International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

1. D. Dobryanskyj
Lviv National Medical University
New Concepts of Newborn
Resuscitation – the new national
protocol

2. Ukraine
0.1% require ICM*
0.05% require medicines
administration
≈ 1 million
< 1% • Should follow to IC**
≈ 5000 children
• LOW level of evidences of
require
children complete resuscitation effectiveness
≈ 30000 * - indirect cardiac massage
** - intensive care
children Approx. 6 million Approx. 3-6% The most
children require initial help (lungs important influence
ventilation with mask) population
≈ 50000 children
Approx. 10 million
Approx. 5-10% require simple
children stimulation (drying and massage) in
order to start breathing independently
130 million All the newborns require immediate condition
children assessment and standard medical measures
S. Wall et al., Int J Gynaecol Obstet. 2009 107 (Suppl 1): S47

3. Інші причини;
0,181 млн. Ukraine, 2009
Природжені 2% 7%
аномалії; 0,27 13%
млн. 15%
Ускладнення
недоношеності; 8% 8%
1,08 млн.;
35% Неонатальні
інфекції; 0,83
млн.; 27% 3%
Інтранатальні 12%
32%
ускладнення;
0,72 млн.;
228 children
23%
Інші Аномалії Інфекції
Сепсис Асфіксія Захв. легень
Born too soon: the global action report on preterm birth, WHO, 2012.
Пневмонії ВШК Пор цер. стат.
Li Liu et al. The Lancet, 2012, V. 379, No. 9832: P. 2151-2161

4. • During 2000-2009 mortality rate of newborns with birth weight 501-1500 g
decreased from 14,3% to 12,4% (dynamics– 21,9%; 95% CI: 22,3-21,5%)
• Severe morbidity in newborns who survived decreased from46,4% to 41,4%
(dynamics – 24,9%; 95% CI: 25,6-24,2%)
• In 2009 mortality rate varied from 36,6% (501-750 g) to 3,5%
(1251-1500 g), and morbidity varied,from82,7% to 18,7%
• 49,2% of all newborns with VLBW 89,2%
of newborns with weighting at birth 501-
750 g either died or survived with severe
disability
Data basedon 355
806 newborns with
birth weight from
501to1500 g from 669
hospitals of the
Years J.D. Horbar et al.
Body 501-750 g 751-1000 g 1001-1250 g 1251-1500 g North America
Pediatrics 2012;129:1019

5.  1996: Regulatory systematic recommendations asresuscitation, 1998
Official opening of Kyiv NMC of Newborns to the initial
resuscitation of newborns. Amendment to Order No.4 of the Ministry of
Healthcare from 05/01/1996
2003: Onapproval of branch program "Initial resuscitation of newborns for
2003-2006 ". Order No. 194 of the MH from06/05/2003
2007: Initial resuscitation and post-resuscitation support of newborns:
Clinical protocol on neonatal support provision . Order No. 312 of the MH
08/06/2007.
2013: Immediate, resuscitative and post-resuscitative support of
newborns: Unified clinical protocol

6. "Avoid hypothermia of a
newborn"
«Fill their lungs with air»
«Do not give oxygen - it is
toxic!»
1895

7. 51%of newborns born at < 28 weeks and 57% at ≥
28 weeks (< 32 weeks) had body temperature <
36,5°С at the time of admission to NICU (2011)1
Ventilation, filling of lungs, РЕЕР СРАР intubation? 2
, ,
«We may come to a reasonable conclusion that in
term and early-born infants -initial lungs ventilation
should be performed with room air (relevant risk of
mortality is 0.71 [95% CI 0.54-0.94])»3
1 Chitty H.E. et al., Wrapping is not sufficient to prevent hypothermia of preterm infants, PAS 2012
2 Wyllie J. et al., Resuscitation 81S (2010) e260
3 Davis P.G. et al., Lancet 2004; 364: 1329

8. differentiate between the interventions needed for 5-10 % of
newborns who really required resuscitation, and stabilization
measures which are standard for 90% of infants and are
taken to avoid further morbidity
• Stabilization of condition (a support for adaptation) is
necessary for all the newborns irrespective of their gestational
age, independent breathing or respiratory problems and heart
rate ≥ 100/min.
• “More” observation, and less “agression”!

