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The successful transition from intrauterine to extra uterine life is dependent upon significant
physiologic changes that occur at birth. In almost all infants (90
percent), these changes are successfully completed at delivery without
requiring any special assistance. However, about 10 percent of infants
will need some intervention, and 1 percent will require extensive
resuscitative measures at birth.

Of the 25 million infants born every year in India, 3-5%

experience asphyxia at birth. Asphyxia is characterized by progressive hypoxia, hypercapnia,
hypoperfusion and acidosis. It may lead to multiorgan dysfunction including hypoxic ischemic
encephalopathy (HIE) which might result in long term neuromotor sequale.

There is a broad consensus on the evidence based resuscitation of newborn

babies at birth. The American Heart Association have recently updated the resuscitation guidelines that
are being propagated worldwide through the Neonatal Resuscitation Program (NRP).

Neonatal resuscitation skills are essential for all health care providers who are involved in the
delivery of newborns.


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.


Neonatal Resuscitation is intervention after a baby is born to help it breathe and to help its heart beat.


The process of sustaining the vital functions of a person in respiratory or cardiac failure while reviving
him or her, using techniques of artificial respiration and cardiac massage correcting acid base imbalance
and treating the cause of failure.
Before a baby is born, the placenta provides oxygen and nutrition to the blood and removes carbon
dioxide. After a baby is born the lungs provide oxygen to the blood and remove carbon dioxide.

The transition from using the placenta to using the lungs for gas exchange begins when the umbilical cord
is clamped or tied off, and the baby has its first breath.

Many babies go through this transition without needing intervention. Some babies need help with
establishing their air flow, breathing or circulation.


To establish effective circulation and respiration promptly.

To prevent irreversible cerebral anoxic damage.


A. Antepartum Factors


Age 16 or 35 years.
Cardiac, renal, pulmonary or neurologic disease.
Bleeding in 2nd or 3rd trimester.
Pregnancy induced hypertension.
Substance abuse.
Premature rupture of membrane.


Preterm or term baby.

Multiple gestation.
Diminished foetal activity.
Previous foetal or neonatal death.


Assisted delivery
Prolonged rupture of membrane 18 hours
Prolonged labour 24 hours
Placenta previa
Antepartum haemorrhage


Foetal arrhythmia
Meconium stained amniotic fluid
Prolapsed cord

Principles of Resuscitation

1. Adequate preparation
Communication: Proper communication between healthcare member caring for the mother
and infant, details of antepartum and intrapartum maternal medical condition and foetal
condition should be known.
Availability of trained personnel.
Getting ready: Always be ready with an unforeseen delivery with the resuscitation tray.
2. Anticipation and immediately recognising the infant in need of resuscitation.
3. Initiating the procedure promptly.
4. Performing the procedure skilfully.

Articles and Supplies Needed For Newborn Resuscitation

a. Suction Equipment
Meconium aspirator
Mechanical suction
Suction catheter
Feeding tube 6F and 20 ml syringe
b. Bag And Mask Equipment
Neonatal resuscitation bags
Face mask, newborn and premature size
Oxygen With flow meter and tubing
c. Intubation Equipment
Laryngoscope with blade 0(preterm) and size 1(term)
Extra bulb and batteries for laryngoscope
Endotracheal tubes 2.5, 3, 3.5, 4 mm ID
d. Medications
Naloxone hydrochloride
Volume expanders
Normal saline
Albumin 5%
Ringer lactate
Sodium bicarbonate4.2%
Dextrose water 10%
Sterile water
e. Miscellaneous
Watch with seconds hand
Radiant warmer
Linen, shoulder roll
Adhesive tape
Syringes of different sizes
Butterfly needles
Umbilical artery catheterization tray
Umbilical catheter 3 & 5 Fr
Feeding tube
Spirit sponges
3 way stopcock
Neonatal Advanced Life Support (NALS): Neonatal Algorithm

The ABC of Resuscitation

The steps in resuscitation of newborn infants follow the well-known ABCs of resuscitation.

A. Establish an open airway by:

- Positioning the infant
- Suctioning the mouth, nose and sometimes trachea.
B. Initiate breathing by
- Use of tactile stimulation to initiate respiration
- Positive pressure ventilation by bag and mask/intubation
C. Maintain circulation with chest compressions.
D. Medications.


Basic steps include rapid assessment, initial steps and stabilization.

