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Neonatal Resuscitation

Neonatal resuscitation skills are important because of the potential for serious disability or death
in high-risk infants and in a few unpredicted full term low-risk deliveries. Careful review of
resuscitative procedures is important before problem deliveries arise.

I. Preparation
A. Advanced preparation requires acquisition and maintenance of proper equipment and

Neonatal Resuscitation Equipment and Supplies

Suction Equipment

Bulb syringe Mechanical Suction

Suction catheters,5 (or 6), 8, 10 Fr 8 Fr feeding tube and 20 cc syringe
Meconium aspirator

Bag-and-Mask Equipment

Oral airways, newborn and premature Oxygen with flow meter and tubing
sizes Cushion rim face masks in newborn and
Infant resuscitation bag with a pressure- premature sizes
release valve/pressure gauge to give 90-
100% O2

Intubation Equipment

Laryngoscope with straight blades, No.O Stylet

(preterm) and No.1(term newborn). Scissors
Extra bulbs and batteries for Gloves
Endotracheal tubes, Size 2.5, 3.0, 3.5,
4.0 mm


Epinephrine 1:10,000, 3 cc or 10 cc Volume expanders-one or more of these:

ampules Albumin 5% solution
Naloxone 0.4 mg/mL,1 mL ampules Normal Saline
Dextrose 10% in water, 250 cc Ringer’s Lactate solution
Sterile water, 30 cc


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Radiant warmer and towels or blankets Alcohol sponges
Stethoscope 3-way stopcocks
Adhesive tape, ½ or 3/4 inch width 3 Fr feeding tube
Syringes, 1 cc, 3 cc, 5 cc, 10 cc, 20 cc, Umbilical tape
50 cc Needles, 25, 21, 18 gauge
Umbilical artery catheterization tray Umbilical catheters 3 1/2 and 5 Fr
Cardiotachometer and ECG oscilloscope

B. Immediate Preparation
1. Suction, oxygen, proper-sized face mask and the resuscitation bag should be
2. Appropriately sized ET tubes, cut to 13 cm, should be laid out.
3. Medications should be prepared and an umbilical catheter and tray should be
II. Neonatal Resuscitation Procedures
A. Immediate evaluation includes assessment of muscle tone, color, and respiratory effort
during the delivery.
B. After delivery, the infant should be placed on a preheated radiant warmer after the cord
is clamped. The infant should be quickly dried with warm towels. The infant should be
placed supine with its neck in a neutral position. A towel neck roll under the shoulders
may help prevent neck flexion and airway occlusion.
C. The upper airway is cleared by suctioning; the mouth first, and then the nose, using a
bulb syringe or a mechanical suction device, with an 8 or 10 Fr catheter. Suctioning
should be limited to 5 seconds at a time.
D. Determine whether breathing is effective and pulse is >100 beats/min. If so, positive
pressure ventilation (PPV) is not needed. If cyanosis is present, oxygen should be
E. Free flowing oxygen may be given at a rate of 5 L/min by holding the tubing ½ inch in
front of the infant’s nose. Alternatively, an oxygen mask and resuscitation bag may be
used. When the infant’s color is pink, the oxygen should be gradually discontinued while
observing the skin color for recurrence of cyanosis.
F. Positive pressure ventilation should be initiated if the infant is not breathing effectively
after the initial steps. Response to brief tactile stimulation should be assessed by gently
slapping the soles of the feet or rubbing the back. If the infant is apneic or gasping, begin
PPV with 100% O2, immediately. If the heart rate is <100 beats/min, give PPV
immediately by bag-mask.

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1. Bag-Mask ventilation. The infant should be in the supine position with head slightly
extended or neutral. The first ventilations should be given at a rate of 40-60/min.
Visible chest wall movement indicates adequate ventilation.
2. Endotracheal intubation is initiated if the infant is nonresponsive to bag-mask
PPV.When effective ventilation is in place, the first cycle of evaluation and care is

Endotracheal Tube Size and Depth of Insertion From Upper Lip

Weight Gestational Age Size Depth

<1000 g <28 weeks 2.5 mm 7 cm
1000-2000 g 28-34 weeks 3.0 mm 8 cm
2000-3000 g 34-38 weeks 3.5 mm 9 cm
3000 g or more 39->40 weeks 4.0 mm 10 cm

