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Neonatal Resuscitation

Most newborn babies are vigorous. Only about 10% require some kind of assistance
and only 1% needs major resuscitative measures (intubation, chest compressions,
and/or medications) to survive.

Primary and Secondary Apnea

When a fetus/newborn first becomes deprived of oxygen, an initial period of

attempted rapid breathing is followed by primary apnea and dropping heart rate
that will improve with tactile stimulation.

If oxygen deprivation continues, secondary apnea ensues;it is accompanied by a

continued fall in heart rate and blood pressure. Secondary apnea cannot be
reversed with stimulation; assisted ventilation must be provided, resulting in a rapid
improvement in heart rate.


Every delivery should be attended by at least one trained person whose only
responsibility is

the infant, and who is capable of initiating resuscitation. Either that person or
someone else who is immediately available should have the skills required to
perform a complete resuscitation. When resuscitation is anticipated, additional
personnel should be present in the delivery room before the delivery occurs.


Turn on the radiant warmer

Check resuscitation supplies and equipments

-Suction equipment

-Bag-and-mask equipment

-Intubation equipment

-Umbilical vessel catheterization tray with (3.5Fr, 5Fr) catheters, and three-way


-Epinephrine (1:10,000 solution)

-Normal saline or Ringer's lactate

-Glucose 10% solution

-Sterile water

-Naloxone hydrochloride


-Stethoscope (neonatal head preferred)

-Feeding tubes (6Fr, 8Fr)

-Warmed linens


-Oropharyngeal air ways

N.B.: Pulse oximetry can be applied for information on oxygen saturation

and heart rate, and should be available for premature infant.

Initial Assessment

All newborns require initial assessment to determine whether resuscitation is


The following questions must be asked:

-Term gestation?

-Clear amniotic fluid?

-Breathing or crying?

-Good muscle tone?

If the answer to any of these questions is "No", resuscitation should be started

Resuscitation should proceed rapidly:

You have approximately 30 seconds to achieve a response from one step before
deciding whether you need to go on to the next.

Evaluation and decision making are based primarily on respirations, heart rate, and

The Apgar score is assigned at 1, 5, and, occasionally, 10-20 minutes after

delivery. It gives a fairly objective retrospective idea of how much resuscitation an
infant required at birth and the infant's response to resuscitative efforts.

The Apgar score is not used to determine when to initiate resuscitation or in making
decisions about the course of resuscitation. Resuscitation is in seconds not minute.

N.B.: Simultaneous assessment of respiratory activity, heart rate and skin

color provides the quickest and most accurate evaluation of the need for
continuing resuscitation.

Initial steps

Provide warmth by placing the infant under radiant warmer.

Dry the infant thoroughly and gently, the wet towels should be promptly removed
to avoid evaporative heat loss.

Position head and clear airway as necessary, by placing the newborn on the back
with head in midline position and with slight neck extension "sniffing position".
Suction the mouth first, and then the nose gently and briefly by suction bulb or a
large- bore suction catheter. Suctioning should limited to 5 seconds at a time.

If meconium is present

Evaluate the newborn's respiratory effort, heart rate and muscle tone

-If the infant is vigorous (has strong respiratory effort, good muscle tone, and heart
rate >100 beats/minute): suction the mouth and nose only, and proceed with
resuscitation as required.

-If the infant is not vigorous: Insert an endotracheal tube and attach it to a
meconium aspirator which has been connected to a suction source; then suction the
infant's trachea while the tube is slowly withdrawn before proceeding with any other

-Repeat as necessary until little additional meconium is recovered, or until the

infant's heart rate indicates that resuscitation must proceed without delay.

Stimulate the infant to breathe

If the infant is still apneic, tactile stimulation is performed by slapping or flicking the
soles of

the feet or by gently rubbing the back once or twice.

Evaluate respiration, heart rate (counted in 6 seconds then multiplied by 10) and

-If the infant is breathing and heart rate is more than 100 beats/minute but with
central cyanosis, free-flow oxygen (5-8 L/minute) is administered by an oxygen
mask held firmly over the infant's face, or oxygen tubing cupped closely over the
infant's mouth and nose.

-If the infant is apneic/gasping or heart rate is less than 100 beats/minute, even if
breathing or central cyanosis persists despite 100% free flow oxygen, positive-
pressure ventilation is indicated.

