dr. Christofel P, Sp.

OG (K) FM

Dewi Rezeki Arbi

030.11.074

Departemen Ilmu Kebidanan dan Kandungan

RSUD Kota Bekasi

Introduction
Under normal circumstances, the transition
from womb to world is a series of dramatic and
rapid physiologic changes leading to the birth of an
infant prepared to continue the processes of
growth and development. The goal of delivering a
healthy infant intact ready to continue normal
development is,
unfortunately,
not always
At birth, neonatal resuscitation may be
possible.
necessary. However, because it is not possible to
predict every infant who may require resuscitation,
the ability to conduct an effective resuscitation is
an integral part of the considerations and planning
for any delivery. Regardless of level of care, a
trained and experienced team, readily available, is

Elements of Birth
Depression

Causes of birth depression

Responses to hypoxia

In the normal fetal circulation,

blood returning to the heart
from the body and placenta is
primarily shunted through the
foramen ovale to the left side of
the
heart
facilitating
oxygenated blood to going to
the head and the heart. Blood
that reaches the right ventricle
is shunted through the ductus
arteriosus
to
the
aorta,
bypassing the lungs as a result
of a high pulmonary vascular
resistance.
This serves the
fetus well as the major organ of
gas exchange is the placenta

Responses to hypoxia

Responses to hypoxia

Responses to hypoxia

Elements of Birth
Depression

Primary and secondary apnea

Superimposed
on
these
circulatory and hemodynamic
changes
is
a
characteristic
respiratory pattern response to
asphyxia. The fetus or neonate
will initiate gasping respirations
(which may occur in utero) and,
should the asphyxia persist, enter
an apneic phase known as
primary apnea.
If the asphyxia continues, the
primary apnea will be followed by
a period of irregular gasping
respirations. Continued asphyxia
will lead to a period of unremit-

Elements of Birth
Depression

Primary and secondary apnea

If an infant is in primary apnea and

exposed to oxygen when gasping
respirations ensue, exposure to
oxygen may be sufcient to reverse
the process. However, once the
infant reaches secondary apnea,
positive pressure ventilation is
required to initiate spontaneous
ventilation.
Furthermore, the longer the duration
of secondary apnea, the longer it will
take for spontaneous respiratory
effort to return following the
administration of positive - pressure

Elements of Birth
Depression

Use of the Apgar Score

Elements of a
Resuscitation

Importance of establishing
ventilation

Elements of a
Resuscitation

Preparation for a Resuscitation

Elements of a
Resuscitation

Initial steps

Immediately after birth, the infant with any

degree of compromise, or for whom there is
any concern, should be placed in the
microenvironment of a preheated radiant
warmer.
The infant should be throughly dried with all
wet blankets removed to reduced evaporative
heat loss.

These simple measures can minimize the

signicant drop in infant core body temperature
experienced immediately after birth

The premature and/or small infant

represents an especially difcult
problem from the aspect of
temperature control.
There are three things that can be
done to help diminish heat loss in
the preterm/small infant. The rst
two should be done before the
anticipated delivery: (i) increase the
temperature of the delivery room
and (ii) make sure that the radiant
warmer is pre- heated before the
birth of the infant.
for infants less than 28 weeks, it is now recommended that consideration be
given to placing the infant in a standard, food - quality 1 - gallon
polyethylene bag that can easily be obtained from a grocery store. A hole is
cut in the closed end of the bag and the bag slipped over the baby with his or

The airway is normally cleared

with the use of a bulb syringe or
suction catheter. The mouth is
suctioned rst and then the nose.

This is done to rst clear

secretions in the mouth and
potentially
prevent
their
aspiration should deep breaths
occur with nasal suctioning.
Gentle suctioning of the mouth
will avoid the reex bradycardia
associated with stimulation of the
posterior pharynx.

If there is no immediate response to these supplemental methods,

positive pressure ventilation should be promptly initiated. Continued
tactile stimulation in an unresponsive infant will not succeed and may
prolong the asphyxial process. If, after suctioning and tactile
stimulation an infant exhibits apnea or a heart rate of
100
beats/min, positive pressure ventilation should be initiated.

In the infant who is breathing spontaneously with

no or minimal signicant signs of respiratory
distress and whose heart rate is above 100, yet
who remains cyanotic, there is general agreement
that there is a need for supplemental oxygen.

However, when to introduce the oxygen and at what

levels to start are not well agreed upon.

In the breathing infant with a heart rate of

above 100 who appears cyanotic, the use of a
pulse oximeter may be of some value.

Assisted Ventilation
If an infant is not breathing, is breathing but incapable of
sustaining a heart rate of above 100, or is in signicant
respiratory distress and requiring supplemental oxygen, some
form of assisted ventilation may be necessary.
This may be simply the provision of a continuous positive end
expiratory pressure to a spontaneously breathing infant or
intermittent mandatory positive pressure ventilation with end
expiratory pressure to infants who are not breathing or are in
signicant respiratory distress.
When resuscitating a newborn, one must establish a functional
residual capacity (FRC) and provide tidal volumes breaths. In the
past when positive pressure ventilation was used the concerns
were to provide a peak inspiratory pressure capable of effecting

Assisted Ventilation

Chest compressions
The
American
Heart
Association/American
Academy
of
Pediatrics
currently
recommends
beginning
chest
compression for a heart rate
of less than 60 beats/min.
This can be done with the two
nger method, or the thumb
method may be used to
administer
adequate
chesta
It is currently recommended that chest compressions
occur 90 times
compressions.
minute with ventilation interposed after every
third compression. Thus, in a

2- second period, 3 compressions and 1 breath are given. This provides 90

compressions and 30 respirations in each minute. Intermittently, chest
compressions should be stopped to check for a spontaneous heart rate. If
the spontaneous heart rate is greater than 60 beats/min compressions may
be stopped.
If well coordinated chest compressions and ventilation do not raise the

Medications
If the heart rate remains below 60/min, despite ventilation and
chest compression, the rst action should be to ensure that
ventilations and compressions are well coordinated and optimal
and 100% oxygen is being used before proceeding with
medications.

Screening for Congenital

Anomalies

External physical
examination

A rapid external physical examination will

identify obvious abnormalities such as:

Abnormal facies, and limb,

Abdominal wall or spinal column defects.
A scaphoid abdomen may be a clue to the
presence of a diaphragmatic hernia, whereas
a two vessel umbilical cord should alert the
examiner to the increased prob- ability of
other congenital abnormalities.

Internal physical
examination