Newborn Resuscitation..

NEWBORN
RESUSCITATION
R DH@KER, Asst. Professor, PCNMS 1

What is neonatal resuscitation ?
Assessment of the fetus at birth
Identification of the babies requiring resuscitation
Initial steps of resuscitation
Pulmonary resuscitation
Vascular Resuscitation
Termination of resuscitation
Burden of the problem
• Birth asphyxia
• 23% of the 1 million neonatal deaths in India
• Long term neurological complications
• Death
• NNR (Neonatal resuscitation) :simple,
inexpensive, cost effective method
• Problem: NNR often not initiated, incorrect use
of methods.

Which babies need resuscitation?
Newborn rapidly assessed for
● Term gestation? ●Crying or Breathing?
● Good muscle tone?
If “yes,” for all 3 questions
Baby does not need resuscitation and

should not be separated from mother.
CONT…Which babies need resuscitation?
• If the answer to any of these assessment

questions is “NO”
• A. Initial steps of stabilization

• B. Ventilate and oxygenate (HR/Breathing)
• C. Initiate chest compressions (HR < 60)
• D. Administer epinephrine and/or volume
Approximately 60 seconds (“the Golden Minute”) are
allotted for completing
initial steps, revaluating and

beginning ventilation if required
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.

Causes of Neonatal Mortality
Diarrhoea
Tetanus
3%
7% Others
Congenital 7% Preterm
7% 27%
Asphyxia Sepsis &

23% pneumonia
26%
4 million neonatal deaths: When? Where? Why? Lancet 20058

R DH@KER, Asst. Professor, PCNMS
What does it involve?
1. Preparation at every birth
2. Assessment of the baby’s condition at birth
3. Interventions
1. Dry / stimulate
2. Clear airway BASIC
3. Support breathing
• Ventilate (bag/mask)
• Oxygen
1. (Advanced support)
• Chest compressions
• Intubation / ventilation
• Medications
4. Ongoing assessment
How many babies require resuscitation?
NOT POSSIBLE
TO PREDICT
WHICH BABIES
NEED HELP.

Overview and Principles
WHY TO LEARN NEWBORN RESUSCITATION?
• Birth asphyxia accounts for about 1/4th of the 4

million neonatal deaths that occur each year
worldwide.
• For many newborns resuscitation is not available
• Outcomes of these newborns can be improved with
timely and effective resuscitation.
CONT…Overview and Principles
• Approximately 90% of newborns make smooth

transition from intrauterine to extrauterine life
requiring little or no assistance.
• 10% of newborns need some assistance
• Only 1% require extensive resuscitation
• We must always be prepared to resuscitate, as
even some of those with no risk factors will
require resuscitation.
CONT…Overview and Principles
ADULT vs. NEONATAL RESUSCITATION
 The sequence of resuscitation in adults is C-A-B

 But in newborns the sequence remains
T-A-B-C as the etiology of neonatal compromise is
nearly always a breathing difficulty
 Temperature
 Airway(position And Clear)
 Breathing (Stimulate To Breathe)
 Circulation (Assess Hr And Oxygenation)
• T- Maintenance of Temperature
– Dry the baby quickly
– Remove wet linen
– Place the baby under radiant warmer
• A- Establish an open airway
– Position the infant
– Suction mouth and nose
– ET intubation, if needed to ensure open
airway.

• B- Initiate Breathing
– Tactile stimulation to initiate respiration
– PPV when necessary, using either Bag and Mask or

Bag and ET tube.
• C- Circulation
– Chest compression
– Medications ( If needed)

Equipment Required
Oral mucus sucker
Suction Catheter
Radiant warmer R DH@KER, Asst. Professor, PCNMS 16

TRANSPORT
INCUBATOR

This person must be capable of initiating
resuscitation, including-
• Endotracheal tubes (size 2.5-4)
• Tape and scissors
• Laryngoscope (with size 0 and 1 blades)
• Extra bulbs and batteries
• Carbon dioxide detectors
• Stylettes for endotracheal tubes (optional)
• Laryngeal mask airway (optional)