N.B.: Continued use of tactile stimulation in a newborn who is not

breathing wastes valuable time. For persistent apnea give positive
pressure ventilation.

Positive pressure ventilation (PPV)

-Ventilation of the lungs is the single most important and most effective step
in cardiopulmonary resuscitation of the compromised newborn infant.

-Positive pressure ventilation (PPV) is performed using a resuscitation self-

inflating bag with a reservoir.
-The Neonatal Resuscitation Program (NRP) recommends use of 90-100%
oxygen when (PPV) is required during neonatal resuscitation. If oxygen is
unavailable, use room air to deliver PPV (21% oxygen).

-Before beginning PPV; select appropriate-sized mask which should cover tip
of chin, mouth and nose and leave eyes uncovered, be sure airway is clear,
position infant's head in sniffing position by placing a small roll under the
shoulders, and position yourself at infant's side or head.

-An airtight seal is essential to achieve effective positive pressure in order to

inflate the lungs when the bag is squeezed.

-Ventilate with a rhythm of (breathe, two, three, breathe, two, three), and at
a rate of 40-60/minute
-You should ventilate with the lowest pressure required to move the chest
-The first few breaths will often require higher pressures (30-40 cmH2O) and
longer inflation time than subsequent breaths (15-20 cmH2O)
-Don't allow your fingers to rest on the infant's eyes, and don't let the mask
go down on the face.
-Improvement during PPV is indicated by a rapid increase in heart rate and
subsequent improvement in color and oxygen saturation, muscle tone and
spontaneous breathing.
If there is no physiologic improvement and no perceptible chest expansion
during PPV, the following actions should be attempted:
-Reapply mask to face using light downward pressure and lifting the
mandible up toward the mask.
-Reposition the head.
-Check for secretions; suction mouth and nose.
-Ventilate with the infant's mouth slightly open.
-Increase pressure of ventilations.
-Recheck or replace the resuscitation bag.
-After failure of reasonable attempts, consider intubation of the infant.
-Newborns requiring PPV with a mask for longer than several minutes should
have an orogastric tube inserted and left in place.
-After 30 seconds of PPV, evaluate the heart rate:
Heart rate >100 beats/minute evaluate the color and if cyanosed give free
flow oxygen as before.
Heart rate >60 but <100 beats/minute repeat PPV for 30 seconds.
Heart rate <60 beats/minute provide PPV with chest compressions for 30

Chest compression
-It is indicated when the heart rate remains less than 60 beats/minute,
despite 30 seconds of effective PPV.
-It compresses the heart against the spine, increases intra-thoracic pressure
and circulates blood to the vital organs, including the brain.
-Two persons are needed, one that performs chest compression while the
other continues ventilation.

The most efficient method of delivering chest compression is to stand at the
foot of the infant and grip the chest in both hands in such a way that the two
thumbs can press at the junction of the middle and lower thirds of the
sternum, just below an imaginary line joining the nipples, with the fingers
wrapped around and supporting the back. Alternatively, one can stand at the
side of the infant and compress the lower third of the infant's sternum with
the index and third fingers of one hand and with the second hand supporting
the back
The two-finger technique may be preferable when access to the umbilicus is
required during insertion of an umbilical catheter.
-To ensure proper rate of chest compressions and ventilation, the compressor
repeats "One-and-Two-and-Three-and-Breathe-and..."
During chest compressions, the breathing rate is 30 breaths/minute, and the
compression rate is 90 compressions/minute. This equals 120 "events" per
minute. One cycle of three compressions and one breath takes 2 seconds.
-During chest compression, ensure that chest movement is adequate during
ventilation, supplemental oxygen is being used, compression depth is one
third the diameter of the chest, pressure is released fully to permit chest
recoil during relaxation phase of chest compression, thumbs or fingers remain
in contact with the chest at all times. The duration of the downward stroke of
the compression is shorter than duration of the release and chest
compressions and ventilation are well coordinated.
-After 30 seconds of well coordinated chest compressions and ventilation,
suspend both ventilation and compression, and check the heart rate:
If heart rate is >100 beats/minute, discontinue compressions and gradually
discontinue ventilation, if the newborn is breathing spontaneously.
If heart rate is >60 beats/minute, discontinue compressions and continue
ventilation at a rate of 40-60 breaths/minute.
If heart rate is <60 beats/minute, give epinephrine, preferably intravenously,
and intubate the newborn if not already done. Intubation provides a more
reliable method of continuing ventilation.