9. Term newborn
Preterm newborn

10. Total blood volume in fetal/placental circulation for
gestational period is 110-115 vl/kg
In case of urgent delivery 2/3 of this volume are in fetus
blood vessels and ? stay in placenta
At 30 weeks of GA these volumes are about the
same
Immediate clamping of umbilical cord leads to newborn
blood volume ≈ 45 vl/kg ('loss'– 25-35 ml/kg)
15-20 ml is contained in the cord; 'half' of cord length – 10
ml
4 'wringings' give 40-50 ml of transfusion et al. Pediatrics 2006;117;93
N. Aladangady
Rabe H. et al. Obstet Gynecol. 2011; 117(2 Pt 1):205

11.  Blood volume
Less transfusions needed [ВР-0.61; 95% CI 0.46-0.81]
 blood pressure and decreased need in inotropes
administration [ВР-0,42; 95% CI 0.23-0.77]
Better circulation in upper hollow vein
Betteremission from left ventricle
 Cerebral oxygenation index
Decreased number of any IVH [ВР-0.59; 95% ДI 0.41-
0.85] (no differences in the number of severe IVH)
Decreased number of NEC [ВР-0.62; 95% ДI 0.43-0.90]
Raju T.N.K., Singhal N. Clin Perinatol 2012;39:889
Rabe H. et al. Cochrane Database of Systematic Reviews 2012, Issue 8

12. 5 RCS(2008-2012)*
8 controlled studies
Unfortunately, there is no systematic review and
meta-analysis so far
Preliminary finding: the same positive clinical results
that were obtained after delayed cord clamping
No negative effects of this clinical practice were
observed for term and preterm infants
* Hosono08, Minami08, Rabe11, Erickson-Owens12, Gotwal12

13. Put a child into a plastic bag (< 28 weeks); in case
there is no independent respiration immediately*
separate and transport….
Put a child into a plastic bag (< 28 тиж) and in case
of independent breathing hold below the placenta
level; clamp and cut the cord after 30-45 s*
* in case any delay is impossible, quickly wring
blood out of the cord 3-4 times directing it to a child
(A)
Immediate, resuscitative and post-resuscitative support of newborns, Kyiv, 2013

14. Visual assessment of skin colour and adequate
independent breathing especially in deeply preterm
infants is inacurate and subjective
Assessment according to Apgar scale is also rather
subjective and especially complicated for deeply
preterm infants
Standard methods of heart rate measurement
(auscultation and palpation) are inaccurate
J. Wyllie et al. Resuscitation 81S (2010) e260

15. % of observers considering that a SpO2 corresponding to clinical
child has cyanosis definition of pink colour
SpO2%
Maximum level of SpO2 during Results from 20 videoclips are indicated
videorecording
C. Kamlin et al. J Pediatr 2008;152:756

16. 1 min 60-65%
2 min 65-70%
SpO2 (%)
3 min 70-75%
4 min 75-80%
5 min 80-85%
10 min 85-95%
Minutes after delivery
10th 25th 50th 75th 90th
Percentile
J.A. Dawson et al. Pediatrics 2010;125;e1340

17. 0
Median differences (95% CI) between clinical
heart rate measurement and ECG data
-5 Deviation from actual
value
-10
-15
-20
-25
-30
-35 Auscultation Palpation
(n=26) (n=21)
C. Kamlin et al. Resuscitation 2006; 71: 319

18. Prospective , randomized (heart rate measurement
techniques [auscultation or palpation] and scenario),
controlled study
64 experienced physicians
3 training scenarios (SimNewB®, Laerdal Inc.,
Stavangar, Norway)
Heart rate measurement bias were observed at 26-48%
initial and 26-52% follow-up assessments
Measurement method did not affect the result
Clinical measurement of heart rate in case of RN is
unreliable
Chitkara R. et al., Resuscitation 2012, In press

19. If PO shows heart
rate < 100/min, the
PO heart rate minus ECG heart rate
probabilty of
2SD bradycardia is 83%
0 If PO shows heart
2SD
rate > 100/min, the
possibility that an
infant has no
bradycardia is 99%
Mean heart rate C. Kamlin et al. J Pediatr 2008;152:756
+ 2 SD (24 strikes/min.); 0: mean (-2 strikes/min.); - 2 SD (-28 strikes/min)