Rapid Assessment

Assessment of the newborn begins at the time of birth. The type of following five questions clearly
differentiate the baby in need of assistance from the baby who can receive routine care.
- Is the amniotic fluid clear of meconium?
- Is the baby crying or breathing well?
- Is there good muscle tone?
- Is the babys colour pink?
- Is the baby term?
If in rapid assessment baby is found normal, give only routine care, warmth, drying and clearing
the airway. All other babies go through the following steps.

Initial Steps

A. Provide Warmth
B. Clear the airway
C. Tactile stimulation (if needed)
D. Oxygen administration (if required)
Amniotic fluid temperature may be 37C while outside the temperature will be 23 to 25C.
Do not give the baby a cold welcome. Cold babies are difficult to resuscitate.
They use up oxygen, glucose stores and become acidotic and have decreased surfactant production
and increased mortality.
Keep the warmer on at least 15 minutes before delivery. Keep two pre-warmed towels ready.
Receive the baby in the pre-warmed towel and place under the radiant warmer.
Rapidly dry the baby with the pre-warmed towel and immediately remove the wet towel and place
the baby on another dry warm cloth,
Place the baby supine on a firm surface with the neck slightly extended (in a sniffing position).
Avoid hyperextension of the neck which will occlude the trachea.
A fold of cloth or towel approximately 2 cm thickness can be placed under the shoulder and not
under the neck, which may be helpful in maintaining proper head position.
This is very important in newly born babies who have a large head due to caput or small for
gestational age.
Suction the mouth first and then the nose.
If the nose is sucked first, the baby may take gasp or deep breath and aspirate the secretions in the
Gentle and intermittent suctioning only is needed.
An electric suction may be used, negative pressure should not exceed 100 mm Hg. Take only 2-3
seconds for suctioning. Suction tube should go only about 3 inches.
Healthy vigorous crying babies do not need any suctioning.

Drying and suctioning stimulate most babies to start breathing or crying; if not, then give gentle
tactile stimulation.
Rubbing the babies back firmly, slapping or flicking the heels of the baby twice are enough and
Slapping the baby vigorously on the back and buttocks, dilating the anal sphincter, pouring cold
water on the baby, holding the baby upside down or rocking the baby violently are harmful
Evaluate the baby simultaneously for respiration, heart rate and colour.
If the respiration is irregular, gasping or no respiration, start bag and mask ventilation.
If the heart rate is less than 100, even if respiration is present, start bag and mask ventilation.
If the heart and respiratory rates are good but there is central cyanosis, then give free-flow oxygen.
Free-flow oxygen needs to be administrated at 5 litres per minute and be provided by face mask or
oxygen tubing with cupped hand, holding the tube close to the nose or mouth without dangling.
Once cyanosis disappears, wean the baby of oxygen slowly over a period of minutes instead of
withdrawing it suddenly.
The bag and mask should not be used to deliver free-flow oxygen as there is an inlet valve
preventing the entry of oxygen into the mask unless the bag is squeezed.
The basic step should not take more than 30 seconds.
Time is precious and delay is damaging.



If after tactile stimulation, baby is apnoeic or gasping and respiration is spontaneous but heart rate is
below 100 beat/minute.

Parts of an Ambu Bag

Self-inflating bag 250 ml to 500 ml. use 500 ml capacity bag for term babies.
Air inlet.
Oxygen reservoir to connect the air inlet two types corrugated tube or closed bag.
Oxygen inlet.
Connecting oxygen to the inlet increases the oxygen supply to the baby by 35-40%. If the oxygen
reservoir is connected to Ambu bag, it will increase to 90%. The reservoir has higher concentration
of oxygen at the bag end and every time the bag inflates, it receives the oxygen by venture effect.

{NOTE: Air Mask Bag Unit (patient ventilator), Artificial Manual Breathing Unit (ventilation)}


When squeezing the bag, this valve opens allowing oxygen mixed air to enter the bag. That is why a self-
inflating bag and mask should not be used for free flow oxygen.

Cushioned round mask are more efficient than non-cushioned anatomical masks as they do not cause
injury to the face when firmly held. Ensure that the baby lies in proper position with the neck slightly
extended. Stand at the head end of the baby. Place the mask at the face so that it covers the tip of the chin,
the mouth and the nose. Ensure a good seal by light downward pressure on the mask so that the air does
not leak from the side. The mask can be held on face with the thumb and index finger encircling its rim
like a figure of C, while the ring finger lifts and maintains the neck in a mildly extended position.


