MODULE 5:

Newborn Resuscitation
Principles of
Newborn
Resuscitation
MODULE 5: Newborn Resuscitation
 At the end of this activity, the participants
will understand the following:

● Potential clinical features in Covid-19 positive

pregnant woman

● Mother to infant transmission of Covid-19

Objectives ● Changes in physiology at birth

● Preparation for resuscitation

● Sequence of neonatal resuscitation

● Additional steps and maneuvers in

resuscitation of COVID-19 suspect or
confirmed newborns

● Post-resuscitation debriefing
Clinical
features of a
Covid-19
positive
mothers

* Some Covid-19 positive mothers are

asymptomatic. Pls. follow your
local/hospital guidelines in screening in
Covid-19 suspects
Mother to
infant
transmission
of Covid-19
Attending
Deliveries
 ● Most newly born babies are vigorous

● Only about 10% of newborns require some

Which Babies assistance
Require
Resuscitation? ● Only 1% need major resuscitative measures
(intubation, chest compressions, and/or
medications) to survive
 In the fetus

Fetal ● Alveoli filled with lung fluid

Physiology
● In utero, fetus dependent on placenta for gas
exchange
 The following major changes take place
within seconds after birth:

● Fluid in alveoli absorbed; air enters lungs

Normal ● Blood vessels in lung relax

Transition
● Pulmonary blood flow increases

● Umbilical arteries and vein constrict thus

increasing systemic blood pressure
 ● Lack of ventilation of the newborn’s lungs
results in sustained constriction of the
What can go pulmonary arterioles, preventing systemic
arterial blood from being oxygenated
wrong during
transition? ● Prolonged lack of blood flow and oxygenation
to the baby’s organs can lead to brain
damage, damage to other organs, or death
 All newborns require initial assessment to
Birth determine whether resuscitation is required
For special circumstances:
I. Thorough drying NO
Apnea / gasping
and
or limp?
quick assessment
1. Before entering the scene, all
YES rescuers should don PPE to guard
1.
2.
Call for help
Change wet linen
against contact with both airborne
3.
4.
Clamp and cut the cord
Transfer to warmer
and droplet particles.
5.
6.
Position airway
Clear secretions if needed 2. Limit personnel in the room or on
Provider 7.
8.
PPV
SpO2 monitoring
the scene to only those essential for
patient care.
Response Apnea / gasping NO Labored breathing or NO
or HR < 100 bpm? persistent cyanosis?

YES YES
9. Ventilation corrective steps a. Position and clear airway
10. Intubate if needed b. SpO2 monitoring
c. Supplemental O2 as needed
d. Consider CPAP
NO
HR < 60 bpm?

YES
10. Intubate if not already done
11. Coordinated PPV and chest compressions
12. 100% O2
13. Consider UVC insertion

NO
HR < 60 bpm?

YES
14. IV epinephrine
15. Consider hypovolemia
16. Consider pneumothorax
 ● Assess perinatal risk

Preparation ● Assemble appropriate personnel

for
● Immediate access to supplies and equipment
Resuscitation
● Effective teamwork and communication
 COVID-19 SAFETY PRECAUTIONS:

• Proper DONNING OF PPE

• LIMIT PERSONNEL in the DR
Covid-19 • Procedure especially intubation
performed by an EXPERT PROVIDER
Safety
Precautions
Covid-19
Safety
Precautions
 Antepartum factors Intrapartum factors
• Ruptured membranes • Excessive bleeding
Risk Factors over 18 hours
• Breech presentation
Associated • Pre-eclampsia and
• Meconium
Eclampsia
with the • Abnormal
• Maternal infection
Need for fetal heart tones
✔ Malaria
Resuscitation • Prolapsed or
✔ HIV nuchal cord
✔ COVID-19 • Rapid, hard labor
• Premature labor • Foul smelling fluid
• Multiple births • Prolonged labor

• Others • Shoulder dystocia

 ● All pregnant women should wear a MEDICAL
MASK
● Undergo an established TRIAGE procedure
before delivery which includes:
COVID-19
● History of travel, occupation, contact and
Special clustering (TOCC)
Considerations ● Presence of clinical features of COVID-19
or “influenza-like features”
● Whenever possible, a RT-PCR testing for
COVID-19

Trevisanuto et al. Neonatology. April 2020

 • Minimum number of providers should attend a
delivery to reduce exposure and to minimise
the use of PPE.

Assemble ● Every delivery should be attended by at least

1 EXPERT PROVIDER who is capable of
appropriate initiating resuscitation and do intubation.
personnel ● RESCUE PERSONNEL should be available
for emergency
Immediate
Access to • Appropriate PPE
Supplies and • Bacterial/Viral Filter
equipments
• Acrylic Box
• Disposable Laryngoscopes
• Closed circuit systems
 ● Assign specific roles for each team member
● Closed loop communication is important to
ensure that tasks are being carried out
● For known high-risk cases
● Conduct multi-specialty conference to
plan resuscitation
Team briefing ● Rehearse the resuscitation
● Conduct de-briefing to improve
resuscitation skills prior to actual delivery
● Follow established guidelines regarding
deliveries of COVID-19
suspected/confirmed mothers
● SHARED DECISION prior to delivery
 ● Parents are considered to be the appropriate
surrogate decision makers for their own
infants