Suction equipment includes the following:-
• Bulb syringe
• Regulated mechanical suction
• Suction catheters (6, 8, and 10 French)
• Suction tubing
• Suction canister
• Replogle or Salem pump (10 French
catheter)
• Feeding tube (8 French catheter)
• Syringe, catheter-tipped (20 mL)
• Meconium aspirator
Fluid equipment includes the following:
• IV catheters (22 g) •Drugs used include
• Tape and sterile epinephrine (1:10,000).
dressing material •Procedural equipment
• Dextrose 10% in includes the following:
water (D10W) •Umbilical catheters (2.5
• Isotonic saline and 5 French)
solution •Chest tube (10 French
catheter)
• T-connectors
•Sterile procedure trays
• Syringes, assorted (eg, scalpels, hemostats,
(1-20 mL) forceps)
23
Initial Steps of Resuscitation
• Receiving the newborn baby in a prewar towel
and placing the baby on the preheated radiant
warmer.
• If warmer is not available, room heater or bulb
of 200W can be used, which should be fixed in
a suitable place.
• Never allow the baby to become hypothermic.
Term Gestation? Yes
Breathing or crying? Routine
Good tone? Care
No
Warm
Clear airway if needed
Dry Stimulate
30 sec
HR less than 100?
Gasping or
Apnea?
Cont…Initial Steps of Resuscitation
• Positioning the baby on the

back with the neck slightly
extended sniffing position.
• Hyperextension or under
extension should be prevented
which may decrease air entry.


• To maintain correct position, shoulder roll may

be useful, elevating the shoulder ¾ to 1 inch of
the mattress. If the neonate has copious
secretions, head should be turned to one side.
• Never keep the baby’s head too low for too long
time.
Extension of neck with help shoulder roll: to open the airway

28

• Suctioning of the mouth should be done first then

the nose, otherwise there is chance of aspiration of
secretions from mouth.
• Suctioning should be done carefully to prevent

stimulation of posterior pharynx which can lead to
bradycardia and apnea.

• Suction pressure to be kept around 80 to 100

mmHg (100-130cm water).
• Tracheal suctioning may be needed through

Endotracheal (ET) intubation in meconium stained.

VIDEO

• Drying the baby’s whole body and head quickly

and removing the wet linen immediately.
• The baby is then placed further on a pre-warmed
towel to reduce heat loss.
• Drying the baby prevent evaporative heat loss and
provide gentle stimulation which may help to
initiate respiration.


• Providing tactile stimulation by slapping or

flicking the sole of the feet or rubbing the infant’s
back once or twice to stimulate birthing.
• Continued used of tactile stimulation in an infants

who does not respond, may be harmful and
wastage of valuable time.

The baby who is not taking respiration spontaneously,

may breathe after one or two tactile stimulation only.
39
Dry ,Reposition, Stimulate
Stimulate :
Flicking the soles/
drying & rubbing
the back
• Using free flow oxygen by blowing over the

infant’s nose so that the baby breath oxygen
enriched air.
• This can be given by using oxygen mask or

cupped hand at the flow rate of 5 liters per minute

Free-flow oxygen given via oxygen
tubing
• After these initial steps of resuscitation the baby

should be evaluated for respiration, heart rate and
skin color.
• Evaluation may be done before tactile stimulation.
• If the baby is having spontaneous respiration and

heart rate above 100 beats per minute with skin color
pink or acrocyanosis then the baby needs observation
and monitoring only.
• When the infants has no spontaneously breathing

then positive pressure ventilation (PPV) should be
started with bag and mask.
• If the baby is taking respiration spontaneously but

heart rate is below 100 beats per minute, at that
condition also PPV should be started immediately.

