Transcript IBucens_NewbornRessuscitation

NEWBORN RESUSCITATION
Dr Ingrid Bucens
Layout of talk
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.
What is neonatal resuscitation?
• 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.
What does it involve?
1.
Preparation at every birth
2.
Assessment of the baby’s condition at birth
3.
Interventions
1.
2.
3.
Dry / stimulate
Clear airway
Support breathing
•
•
4.
(Advanced support)
•
•
•
4.
Ventilate (bag/mask)
?oxygen
Chest compressions
Intubation / ventilation
Medications
Ongoing assessment
BASIC
How many babies require resuscitation?
NOT POSSIBLE
TO PREDICT
WHICH BABIES
NEED HELP.
What does it do?
• 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
– PLACENTA/CORD
– After delivery
• Resuscitation not
expedient
• Cord prolapse
• Antepartum haemorrhage
– BABY
• IUGR
• Postmature
• Malpresentation/breech
Why does ASPHYXIA matter?
• 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.
INTRAPARTUM HYPOXIA
Other
Postnatal
hypoxia
STILLBIRTH
ASPHYXIATED
BABY
No breathing
RESUSCITATION
Unsuccessful
DEATH – intrapartum/neonatal
Depending on HR at birth?
‘Successful’
Normal
Neonatal
encephalopathy
Disability
Burden of DEATH from asphyxia
• 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 5TH 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’.
TOTAL NMR / 1000 livebirths
</= 5
6-15
16-30
31-45
>/=45
DEATHS ATTRIBUTED TO INTRAPARTUM ASPHYXIA / 1000 births
Stillborn
1.2
3.8
6.1
10.1
11.4
NMR
0.5
1.9
4.5
8.7
11.8
NEONATAL ENCEPHALOPATHY
% case fatality rate
Median
21
12 (?)
19
31
NA
% survivors w modsevere impairment
29
27
30
25
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)
INTRAPARTUM HYPOXIA
1
STILLBIRTH
ASPHYXIATED
BABY
No breathing
2
RESUSCITATION
Unsuccessful
DEATH – stillbirth/neonatal
Depending on HR at birth?
‘Successful’
Normal
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
• Available at point of birth
• Human resources
– SKILLED BIRTH ATTENDANT
– Other trained in NBR
• Physical resources
– Equipment / supplies
– Health facilities
– Communities!!!!!!!
The reality ….
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
OXYGEN MAY NOT BE
Warming device (electricity)
NECESSARY.
Towels
• 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
• ?Equally effective
• Less ‘user-friendly’
– Tiring to use
– More difficult
to observe baby
• Suction devices
– Electric
– Manual
– One-way valve hand-held
• Infection risk (HIV)
HUMAN RESOURCES
• 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
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
What NBR can do - summary
• 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.
Clinical prognostic predictors
• 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:•
•
•
•
•
•
•
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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
Take home messages
• 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