● Parents must be given relevant and accurate

Role of information about the risks and benefits of
each treatment option
Parents
● Newborn’s best interests

● May not have time for adequate informed

consent
Equipment Check

Link to hi-res video: Equipment check

 I. Thorough drying NO
Apnea / gasping
Birth and
or limp?
quick assessment

The FIRST 1. Call for help

YES

MINUTE 2.
3.
4.
Change wet linen
Clamp and cut the cord
Transfer to warmer
5. Position airway
6. Clear secretions if needed

7. PPV
8. SpO2 monitoring

All newborns require initial assessment to

determine whether resuscitation is required
 COVID-19 Setup
I. Thorough ▪ Pre-identified area for
drying Apnea / NO neonatal resuscitation
and gasping
Birth quick or limp?
with additional equipment
assessment ▪ Options:
YE A: In a separate room
The FIRST 1.
S
Call for help
(preferably negative pressure
room)
MINUTE 2.
3.
4.
Change wet linen
Clamp and cut the cord
Transfer to warmer
5. Position airway
B: In the DR, 2 meters away
6. Clear secretions if needed from the mother with a
physical barrier, with limited
7. PPV providers
8. SpO2 monitoring
C: In the DR, 2 meters away
from the mother with limited
providers in an isolation room

All newborns require initial assessment to

determine whether resuscitation is required
 ● Poor muscle tone
● Slow or no breathing
Signs of a ● Low heart rate
Compromised
● Low blood pressure
Newborn
● Fast breathing
● Cyanosis
 PRIMARY APNEA

In Utero or When a fetus/newborn first becomes deprived

Perinatal of oxygen, an initial period of attempted rapid
Compromise breathing is followed by primary apnea and
dropping heart rate that will improve with
tactile stimulation
 SECONDARY APNEA

● If oxygen deprivation continues,

secondary apnea ensues, accompanied
by a continued fall in heart rate and
blood pressure
● Secondary apnea cannot be reversed
In Utero or with stimulation
Perinatal ● Assisted ventilation must be provided
that will improve with tactile stimulation
Compromise
● All aerosol generating procedures
(AGP) such as face-mask ventilation,
non-invasive ventilation, CPAP, tracheal
intubation) should be performed by
using a respirator, PAPR or N95 mask,
eye goggles, double gloves and gown.
Resuscitation
of a Baby in Initiation of effective positive-pressure
ventilation during secondary apnea usually
Secondary results in rapid improvement in heart rate
Apnea
 I. Thorough drying NO
Apnea / gasping
Birth and
or limp?
quick assessment

The FIRST 1. Call for help

YES

MINUTE 2.
3.
4.
Change wet linen
Clamp and cut the cord
Transfer to warmer
5. Position airway
6. Clear secretions if needed

7. PPV
8. SpO2 monitoring

All newborns require initial assessment to

determine whether resuscitation is required
 After these initial steps, further actions are
based on evaluation of
● Respirations
● Heart rate
Evaluation ● Color
Apnea / gasping NO Labored breathing or NO
or HR < 100 bpm? persistent cyanosis?

YES YES
 Apnea / gasping NO Labored breathing or NO
or HR < 100 bpm? persistent cyanosis?

YES YES
9. Ventilation corrective steps a. Position and clear airway
10. Intubate if needed b. SpO2 monitoring
c. Supplemental O2 as needed

Assisting d. Consider CPAP

Ventilation
 If heart rate <60 bpm
despite adequate ventilation for 30
seconds

NO
Circulation HR < 60 bpm?

YES
10. Intubate if not already done
11. Coordinated PPV and chest compressions
12. 100% O2
13. Consider UVC insertion

• PAUSING CHEST
COMPRESSIONS DURING
INTUBATIONS
 If heart rate <60 bpm
despite adequate ventilation
NO
and chest < 60 bpm?
HRcompressions

YES
14. IV epinephrine
15. Consider hypovolemia
Drug 16. Consider pneumothorax

• Do NOT give EPINEPHRINE

via endotracheal tube
 Resuscitation with
effective communication

Link to hi-res video: Resuscitation ideal

 Resuscitation without
effective communication

Link to hi-res video: Resuscitation non-ideal

 ● Facilitated interactive discussion of a prior
series of events
● Members should talk together and discuss
● What happened during the resuscitation?
De-briefing ● What needs to be improved?
● How can these improvements be made?
Team de-briefing

Link to hi-res video: De-briefing

 1. Effective communication and teamwork
is the key to successful resuscitation

2. The most important and effective action in

neonatal resuscitation is to ventilate the
baby’s lungs

Key Points 3. PPV must be provided within the FIRST

MINUTE of life for infants in secondary
apnea

4. If heart rate does not increase with PPV,

ventilation corrective steps and/or chest
compressions and epinephrine may be
necessary
 Heart rate <60 bpm → Additional steps
needed

Heart rate >60 bpm → Chest compressions

can be stopped
Key Points
Heart rate >100 bpm and breathing
→ Positive-pressure ventilation can be stopped

Time line: if no improvement after 30 seconds,

proceed to next step
Terheggen, U, et al. European consensus recommendation for neonatal and peadiatric retrievals of positive or suspected Covid 19 patients.
Principles of
Newborn
Resuscitation
MODULE 5: Newborn Resuscitation