20. 90th
75th
50th
25th
10th
Heart rate
50th percentile value is less
than 100/min in 1 min after
delivery!
Minutes after delivery
J.A. Dawson et al., Arch Dis Child Fetal Neonatal Ed 2010;95:F177

21. CONCLUSIONS: An improved delivery(24 weeks, ventilation with
Case1 (term infant) Case 2
ETT) room score that
Number of respondents
Number of respondents
decreases variability among medical care323
335
professionals
participants
is needed to accurately reflect the clinical status of
participants
preterm infants.
CONCLUSIONS: An improved assessment scale is
General Apgar score General Apgar score
needed in(28 weeks, СРАР) unify and increase (28 weeks, ventilation with ETT)
Case 3 order to Case 4 accuracy in
defining clinical conditions of preterm infants between
Number of respondents
313 312
different medical professionals participants Number of respondents
participants
General Apgar score General Apgar score
M.T. Bashambu et al. Pediatrics 2012;130;e982
1 min of life 5 min of life 10 min of life

22. Characteris 0 1 2
Time
tic 1 min 5 min 10 min 15 min 20 min
Bradycardia (HR
Heart rate None
(HR <100/min) ≥100/min)
Bradypnoea,
Respiration None Regular, cry
irregular
Dramatically Active
Muscular tone Mild limb bending
low movement
Reflex Cough,
No reaction Spasm
excitability sneezing
Cyanosis or
Colour Limbs cyanosis Pink
paleness
General score
Comments: Resuscitation
Minutes 1 5 10 15 20
Oxygen
Ventilation/CPAP
Intubation
IMC
ААР. Pediatrics, 2006,117,4:1444 Adrenalin

23. After initial help [(1) position ± airways sanitization
[according to indications – meconium, ventilation
need (newborn does not breathe!) or obstructed
respiration]; 2) drying]
Only 2 characteristics may evidence the need inn
resuscitative intervention after initial help – no
breathing (gasping ) or heart rate <100/min
The first minute is a «goldentime frame» and all the
actions during this minute are standardized!
J. Wyllie et al. Resuscitation 81S (2010) e260

24. Mechanisms that support
Adults Primary effects of respiration
Newborns
increased lungs volume at with increased lings volume
expiration at expiration
FRC of
lungs EERV
1. Additional diaphragm and 1. Less energy loss
larynx – lungs volume at rest at 2. Improvement of surfactant
Vr muscles activity
expiration phase effect
2. Starting the following EERVDecrease of lungs vessels
3. – end-expiratory lungs volume
Volume
Moan
inspiration before Vr "Supporting"
resistance
3. Inverse sequesnce of inspiration
4. Optimized ventilation-
glottis opening and perfusion correlation
diaphragm contraction EERV Better gas exchange EERV
5.
Time
Trachea intubation blocks all these physiological
mechanisms!

25. FRC dynamics, CL, і RL after delivery
ml
Free lungs from fluid ml/kPa
Create functional residual
capacity of lungs (FRC) ≈ 30 ml/kg
Stimulate independent
breathing using lungs
aeration
Facilitate gas exchange
Minimize risk of lungs
damage hou
min
r
Lungs resistance [RL] (ml*s/kPa)
FRC (ml)
Roehr C.C. et al. Neoreviews 2012;13;e343 Lungs pliability [CL] (ml/kPa)

26. СРАР only?
"Filling of lungs"  with СРАР?
"Filling of lungs"  with ventilation?
Intubation and ventilation?
INSURE?
Surfactant without intubation?

27. Indications
 No independent breathing
 Respiratory disfunction
Gestational term < 32 weeks
Lungs ventilation with positive pressure
Ventilation frequency – 40-60/min
Peak inspiratory pressure (РІР) – 40-20/25 cm Н2О
Positive end-expiratory pressure (РЕЕР) – 5 cm
Н2О
May be performed with relevantly long-term
("filling of lungs") or short-term (standard
vetilation) tI J. Wyllie et al. Resuscitation 81S (2010) e260

28. Why it is so important to create РЕЕР for deeply preterm
infants?
 Facilitates the development of FRC
 Facilitates aeration
 Improves oxygenation
 Protects lungs from damage (prevents pulmonary collapse)
May be used with
 Resuscitation T-system
 Bag filled with airflow
 Self-filling bag (only in case additional valve and gas flow
(connected gas source) are available!)
Roehr C.C. et al. Neoreviews 2012;13;e343

29. Ventilation: Lower initial inspiratory pressure (20-25
cm Н2О) for preterm infant compared to term infant
(30-40 cm Н2О)
Avoid excessive movement of chest, especially for
preterm infants
РЕЕР: will most likely benefit and is recommended
if technically possible
СРАР: may be used in ingants breathing
independently according to local protocols
J. Wyllie et al. / Resuscitation 81S (2010) e260
© 2010 American Heart Association, Inc.

