Pengurus Pusat IDAI & UKK Neonatologi IDAI

berkolaborasi dengan

American Academy of Pediatrics (AAP)

Training of The Trainers

Neonatal Resuscitation
Jakarta, 9 - 11 Desember 2013

NEONATAL TRANSITION

Objectives

Identify physiologic changes during transition to

extra-uterine life.

Identify primary features of fetal and newborn

pulmonary and circulation.

Identify signs and symptoms of common problems

during transition period.

Identify routine care considerations for a

newborn during the transition period.

Neonatal Transition
Transition is a process of physiologic change in the
newborn infant that begins in utero as the infant
prepares for transition from intrauterine placental
support to extra-uterine self-maintenance.
When the cord is CUT the newborn must switch
rapidly from intrauterine mechanisms to adult
physiology.

Physiological changes at birth

Changes

Time
Breathing

Seconds

Blood flow

Seconds

Glucose homeostasis

Minutes

Temperature control

Minutes

Renal

Hours days

GI tract

Hours - days

Events Happening at Birth

First breath

70-110 cmH2O vs. 5-10 cmH2O for normal breathing

Removal of fluid from the lungs

Closure of ductus arteriosus

Functional and later anatomic closure

Initialy systemic and pulmonary pressures are equal

Pulmonary transition

Intrauterine lung condition

Pulmonary transition at birth

Fluid filled

Air-filled

Pulmonary transition
Basic requirements for gas exchange

Ventilation

Fluid clearance

Establishing an air-filled FRC

Spontaneous breathing

Perfusion

Rapid reduction in PVR

Adequate cardiac output with pulmonary perfusion

Pulmonary transition
Clearance of lung fluid

Pulmonary transition
The first spontaneous breath

Pulmonary transition
PVR changes at birth

As a result of the gaseous distention and increased oxygen in the alveoli,

the blood vessels in the lung tissue relax

Pulmonary transition summary

In case of uncomplicated (physiological) delivery at term
pulmonary transition is a spontaneous unasissted event!!

Circulatory Adaptation

Fetal circulation
Fetus
From 8 weeks until birth
Organs mature to support external life
Circulation
Umbilical-placental circuit via umbilical cord
Circulatory shunts bypass
Liver
Ductus venosus to inferior vena cava
Lungs
Foramen ovale, between right & left atria
Ductus arteriosus connects pulmonary artery to aorta

Circulatory shunts bypass

By pass 1 : DUCTUS VENOSUS

By pass 2 : Foramen ovale

Circulatory shunts bypass

By pass 3 : DUCTUS ARTERIOSUS

Circulatory Adaptation
FETAL CIRCULATION
High pulmonary resistance
Low resistance in systemic blood flow

RIGHT to LEFT
shuntForamen Ovale
(Left atrial pressure low because returned lung blood is low and
right atrial pressure high due to large volume of blood from
placenta)
Ductus arteriosus
(High pulmonary resistance, Low fetal systemic blood and
prostaglandin function)

Circulatory Adaptation

FETAL
CIRCULATION

NEONATAL
CIRCULATION

Circulatory Adaptation
NEONATAL CIRCULATION

Profound changes of circulation at birth

Increased pulmonary blood flow due to the drop of pulmonary

resistance lung expansion.

Venous return from lung increase.

Left atrial press. is raised; Right atrial press. decrease

foramen ovale closed.

Systemic resistance higher than pulmonary resistance (24

hours) Prostaglandin function Ductus arteriosus close

Umbilical arteries constrict and placental blood flow stops.

Transition to Extra-uterine Life

begins when the cord is CUT.

Placenta no longer works as lungs

Lungs begin to exchange gases

First breath inflates lungs and causes circulatory

changes

Lungs inflate - resistance to blood flow through

lungs & blood flow from pulmonary arteries

This results in Newborn Circulation.

Barrier in Transitional Period

The baby may not breath sufficiently to force fluid
from the alveoli
The lungs will not be filled with air

Oxygen will not be available for circulating blood through the lungs

Barrier in Transitional Period

Excessive blood loss or hypoxia/ischemia resulting poor cardiac
contractility and bradycardia

Failure in increasing systemic blood pressure

Systemic hypotension

Barrier in Transitional Period

Low oxygen concentration

Sustained constriction of the pulmonary arterioles

Persistent pulmonary hypertension

Consequences of interrupted transition

1.

Tachypnea

2.

Cyanosis

3.

Resp depression (apnea / gasping)

4.

Bradycardia

5.

Hypotension

6.

Low muscle tone

The Global Need for neonatal Resuscitation, FIGO, Wall et al

Yes

Breathing/crying?
Good tone?

Time
from
Birth

Routine Care

No
Initial Steps

1
minutes
2
minutes
3
minutes
4
minutes
Persistent Central5
Cyanosis
minutes
10
Consider supplemental O2
minutes

Observe breathing, HR and tone

Apnea/gasping, and or HR < 100 bpm

PPV and SpO2 monitoring

Spontaneously breathing

Respiratory Distress

HR < 100 bpm?

CPAP

Adequate chest explansion?

CPAP Failure, consider intubation

Yes

No

HR < 100 bpm

PPV (O2 100%) +
chest
compression
Consider
intubation

Evaluate head
position, airway
obstruction,
leakage,
adequate PIP?
HR < 60 bpm?

Preduct
al Target
O2
Saturati
ons
60-70%
65-85%
70-90%
75-90%
80-90%
85-90%

Information:
Information:
If
If HR
HR >
> 100
100 bpm
bpm and
and target
target oxygen
oxygen
saturation
is
successfully
achieved:
saturation is successfully achieved:

Without
equipment
support

Without
equipment
support

observational
care
observational care
With
With equipment
equipment support
support
postpostresuscitation
care
resuscitation care

Consider drugs and fluid administration

Evaluation-Decision-Action cycle
Evaluation

Action

Decision

Summary

Changes in respiratory and circulation is the

key component of transitional period in
newborn.

Barrier of transitional period in newborn

include delayed removal of lung liquid,
failure of systemic blood pressure increase,
and failure of lung arterioles dilatation

Thank
you

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