The babys neck should be slightly extended to ensure an open airway while he lies on his back. An
appropriate sized bag and mask is selected. The mask is placed in position so that it covers the mouth and
the nose but not the eyes. Then, bagging is started at a rate of 40-60/minute for 15-30 seconds, using
enough pressure to cause chest movements.

EVALUATION: If heart rate 100/minute and infant having spontaneous breathing, stop bagging
(ventilation). If heart rate 100 but infant yet not having spontaneous breathing or is gasping, continue
ventilation. If heat rate 60-100/minute and not increasing, continue ventilation and check for adequacy of
ventilation from chest elevation. If heart rate80/minute, start chest compressions. If heart rate60/minute,
continue to ventilator, start chest compressions and consider intubation.

Sign of Improvement:

Rising heart rate

Spontaneous breathing
Improving color

Do Not

Flex the neck while bending over the baby.

Put pressure on the throat.
Traumatize the eyes using a large face mask.
Use the palm of the hand while squeezing the bag.
Remember the babys lungs need only 20-30 ml of air and the bag capacity is 500 ml.
The bag and mask procedure should take only 30 seconds. Time is precious and delay can be
damaging. At the end of 30 seconds quickly auscultate the heart or feel the umbilical cord for
pulsation (at the base for 6 seconds and multiply by 10).

Diaphragmatic hernia antenatally diagnosed or suspected at birth. During bagging, some air will go into
the intestine and the intestine is already in the mediastinum, thus compromising ventilation.

Meconium aspiration or any other aspiration (blood, milk etc.). Bagging should be avoided before
thorough oropharyngeal, nasopharyngeal and endotracheal suctioning has been done.


Chest compression consist of rhythmic compression of the sternum pressing the heart against the spine. It
results in rise of intrathoracic pressure and circulation of blood to the vital organs. Chest compression are
used to increase circulation and oxygen delivery. Chest compression must always be accompanied by
ventilation with 100% O2. This ensures that the blood being circulated during chest compression is
adequately oxygenated.


If the heart rate is less than 60/minute after 30 seconds of adequate positive pressure ventilation with
100% oxygen.

Once the heart rate increases above 60/minute, discontinue chest compressions but continue with
ventilation till the heart rate is 100/minute and baby has spontaneous breathing.


Compress the lower third of the sternum. Lower third of sternum is located by running finger along the
lower edge of ribs till xiphoid and the area just above the xiphoid are used for chest compressions or to
identify the nipple line and do the chest compressions one finger breadth below.


Two-thumb technique.
Two-finger technique.
1. Two-thumb technique is preferred as it is more effective and less tiring.

The second resuscitator stands at the foot and encircles the chest with both hands and
compresses over the lower third of the sternum with the tips of his or her thumb to a depth of 1/3rd of the
anteroposterior diameter of the chest. It should generate palpable pulse. Do not lift the fingers of the chest
in between chest compressions. The rate of compression is 120/minutes, but after every three chest
compressions, do one ventilation, i.e. squeeze 1-2-3 times. This results in 90 chest compressions and 30
ventilations per minute.

2. Two-finger technique is useful when there is only one resuscitator.

Note: After 30 seconds, discontinue chest compressions and auscultate for 6 seconds and multiply by 10.
Discontinue chest compressions, if the heart rate is 60/minute.

Evaluation: 30 seconds of chest compression should be followed by rechecking of the heart rate. If it is
below 80/minute, the procedure should continue along with bag and mask ventilation with 100% oxygen,
plus medication. If heart rate is 80/minute, stop chest compression but continue ventilation until heart
rate crosses 100/minute and the baby is breathing spontaneously.

Complications of Chest Compressions:

Laceration of liver
Fracture ribs



To suction trachea in the presence of meconium when the newborn is not vigorous.
To improve efficacy of ventilation after fewer minutes of bag and mask ventilation or ineffective
bag and mask ventilation.
To facilitate coordination of chest compressions and ventilation and to maximize the efficiency of
each ventilation.

Steps for Intubating a Newborn

Ideally, it should be completed within 20 seconds.