Endotracheal intubation
A person experienced in endotracheal intubation should be available to assist
at every delivery.
Indications for endotracheal intubation:
1. To suction trachea in presence of meconium when the newborn is not
2. To improve efficacy of ventilation after several minutes of bag and mask
ventilation or ineffective bag-and-mask ventilation.
3. To facilitate coordination of chest compressions and ventilation and to
maximize the efficiency of each ventilation.
4. To administer epinephrine, if required, to stimulate the heart while
intravenous access is being established.
5. When a diaphragmatic hernia is suspected or known to exist

-Intubation procedure ideally should be completed within 20 seconds.

-The laryngoscope is always held in the operator's left hand, use blade No.1 for a
term newborn and No.0 for a preterm newborn, the proper endotracheal tube
size is based on weight

Steps for intubation:

-Stabilize the newborn's head in the "sniffing" position and deliver free flow
oxygen during the procedure.
-Consider cutting the tube to a shorter length (13-15 cm) before the
intubation process.
-Slide the laryngoscope over the right side of the tongue, pushing the tongue
to the left side of the mouth, and advancing the blade until the tip lies just
beyond the base of the tongue.
-Lift the blade slightly and raise the entire blade, not just the tip.
-Look for landmarks. Vocal cords should appear as vertical stripes on each
side of the glottis or as an inverted letter "V"
-Suction, if necessary, for visualization.
-The tube is held with the right hand, inserted into the right side of the mouth
with the curve of the tube lying in the horizontal plane, and then passed
between the vocal cords approximately 2 cm below the glottis (the tip of the
tube is inserted until the vocal cord guide is at the level of the cords). If the
vocal cords are closed, wait for them to open.
-Hold the tube firmly against the infant's palate while removing the
-Hold the tube in place while removing the stylet (if it was used).
-Be certain that you visualize the glottis before inserting the tube, watch the
tube enter the glottis between the vocal cords.
-Proper depth of insertion can be estimated by calculating the depth at the
lips according to the following formula:
Weight (kg) + 6 cm = insertion depth at lip in cm
-After endotracheal intubation, confirm the position of the tube by:
1. Observing symmetrical chest-wall motion.
2. Listening for equal breath sounds, especially in the axillae, and for absence of
breath sounds over the stomach.
3. Confirming absence of gastric inflation.
4. Watching for a fog of moisture in the tube during exhalation.
5. Noting improvement in heart rate, color, and activity of the infant
6. Chest x-ray confirmation, if the tube is to remain in place past initial
-If the tube is inserted too far, it will pass into the right main bronchus,
resulting in over ventilation of one lung and pneumothorax.

-A cardiac stimulant, that is indicated when the heart rate remains below 60
beats/minute, despite 30 seconds of assisted ventilation followed by another
30 seconds of coordinated chest compressions and ventilation.
-Route: IV (through the umbilical vein). Endotracheal administration may be
considered while IV access is being established.
-Dose: 0.1-0.3 ml/kg (consider higher dose, 0.3-1 ml/kg, for endotracheal
route only); dose can be repeated after 3-5 minutes.

-Preparation: 1:10,000 solution.
-Rate: rapidly, as quickly as possible.
Volume expansion
-Indicated if an infant is not responding to resuscitation and appears in shock
(pale color, weak pulses, persistently low heart rate, no improvement in
circulatory status despite resuscitation efforts) and there is a history of
condition associated with fetal blood loss (e.g., extensive vaginal bleeding,
abruptio placentae, placenta previa, twin- to-twin transfusion,etc).
-Recommended volume expander is normal saline, Ringer's lactate, or O Rh-
negative blood packed RBCs.
-Route: umbilical vein.
-Dose: 10 ml/kg (another dose may be needed).
-Preparation: correct volume drawn into large syringe.
-Rate: slowly (over 5-10 minutes).
Sodium bicarbonate
-Not useful during the initial resuscitation. However, after prolonged
resuscitation, it may be indicated for correction of documented severe
metabolic acidosis.
-Do not give sodium bicarbonate unless the lungs are being adequately
-Route: umbilical vein.
-Sodium bicarbonate is very caustic and should not be given through the ET
-Dose: 2 mEq/kg (8.4% concentration).
-Preparation: diluted 1:1 with appropriate diluent (glucose 5% or sterile water
"concentration 0.5 mEq/ml").
-Rate: slowly, no faster than a rate of 1 mEq/kg/minute (to minimize the risk
of intra- ventricular hemorrhage).
Special Considerations
The appropriate action for an infant who fails to respond to resuscitation will
depend on the presentation:
1. Failure to ventilate
2. Persistent cyanosis or bradycardia
3. Failure to initiate spontaneous breathing
1. PPV fails to produce adequate ventilation in
Mechanical blockage of airway:
Meconium or mucus plug
Choanal atresia
Airway malformation (e.g., Robin syndrome)
Other rare conditions (e.g., Laryngeal web)
Impaired function:
Congenital pleural effusion
Congenital diaphragmatic hernia
Pulmonary hypoplasia
Extreme prematurity
Congenital pneumonia