Evaluation
• Respirations
• Heart rate: Best is
auscultation,
alternatively
pulsations at base
of cord is felt.
Count for 6s and
“x”10
• Oxygenation by
oximeter
Bag and Mask Ventilation
• Bag and Mask ventilation should be started of
after tactile stimulation,
– The infant is still apneic or gasping
– Having spontaneous respiration but heart rate is

below 100 beats per minute.
46
CONT…Bag and Mask Ventilation
• For bag and mask ventilation, the baby’s neck

should be slightly extended to ensure open airway.
• Mask to be placed in position and seal to be
checked by 2 to 3 ventilation. Place the mask
covering tip of the chin, the mouth and the nose.

Mask
Appropriate Sizes
• Mask should
Rest on Chin
Cover Mouth
& Nose
Suction & Position
Light Pressure on
mask to create a
seal
Anterior
pressure on
posterior rim of
Cup the chin in the
mandible
mask and then cover
the nose
Self-Inflating Bag
O2 Reservoir
Pressure manometer
attaches
PEEP valve port
200-750ml Bag size

• Rise of chest to be
observed and if chest does
not rise then reapply mask,
reposition baby’s head,
suction if needed and
ventilation with slightly
open mouth and increased
pressure.


Frequency of ventilation:
40 to 60 breaths per minute
Start With 21% ( higher in preterm's) oxygen and

increase according to target Saturation Initial
Pressure at 20mmH2O
• After 15 to 30 seconds ventilation, the baby again

should be evaluated.
• If the heart rate is above 100b/Minute and

spontaneous respiration present then provide
tactile stimulation, monitor heart rate, respiration
and color.
• If no breathing establishes, continue ventilation.

• If heart rate is between 60 and 100 b/m and

increasing then ventilation to be continued.

Ensure Effective PPV
• Most Important sign is the rising of HR
• Improvement in Oxygen Saturation
• Equal and adequate breath sounds B/L
• Good Chest rise

Evaluation No
Postresus.
HR below 100? care
• Subsequent steps Yes
– Ventilation Heart Ventilation corrective

steps
rate less than100
BPM Yes
Continue
HR < 100 but > 60?
ventilation
– corrective steps
No
– Continue BMV
HR < 60?
ventilation
Quick Tangential Point
• Ventilation Corrective Steps – 3 possible reasons for

ineffective ventilation
– Inadequate mask seal

Failure of PPV
– Airway is blocked
– Not enough pressure used

MR SOPA
Measures to improve positive-pressure ventilation

M Mask adjustment
R Reposition airway
S Suction mouth and nose
O Open mouth
P Pressure increase
A Airway alternative
59
Ventilation corrective steps
Corrective steps Action
Mask Adjustment Ensure Good seal of

M mask on face
Reposition airway Sniffing Position
R
Suction Mouth and nose If secretions present
S
Open mouth Ventilate with baby
O mouth slightly open and
lift the jaw forward
Pressure increase Gradually increase the
P pressure every few
breaths
Airway alternative Consider ET or

A Laryngeal mask airway
Evaluation
If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,
Chest Compression
• Chest compression must always be performed
along with ventilation and 100% Oxygen.
• It is indicated if after 15 to 30 second of PPV

with 100% oxygen, the heart rate is below 60
beats per minute and not increasing.
100% Oxygen whenever chest compressions are provided

Cont… Chest Compression
• The pressure is applied to the lower third of the

sternum to depress it ½ to ¾ inches.