30. For infants with ≥ 32 weeks of gestational age it is
recommended to ventilate lungs with air (21% О2)
For more immature infants (< 32 тиж) initial О2
concentration should be  30%
Start of ventilation, CPAP or additional oxygen use
indicate the need in continuous pulse oximetry
Further on О2 concentration (FiO2) is changed
according to SpO2
Ventilation of lungs with 90-100% oxygen is shown for
ICM

31. Total number of death or BPD in 2 groups
Intubation + СРАР from
surfactant as birth on
Study preventive routine basis Relevant risk and 95% CI
measure
For СРАР
For intubation
Rojas-Reyes MX, Morley CJ, Soll R. Cochrane Database of Systematic Reviews 2012, Issue 3

32. Comparative namber of intubations in
case of airbag ventilation using
laryngeal (LM) or conventional (CM)
mask
LM Bag and mask Odds ratio
Study
For LM For CM
LM may be used for neonates with ≥ 34 weeks of GA
and weight > 2000 g Georg M. Schmolzer et al. Resuscitation (2012). In press

33. T-systems or resuscitative bags filled with airflow or
independently may be used for respiratory support
J. Wyllie et al. Resuscitation 81S (2010) e260
T-systems are preferred in developed countries. It is
recommended by European Consensus on
prevention and treatment of RDS
31% in Ireland;  45% in Spain;
80% in Austria;  41% in Germany;
20% in Switzerland;  80% in Poland
C.P. Hawkes et al. Resuscitation 83 (2012) 797
European Consensus Guidelines, Neonatology 2010; 97:402

34. Maximum proximity of real PIP, Insufficient control of РІР, РЕЕР and Ті
PEEP and Ti values to desirable;
minimum variability of these values  risk of volutrauma
 less risks of volutrauma (lower Better ability to feel the pliability of
and more stable VT ) lungs.
Easier modification of ventilation
Limited ability to feel the pliability of
settings
lungs.
Less air leaks from under the
Settings modification requires more
mask
time and skills
Lower impact of flow rate
Increased air leak from under the
changes to ventilation settings
mask
Change of flow rate significantly
alters ventilation settings
C.P. Hawkes et al. Resuscitation 83 (2012) 797

35. ml cm Н2О
p < 0,0005 p < 0,001
Self-filling bag Т-system Self-filling bag Т-system
Respiratory volume (VT), ml Peak inspiratory pressure (РІР), cm
Н 2О
C.C. Roehr et al. Resuscitation 81 (2010) 202

36. Median, 25th-
75th
percentiles
SpO2 (%)
and
measurement
limits are
displayed
p>0,05
Minutes after delivery Т-system Bag
J. A. Dawson et al., J. Pediatr. 2011;158:912

37. Face masks
 Round masks are used more often
 Facilitate the use of ventilation, filling of lungs,
РЕЕР і СРАР
 Their use may be often accompanied by airways
obstruction and/or air leaks
Nasal prongs/ special cannula
 Shortened endotracheal tube
 Significant air leak
 May be more effective than mask

38. Equipment: Resuscitative bags of both types and
T-systems may be used
Nasal prongs/cannula may provide more effective
ventilation than mask
Monitoring: to use pulse oximentry, insifficient data
to recommend respiratory volume measurement
J. Wyllie et al. / Resuscitation 81S (2010) e260
© 2010 American Heart Association, Inc.