The newborn is placed on a resuscitation table (high enough and with flat surface) in a supine
position with full extended neck at the edge of the table. It is good to place folded towel or blanket
beneath the shoulders to facilitate thus position.
The operator sits on a stool at the head end.
As he opens the infants mouth with the index finger and the thumb of the right hand, his left hand
introduces the lighted laryngoscope (infant size) into the nasopharynx up to the epiglottis.
The glottis is cleared by gentle suction. This makes it easier to clearly see the epiglottis and the
surrounding structures.
When the glottis is visible, a curved endotracheal tube is gently inserted through the larynx. Make
sure that it is not pushed too far to prevent its entry into the right bronchus.
The laryngoscope is now withdrawn.
The intermittent positive pressure respiration is given through the tube either by simply puffing in
air from operators mouth or with a bag or mechanical respirator, as soon as respiration gets
established, the tube should be withdrawn.
If the response is poor, still efforts have got to be continued as long as the heart beat exists.

Precaution during intubation:

In order to prevent hypoxia during intubation, provide free-flow oxygen, limit intubation
attempt to 20 seconds and avoid excessive flexion of neck.

Precaution during Extubation:

1. Give free-flow oxygen through the lid of the endotracheal tube for a few seconds.
2. Always take help of a laryngoscope during extubation.
3. Continue bag and mask ventilation for 15 seconds after extubation.

Use of Medication:

Medication Indication Doses Effects

Epinephrine (1:1000) Heart rate less than 0.1-0.3 ml/kg of 1:10,00 Inotropic
IV/IO 60/minutes after 30 (Dilute 1 ml of Adrenaline Chronotropic
seconds of ventilation and in 9ml water for injection Peripheral
chest compression to make it 1:10,000) vasoconstriction
Volume expander (Normal Evidence of hypovolemia 10ml/kg Better tissue perfusion,
Saline) better intravascular
Sodium bicarbonate Documented metabolic 4ml/kg prepare at 1:1 Correction of acidosis
0.9meq/ml (IV) acidosis, APGAR 3 or less dilution (using water for
at 5 minutes injection
Naloxone (0.4 mg/ml) Respiratory depression, 0.1mg/kg administer only Narcotic antagonist
administration of after positive pressure
narcotics within 4hrs ventilation has restored
before delivery oxygenation
Dopamine 5-20 Poor peripheral perfusion, 2 -20g/kg
mcg/kg/minute as a weak pulse, hypotension,
continuous IV infusion tachycardia and urine
output persist.

Donts in Neonatal Resuscitation

Dont administer heavy sedation to the mother.

Dont do heavy and continuous suction.
Dont let the neonate develop hypothermia.
Dont carry on with tactile stimulation beyond 2 and never beyond 4 flicks.
Dont delay endotracheal intubation in an apnoeic neonate.
Dont blow your lungs into neonates mouth.
Dont use full palmar grasp for giving bag and mask ventilation.
Dont give respiratory stimulants.
Dont suck the nose first and the mouth later. The breathing effort that follows sucking the nose first
may allow secretions in the mouth to be suddenly aspirated into the lower airway.
Dont slap the back.
Dont squeeze the rib cage
Dont force thighs on the abdomen.
Dont dilate the anal sphincter.

Management of Newborn after Resuscitation

Cut the umbilical cord and tie it.

Examine the baby completely (malformation and sign of sickness)
Weigh the baby, take weight, note sex and show the baby to the attenders and mother. Apply
identification tags.
Administer 1 mg of vitamin K IM.
Decide whether this is a normal, at risk or sick neonate and accordingly decide the level of care.
If normal: Cloth the baby and transfer the baby to mother initiate breastfeeding and KMC,
administer vaccination, follow up care, and communicate with mother and family.

For the baby

The mother and baby should be kept together with the baby in skin-to-skin contact.
Encourage the mother to breastfeed her baby as soon as it is ready. This will help to prevent
Help the mother breastfeed her baby, if needed.
Good suckling is a sign of recovery. If the baby is unable to suck effectively, ask the mother to
express colostrum; help her in expression of milk.
Record all the events in babys record book

For the mother and family

After resuscitation, explain to the mother and family what has happened and how the baby is now.
Keep the mother and baby in the delivery room and do not separate them.
Never leave the newborn and woman alone. Monitor them every 15 minutes during the first hour.
a. Record the events.
b. Examine the baby before discharge.


Complete documentation includes narrative description of the interventions and their timing.


Liver laceration
Rib fracture
Intraventricular haemorrhage


Neonatal resuscitation is a very important procedure to save lives of newborn which require special skills
and trained personnel. A trained personnel should be available in each delivery room every time. A
resuscitation trolley should be available24 hours suspecting each newborn baby may be in need of



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