Principle:
• Rhythmic compressions of
sternum that-
– Compress the heart against the
spine
– Increases intrathoracic pressure
– Circulate blood to vital organs
– Chest compressions 
compresses heart & increased
Intrathoracic pressure  blood
pumped into arteries
– Pressure released  blood
enters heart from veins
Positions :
• Chest compressions are of
little value unless the lungs
are effectively ventilated
• 2 persons are required
– 1 – chest compressions
provider should have access
to the chest with his hands
positioned correctly
– 2 – Ventilation provider
should be at head end to
maintain effective mask-face
seal or to stabilize ET tube
Technique:
• Thumb technique: 2 thumbs
depress the sternum, hands
encircle the torso and the
fingers support the spine.
Preferred technique
• 2 – Finger technique: Tips of

middle & index/ring finger of
one hand compresses sternum,
other hand supports the back.
• Thumb technique is
preferred as
– Better control of depth of
compression
– Can provide pressure
consistently
– Superior in generating
peak systolic and
coronary arterial
perfusion pressure.
Chest compressions
For small chests with

thumbs overlapped
2- finger technique
Chest compressions
• Depth : 1/3rd of the

anteroposterior
diameter of chest.
• Duration of
downward stroke
should be shorter
than the duration of
release
• Do not lift the fingers
off the chest
Chest compressions
Coordination of chest compressions and

ventilation:
• Avoid giving compression and ventilation
simultaneously
• 1 breathe after every 3 compressions
– Ratio is 1 : 3 or 30: 90 per minute
– One cycle: 2 sec, 3Compresssions + 1 ventilation
– 1 minute : 30 cycles or 120 events (90 compressions
+ 30 breaths)
Evaluation
• Subsequent steps Ventilation corrective
steps
– Heart rate < 60 Yes Continue
BPM HR < 100 but > 60? ventilation
• Chest
No
compressions
(90/min) HR < 60?
• Continue
Yes
ventilation at 30
BPM Chest compressions
Consider intubation
– Reassess Coordinate with PPV
HR < 60?
Endotracheal Intubation
Cont… Endotracheal Intubation
• Endotracheal (ET) intubation is a specialized and

skilled procedure. It is indicated when, -
• Prolonged PPV is required
• Bag and mask ventilation is ineffective
• Tracheal suction is needed
• Diaphragmatic hernia is suspected.

WHEN TO CONSIDER INTUBATION ?

Indications in resuscitation
 Baby is floppy, not crying, and preterm
 HR < 100/min, gasping/apnea
 HR < 60/min
 No adequate chest rise and no clinical
improvement
 If chest compressions are needed, intubation
provides better coordination and efficacy of PPV
 To administer drugs
WHEN TO CONSIDER INTUBATION ?

Special conditions
 Meconium aspiration if baby is depressed in
which it is the first step to be done
 Extreme Prematurity
 Surfactant administration
 Suspected diaphragmatic hernia
Endotracheal Intubation- Equipment
and supplies
• Laryngoscope with extra

blades and bulbs
• Straight blades
• Term – 1
• Preterm – 0
• Extremely preterm - 00
ET tube sizes
Weight GA(weeks) Tube size(mm)

(internal diameter)
Below 1 kg 28 2.5
1-2 kg 28-34 3.0
2-3 kg 34-38 3.5

>3kg >38 3.5- 4.00
ET tube – Uniform diameter, uncuffed
ET tube – Vocal cord guide
Procedure… Position
Position
Position
Position
CRICOID PRESSURE
SUCTIONING
Endotracheal Intubation:
Anatomic Landmarks
Fixing ET tube
Wt Depth of insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm
• Add 6 to baby’s wt.

Lip reference mark: (6 + weight in kg) cm
9-10 cm at the lip

for this term infant
Confirm position
• Watching the tube passing between cords
• Watching for chest movements
• Listening for breath sounds ( Axilla and stomach)
• Improvement in HR and Spo2
• Vapour Condensing inside tube
Laryngeal Mask Airway
LMA
Medication
• All essential medications should be kept in the
resuscitation room and should be
administration aseptically.
• Umbilical vein is preferred route via a catherer,
because scalp veins and extremities are
difficult to approach.