39. • «No
Resuscitation teams could not give visual movements» -
4.4 (3.0-7.0)
assessment of chest excursion adequacy for ml/kg
EPNs! • «Uncertain
movements» -
Expiration volume (ml/kg)
3.7 (3.0-5.6)
20 newborns at ≈ 27 ml/kg
weeks of gestation
• «Proper
movements» -
5.2 (2.9-8.9)
ml/kg
• «Excessive
movements» -
5.8 (2.4-8.6)
ml/kg
• «Insufficient
movements» -
7.8 (3.6-10.3)
ml/kg
Royal Women Hospital, Melbourne, Australia D.A. Poulton et al., Resuscitation 82 (2011) 175

40. Non-invasive respiratory support optimization
Detection of airways obstruction
Providing of proper RV
Independent breathing diagnostics
Assessment of ventilation frequency
Inspiration and expiration duration
Correct ETT position and gas leak availability
G. Lista et al., Neoreviews 2012;13;e364

41. Pressure
(cm Н2О)
Inspiratory flow
Flow
(ml/s)
Expiratory flow
Volume
(ml)
G. Lista et al., Neoreviews 2012;13;e364

42. Uncontrolled ventilation Controlled ventilation
G. Lista et al., Neoreviews 2012;13;e364

43. Pressure
(cm Н2О)
Gas leak
Flow
(ml/s)
No flow – obstruction
Volume
(ml)
K. Schilleman et al. J. Pediatr. 2012. In press

44. UC San Diego Medical Center, USA
Finer N. et al. Clin Perinatol 39 (2012) 931

45. Covers all the new regulations of International Scientific
Consensus of 2010.
Includes the concept of initial stabilization of preterm
infants condition
Proposes the necessity to use modern methods of
respiratory support and monitoring (resuscitative T-
system, laryngeal mask, СО2 detectors, pulsoxymeters)
Includes separate detailed rules of preterm infants care
and expanded Apgar scale
Reprecents the concept of palliative care
Contains a separate protocol on therapeutic hypothermia

46. BIRTH Term delivery? Yes Routine care
Breathing or crying? • Provide warming
To leave with
Muscular tone is good? • Free airways
mother • Dry
No
• Assess condition in dynamic
Provide warming and free airways,
state
dry, and stimulate
No
No Complicated breathing or stable
30 s Apnoea, gasping or heart rate<100?
cyanosis?
Yes Yes
Ventilation, need in SpO2 monitoring Free airways, need in SpO2 ≥ 32
60 s Heart rate < 100?
monitoring, CPAP
weeks!
Yes
No Adequate ventilation control Post-resuscitative EffectiveSpO.
care norms2%
Heart rate < 60? 1 min 60-65%
Correct ventilation Yes 2 min 65-70%
Intubate if no Necessity of intubation 3 min 70-75%
movements Start ICM, coordinate with ventilation 4 min 75-80%
observed!
5 min 80-85%
Possibility of:
Heart rate < 60? 10 85-95%
• Hypovolemia Yes min
© 2010 American Heart Association, Inc.
• Pneumothorax Adrenalin IV J. Wyllie et al. / Resuscitation 81S (2010) e260

47. No
independent Independent breathing (IB): hold a newborn below placenta level;
BIRTH breathing clamp and cut the cord after 30-45 s*; provide thermal protection
(IB)*...
• Transfer to resuscitation table
•
•
Provide warming and free airways, dry, and stimulate
Attach pulsoximeter sensor to the right hand (preductively)
< 32 weeks!
• Assess the ability to breathe independently, heart rate and SpO2
• Sanitate upper airways (upon indication) • Monitoring:
1. IB available
• Independent 2. Complicated
• Apnoea, gasping OR respiration
Conditi breathing
• Heart rate<100 OR 3. SpO2
on • Heart rate ≥ 100 4. Heart rate
• SpO2 < 40%
assess • SpO2 ≥ 40% 5. Skin colour
ment Yes 6. Activity
Yes
30 s • Transfer to NICU
• «Lungs filling** 10 s (РІР 20-25 cm СРАР • Surfactant (in case
Н2О; FiO2 30-40%)  СРАР (5 cm 5-7 cm of intubation
Initial RS Н2О; FiO2 30-40%) OR Н2О**** FiO2>0,3)
• ventilation(РІР 20-25 cm Н2О, РЕЕР 5
cm Н2О, FiO2 30%)
Independent breathing
60 s
Assessment: Yes Apnoea,
HR increased?
HR, SpO2, IB N gaspings
• o
Adequate filling/ventilation?
• Continue ventilation(РІР 20-25
cm Н2О; РЕЕР 5 cm Н2 О;
• Repeat filling of lungs, start ventilation
FiO2****)