-Symptoms from choanal atresia can be helped by placing an oral airway. An

endo- tracheal tube, inserted through the mouth, may be needed.
-Airway obstruction from Pierre Robin syndrome can be helped by inserting a
naso- pharyngeal tube and placing the infant prone.

-In an emergency, a pneumothorax can be detected by transillumination and

treated by inserting a needle in the chest.

-If diaphragmatic hernia is suspected (persistent respiratory distress, scaphoid

abdomen, and diminished breath sounds on the side of the hernia), avoid
positive-pressure ventilation by mask. Immediately intubate the trachea and
insert an orogastric tube.

Persistent cyanosis and bradycardia

-These are rarely caused by congenital heart disease. More commonly, the
persistent cyanosis and bradycardia are caused by inadequate ventilation.

-Ensure chest is moving with ventilation.

-Listen for equal bilateral breath sounds.

-Confirm 100% oxygen is being given.

-Consider congenital heart block or cyanotic heart disease (rare).

Failure to initiate spontaneous respirations


Brain injury (hypoxic ischemic encephalopathy)

Severe acidosis, congenital neuromuscular disorder

Sedation, secondary to maternal drugs

If a mother has recently received narcotics within 4 hrs of delivery and her infant
fails to breathe, first assist ventilation with positive pressure, and then consider
giving naloxone to the infant (0.1 mg/kg, 1mg/ml solution, I.V. or I.M).

Resuscitation of Preterm Newborns

Preterm babies are at additional risk for requiring resuscitation because of their:

Excessive heat loss

Vulnerability to hyperoxic injury

Immature lungs and diminished respiratory drive

Vulnerability to infection, Low blood volume, increasing the implications of

blood loss

Additional resources needed to prepare for an anticipated preterm birth include:

Additional trained personnel, including intubation expertise

Careful attention for maintaining temperature

Compressed air

Oxygen blender

Pulse oximetry

-Premature babies are more vulnerable to hyperoxia; use an oximeter and

blender to gradually achieve oxygen saturations in the 85-95% range during and
immediately following resuscitation.

-Decrease the risk of brain injury by:

Handling the infant gently

Avoiding the Trendelenburg position

Avoiding high airway pressures, when possible

Adjusting ventilation gradually, based on physical examination, oximetry, and

blood gases.

Avoiding rapid intravenous fluid boluses and hypertonic solutions because of

the risk of intraventricular hemorrhage

After resuscitation:

Monitor and control blood glucose level

Monitor for apnea, bradycardia, or desaturations, and intervene promptly

Monitor and control oxygenation and ventilation

Consider delaying feeding if perinatal compromise was significant

Increase your suspicion for infection

Post-resuscitation Care

-An infant who has required resuscitation must have close monitoring and
management of oxygenation, infection, blood pressure, fluids, apnea, blood
sugar, feeding, and


-Be careful not to overheat the infant during or following resuscitation.

-The Apgar scores should be recorded in the neonate's birth record.

-Complete documentation of the events taking place during resuscitation must

also include a description of interventions performed and their time.

Withdrawal of Resuscitation

Discontinuation of resuscitation effort may be appropriate if there are no signs of
life (no heart rate and spontaneous breaths) in an infant after 15 minutes of
complete and adequate

resuscitation effort with no evidence for other causes of newborn compromise.