Drug Syringe Dosage Rate/Precautions
Give rapidly IV or ET
Epinephrine 0.01-0.03mg · kg-1
1 ml Repeat q3-5 min
(1:10,000) (0.1-0.3 ml · kg-1)
(ET: dilute to 1-2 ml with NS)
Volume Expanders
NS or RL
5% Albumin 40 ml 10 ml · kg-1 Give IV over 5-10 min
O-neg Blood
Naloxone 0.1 mg · kg-1

Give rapidly
(0.4 mg·ml-1) 1ml (0.25 ml·kg-1)
IV or ET preferred
(1.0 mg·ml-1) 1ml (0.1 ml·kg-1)
Reserved for prolonged

resuscitations only
Sodium Bicarbonate
10 ml 2 mEq · kg-1 Give slowly, over at least 2 min, IV ONLY,
(0.5 mEq·ml-1 = 4.2%
(4 ml · kg-1) Infant must be ventilated
soln) (x2)
Dopamine
5-20 mcg·kg-
(6 x weight in kg = mg of Continuous infusion by
dopamine diluted to 100
100 ml 1·min-1
(5-20 ml · hr-1) pump
ml)
99
Cont… Medication
• No intracardiac injections are recommended in

neonates.

NEWBORN RESUSCITATION ALGORITHM
Summary
• Doing the simple things better is probably the
most cost-effective policy.
• Resuscitation can come as complete surprise So
be prepared for resuscitation.
• It may take several hours to learn but it should be

implemented over seconds.
• Practice makes one perfect.
Any Questions???
MCQ1
For successful neonatal resuscitation following
is/are needed except:
1. Anticipation
2. Adequate preparation
3. Skilled personnel
4. Delayed initiation of support

MCQ2
• Following are true in relation to initial steps of
neonatal resuscitation except
1. Provide warmth
2. Tactile stimulation
3. Clear airway and intubation
4. Drying the baby

MCQ3
• The following is the primary measure of
adequate ventilation
1. Chest wall movement
2. Improvement in heart rate
3. Pink extremities
4. Spo2 of 80%
MCQ4
• Endotracheal intubation may be indicated at
several points during neonatal resuscitation except
1. If BMV is ineffective
2. When chest compressions are performed
3. Endotracheal suctioning of vigorous meconium stained
newborns
4. For special resuscitation circumstances like extremely
LBW
MCQ5
• The recommended compression to ventilation

ratio in neonatal resuscitation is
1. 2:1
2. 3:1
3. 4:1
4. 5:1
MCQ6
• The recommended dose(mg/kg per dose) and
route of epinephrine in neonatal resuscitation
1. 0.01-0.03,IV
2. 0.01-0.03,IM
3. 0.03-0.05,1V
4. 0.05-0.1,IV
MCQ7
• Recommended method/clinical indicator of
confirming ET placement is
1. Condensation in ET
2. Chest movement
3. Equal breath sounds on auscultation
4. Exhaled C02 Detection

MCQ8
• Which of the following is not an advantage of a
self inflating bag over anaesthesia bag?
A. It is readily usable in an emergency
B. It can be used even without a compressed gas
source
C. It inflates even without an adequate seal
D. It can help in the judgement of compliance of the
lungs

MCQ9
• Which of the following is not an indication to

start positive pressure breaths to a baby?
A. HR < 100/mt
B. Apnoea
C. Shock
D. Gasping breathing
MCQ 10
• The air that fills the baby's alveoli during
normal transition contains _______ oxygen.
A. 15%
B. 21%
C. 30%
D. 40%

MCQ 11
• What percentage of newborns will require
extensive resuscitation to survive?
A. 1%
B. 5%
C. 10%
D. 15%

MCQ 12
• What is the most important and most effective
action that can be taken in neonatal resuscitation?
A. Chest compressions
B. Epinephrine administration
C. Ventilation
D. Intubation

MCQ 13
• When doing CPR on a neonatal you stop what

over extend ____?
A. Back
B. Chest
C. Legs
D. Neck

MCQ 14
• How any cycle of CPR can do in 30 seconds?
A. 10
B. 15
C. 20
D. 30

MCQ 15
• When do you reassess the heart rate?