48. • Continue ventilation(РІР 20-25
• Adequate filling/ventilation?
cm Н2О; РЕЕР 5 cm Н2 О;
• Repeat filling of lungs, start ventilation
FiO2****)
Assessment:
HR, SpO2 HR<60 60<HR<100 HR>100
• Trachea intubation*** • Trachea intubation*** < 32 weeks!
• Start ICM • Continue ventilation (РІР
• Continue ventilation (РІР 20-25 cm Н2О; РЕЕР 5 cm
20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2 40%)
Н2О; FiO2 90%)
• Coordinate ICM and
ventilation
HR>100
Assessmen
HR<60 60<HR<100
t:
HR, SpO2
• Inject adrenalin into trachea • Administer adrenalin IV
• Continue ventilation (РІР 20-25 • Continue ventilation (РІР 20-25 cm
cm Н2О; РЕЕР 5 cm Н2О; FiO2 HR<60 Н2О; РЕЕР 5 cm Н2О; FiO2 90%)
90%) • Continue ICM
• Continue ICM • Administer physiological
• Catheterize cord vein solution IV*****

49. • Put a child into a plastic bag
BIRTH No independent IB: hold a newborn below placenta level; clamp and cut the cord after
breathing... 30-45 s*
< 28 weeks!
• Transfer to resuscitation table
• Provide warming and free airways, dry, and stimulate
• Attach pulsoximeter sensor to the right hand (preductively)
• Assess the ability to breathe independently, heart rate and SpO2
• Sanitate upper airways (upon indication) • Monitoring:
1. IB available
• Apnoea, gasping OR • Independent 2. Complicated
Conditi breathing respiration
• Heart rate<100 OR 3. SpO2
on • Heart rate ≥ 100
• SpO2 < 40% 4. Heart rate
assess • SpO2 ≥ 40% 5. Skin colour
ment Yes
Yes 6. Activity
30 s
• «Lungs filling** 10 s (РІР 20-25 cm СРАР • Transfer to NICU
Н2О; FiO2 30-40%)  СРАР (5 cm 5-7 cm • Surfactant (in case
Initial RS Н2О; FiO2 30-40%) OR Н2О**** of intubation)
• ventilation(РІР 20-25 cm Н2О, РЕЕР 5
cm Н2О, FiO2 30%)
Independent breathing
60 s
Assessment: Yes Apnoea,
HR increased?
HR, SpO2, IB N gaspings
• o
Adequate filling/ventilation?
• Continue ventilation(РІР 20-25
cm Н2О; РЕЕР 5 cm Н2 О;
• Repeat filling of lungs, start ventilation
FiO2****)

50. • Continue ventilation(РІР 20-25
• Adequate filling/ventilation?
cm Н2О; РЕЕР 5 cm Н2 О;
• Repeat filling of lungs, start ventilation
FiO2****)
Assessment:
HR, SpO2 HR<60 60<HR<100 HR>100
GA < 25 GA ≥ 25 < 28 weeks!
weeks weeks
• Trachea
• Trachea intubation*** intubation***
• Stop • Start ICM • Continue
resuscitatio • Continue ventilation (РІР ventilation (РІР
n 20-25 cm Н2О; РЕЕР 5 cm 20-25 cm Н2О;
• Start Н2О; FiO2 90%) РЕЕР 5 cm Н2О;
palliative • Coordinate ICM and FiO2 40%)
care ventilation
HR>100
Assessment:
HR<60 60<HR<100
HR, SpO2
• Administer adrenalin IV
• Inject adrenalin into trachea • Continue ventilation (РІР 20-25
• Continue ventilation (РІР 20-25 cm Н2О; РЕЕР 5 cm Н2О; FiO2
cm Н2О; РЕЕР 5 cm Н2О; FiO2 HR<60 90%)
90%) • Continue ICM
• Continue ICM • Administer physiological
• Catheterize cord vein solution IV*****

