
• Greater likelihood of intra-partum / perinatal asphyxia
• Cannot satisfy these diagnostic criteria
• Less litigation

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

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