A. 1 minute
B. 35second
C. 30 second
D. 40 second

MCQ 16
• When do you do you first assess a newborn for

tone, breathing and heart rate?
A. 1 minute
B. 30 minutes
C. 30 seconds
D. 60 seconds

MCQ 17
• Neonatal is what age ?
A. 0 -28 days
B. 0 - 1 year
C. 0 - 3 months
D. 0 - 6 months

MCQ 18
• The first 30 seconds from birth you ?
A. Assess (tone) and breathing
B. Assess the ABC
C. Dry the baby
D. Give inflation breaths

MCQ 19
• After 30 seconds drying a baby you assess the
following ?
A. Colour and heart rate
B. ECG
C. Heart rate
D. Pulse rate
E. Tone, breathing and heart rate

MCQ 20
• What is the heart rate to indication to start
chest compression after doing 5 inflation
breaths?
A. 0
B. 60
C. 80
D. 100 R DH@KER, Asst. Professor, PCNMS 127

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NEWBORN

R DH@KER, Asst. Professor, PCNMS 1

Assessment of the fetus at birth

Identification of the babies requiring resuscitation

Initial steps of resuscitation

R DH@KER, Asst. Professor, PCNMS 3

If “yes,” for all 3 questions

Baby does not need resuscitation and

• If the answer to any of these assessment

• A. Initial steps of stabilization

initial steps, revaluating and

• Newborn resuscitation assists babies who fail to

R DH@KER, Asst. Professor, PCNMS 7

Asphyxia Sepsis &

4 million neonatal deaths: When? Where? Why? Lancet 20058

2. Assessment of the baby’s condition at birth

R DH@KER, Asst. Professor, PCNMS 10

• Birth asphyxia accounts for about 1/4th of the 4

• Approximately 90% of newborns make smooth

ADULT vs. NEONATAL RESUSCITATION

 The sequence of resuscitation in adults is C-A-B

R DH@KER, Asst. Professor, PCNMS 14

– PPV when necessary, using either Bag and Mask or

R DH@KER, Asst. Professor, PCNMS 15

Oral mucus sucker

Radiant warmer R DH@KER, Asst. Professor, PCNMS 16

R DH@KER, Asst. Professor, PCNMS 19

R DH@KER, Asst. Professor, PCNMS 21

• Positioning the baby on the

R DH@KER, Asst. Professor, PCNMS 26

R DH@KER, Asst. Professor, PCNMS 27

• To maintain correct position, shoulder roll may

Extension of neck with help shoulder roll: to open the airway

R DH@KER, Asst. Professor, PCNMS 29

• Suctioning of the mouth should be done first then

• Suctioning should be done carefully to prevent

R DH@KER, Asst. Professor, PCNMS 30

• Suction pressure to be kept around 80 to 100

• Tracheal suctioning may be needed through

R DH@KER, Asst. Professor, PCNMS 31

R DH@KER, Asst. Professor, PCNMS 33

• Drying the baby’s whole body and head quickly

R DH@KER, Asst. Professor, PCNMS 35

R DH@KER, Asst. Professor, PCNMS 36

• Providing tactile stimulation by slapping or

• Continued used of tactile stimulation in an infants

R DH@KER, Asst. Professor, PCNMS 38

The baby who is not taking respiration spontaneously,

Flicking the soles/

drying & rubbing

• Using free flow oxygen by blowing over the

• This can be given by using oxygen mask or

R DH@KER, Asst. Professor, PCNMS 41

• After these initial steps of resuscitation the baby

• Evaluation may be done before tactile stimulation.

• If the baby is having spontaneous respiration and

• When the infants has no spontaneously breathing

• If the baby is taking respiration spontaneously but

R DH@KER, Asst. Professor, PCNMS 44

– The infant is still apneic or gasping

– Having spontaneous respiration but heart rate is

• For bag and mask ventilation, the baby’s neck

R DH@KER, Asst. Professor, PCNMS 47

200-750ml Bag size