51. Resuscitation refuse or its discontinuation do not mean that
no medical care is provided to the patient. It means a
transfer to the so-called palliative or "comforting" care if a
newborn still stays alive
PC for a newborn infant means complete set of measures
that prevent or alleviate additional suffering and improve
conditions of the last period of infant's life
PC is prescribed to a newborn in 3 cases:
 lethal developmental abnormalities;
 resuscitation does not correspond to the best interests of a
child;
 obvious useless on intensive care
Catlin A. J. Perinat. 2002; 22:184
Palliative care. Nuffield Council on Bioethics, London, 2006: 97

52. J.E. Tyson et al., N Engl J Med 2008;358:1672
N.A. Parikh et al., Pediatrics 2010;125;813
Days * EPN – extremely preterm newborn
591
600 Ventilation term
Тривалість ШВЛ Hospitalization term
Тривалість госпіталізації
500 USA, 4446 infants of 22-25 weeks, 2008
395 378
400 25
303 weeks
300
221 238
210 >60%
204
200 140 139 140
95 94 114
100 52 36
0
<5% 5-9% 10-14% 15-24% 25-32% 33-49% 50-66% >66%
22 weeks, <10% Likelihood of survival without severe disability (%)

53. % of survivals
% of general "acceptable" survival • Survival of newborns with <
% of "acceptable" survival in NICU 600 g depends on gestational
age, according to data from
NICHD
• "Intact" survival in NICU is
relevantly independent of GA!
Gestation week
• % of all infants of < 26 weeks of GA, week
which survived with severe neurological s
week
results depending on GA s
week
s
week
• Most infants who survived with these s
results were born at  GA, as the survival
depends on the GA while the % of affected
infant does NOT! Meadow W. et al. Clin Perinatol 39 (2012) 941

54. Time and money
Refusal from Death in the delivery Death in NICU
resuscitation room
Prenatal Treatment Discharg
Resuscitatio
consulting attempt e from
n
NICU
GA; ACS; multiple GA; ACS; multiple SNAP, intuition, RN, BPD, cerebral
gestation, SGA gestation, SGA, Apgar NSG palsy
Prognostic criteria GA - gestational age; ACS – antenatal corticosteroids; SGA – small
for gestational age; SNAP – the scale for evaluation of condition
severety; NSG - neurosonography
Meadow W. et al. Clin Perinatol 39 (2012) 941

55. 90 82
% 72
77
80
66 68
70
55
60
50
40
30 20
16
20 8 9
6
10 0
0
Вижили Вижили без важких Припинення ШВЛ до
наслідків смерті
9575 infants of GA 22-28 weeks, 2003-2007
B.J. Stoll et al. Pediatrics 2010;126;443

56. Short-term ventilation using mask and air (≤ 60 s) Long-term ventilation (> 60 s) or complete *
resuscitation
• Apgar score at 5 min ≥ 7 • Complete objective inspection immediately
• Within 15 min after ventilation was discontinued after resuscitation
– HR>100/min
– SpO2 > 85%, no central cyanosis (without supportive
О2 ) Eligibility to participate in
– No respiratory disfunctions therapeutic hypothermia
– Acceptable or lightly decreased muscle tone programme (art. 4.19)**
– No other pathological characteristics
Yes
• Start of passive cooling No
Yes No
(art. 4.5)
• Put a hat and socks on
• Return infant to the mother's chest, providing skin-
to-skin contact
• Urgent transfer to neonatal intensive care unit
• Cover with cloth and blanket
(following the rules of "warm chain")
• Continue observation (amendment 4)
• Administration of additional oxygen or CPAP in case
of relevant indication
Unstable condition with • Provision of access to vessels and intravenous fluid
Stable condition with N introduction in case of indications
deviation of any
monitoring values • Monitoring and maintenance of main life functions
valuefrom N
• Consultation with regional centre*
• Call of transport team in case of indications*
• Standard clinical • Immediate complete
measures objective inspection

57. resuscitative support given to newborns often
'deviates' from the requirements, and description of
interventions provided in clinical documents differs
from real practice of medical staff»
Organization
Video registration, self-assessment and debriefing
Training in simulated environment
Monitoring of the results
Documentation
M. Rudiger et al. Early Human Development 87 (2011) 749
W.D. Rich et al. Clin Perinatol 37 (2010) 189
Finer N. & Rich W.D. Journal of Perinatology (2010) 30, S57

58. «No other medical profession gives this unique privilege – not
only preventing the last breath but presenting the first
inspiration…» D.Vidyasagar