G. Evaluation of Heart Rate

1. If the heart rate is >100 beats/min, PPV can be discontinued after the infant is
breathing effectively. Support should be gradually withdrawn while observing for
adequacy of spontaneous breathing and heart rate.
2. Chest compressions should be started if the heart rate is <80 beats/min, after 15-
30 seconds of adequate ventilation. PPV should also be continued.
a. Compressions are applied to the lower sternum just below the nipple line, but
above the xiphoid process. The resuscitator’s thumbs are used to compress the
sternum while the fingers surround the chest, or the middle and index fingers
of one hand may be used to compress while the other hand supports the
infant’s back. The sternum is compressed ½ to 3/4 inch.
b. Chest compressions are alternated with ventilations at a ratio of 3:1. The
combined rate should be 120/min (ie, 80 compressions and 30 ventilations).
After 30 sec, evaluate the response. If the pulse is >80 beats/min, chest
compressions can be stopped and PPV continued until the heart rate is 100
beats/min and effective breathing is maintained.
3. Epinephrine should be given if the heart rate remains below 80/minute after 30
seconds of PPV and chest compressions.

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Neonatal Resuscitation Medications

Medication Concentration Preparation Dosage Rate/Precautio


Epinephrine 1:10,000 1 mL 0.1-0.3 mL/kg Give rapidly.

IV or ET May dilute 1:1
May repeat in with normal
3-5 min if HR saline if given
is <80/min via ET

Volume Whole blood 40 mL 10 mL/kg IV Give over 5-10

expanders Albumin 5% min by syringe
Normal saline or IV drip
Ringer lactate

Naloxone 0.4 mg/mL 1 mL 0.1 mg/kg Give rapidly

(0.25 mL/kg)

Naloxone 1.0 mg/mL 1 mL 1 mg/kg IV, ET preferred

(0.1 mL/kg) IV, IM, SQ
ET, IM, SQ acceptable

Sodium 0.5 mEq/mL 20 mL or two 2 mEq/kg IV Give slowly,

bicarbonate (4.2% solution) 10-mL prefilled over at least 2
Diluted with syringes min.
sterile water to
make 0.5

4. Other Medications
a. Volume Expanders. Hypovolemia may be caused by either occult blood loss
(eg, fetal-maternal transfusion) or by obvious hemorrhage. Volume expansion
is indicated for patients who have known or suspected blood loss and poor
response to other resuscitative measures. Albumin 5%, normal saline, or
Ringer lactate can be given in boluses of 10 mL/kg over 5 to 10 minutes. If

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acute blood loss sufficient to cause shock and neonatal depression, much
larger volumes will be necessary and O-negative blood may be justified.
b. Sodium bicarbonate is recommended for infants during prolonged
resuscitation for infants refractory to other measures.
c. Naloxone hydrochloride is given to infants with prolonged respiratory
depression following narcotic anesthesia given to the mother within 4 hrs
before delivery. Naloxone is contraindicated in infants of mothers who are
addicted to narcotics.
5. Umbilical vessel catheterization is recommended when vascular access is
required during resuscitation. The large, centrally located, thin-walled and flat vein
is used, and a 3.5 or 5.0 Fr radiopaque catheter is inserted into the vein until a free
flow of blood can be aspirated.
III. Special Cases
A. Meconium Staining
1. Meconium staining occurs in 12% of deliveries. A few of these infants develop
meconium aspiration syndrome (MAS), which consists of small airway obstruction,
air-trapping, and inflammatory pneumonitis. Complications include pneumothorax
and persistent pulmonary hypertension. MAS is seen most often in infants with
asphyxia and thick “pea soup” meconium staining at birth.
2. If meconium staining is detected, the infant’s mouth, nose, and posterior pharynx
should be suctioned thoroughly before the delivery of the shoulders and thorax.
Meconium should be removed before the first breath occurs.
3. When meconium is thick and particulate and/or the infant is apneic or depressed,
the infant should be quickly intubated and suctioned endotracheally. The ET tube is
withdrawn slowly while continuing suction. Reintubation and suctioning should
continue until no more meconium is produced.
B. Preterm Infant Resuscitation. Infants weighing <1500 g are more likely to need
resuscitation. PPV and early intubation are usually required. ET tube placement is
necessary for all infants <1250 g.
IV. Post-resuscitation Management
A. Vital signs should be monitored and infant’s feedings withheld. Ten percent glucose is
often given IV.
B. The circulation, perfusion, neurologic status, and urine output should be monitored.
Moderate fluid restriction is usually instituted. A physical exam and lab studies, such as
blood gases, glucose, and hematocrit, should be completed. §

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