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The Newborn Baby: Definitions and Contacts CPG N0101

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Newborn definition
• 'Newborn' refers to the first min to hours post birth. For the purpose of resuscitation, AV accepts up to

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the first 24 hours from birth in the newborn definition. This is due to the adaptations of the respiratory and
cardiovascular systems in this time.

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Preterm infant (24 - 37 completed weeks gestation)
• Gestational age has an effect on the development of lung and pulmonary circulation and therefore
influences how well these newborns establish effective respiration.

E
• The primary focus in prehospital Mx is establishing and maintaining effective ventilation and preventing
hypothermia.

C
• Newborns > 32 and < 37 weeks gestation require Tx to a Level 2 Hospital (paediatrician and midwife staff on
site 24/7).

N
• Newborns < 32 weeks gestation or any infants who are intubated require Tx to a tertiary centre: Mercy Hospital
for Women (MHW), Monash Medical Centre (MMC), Royal Women's Hospital (RWH) or Royal Children's
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Hospital (RCH). Consult with PIPER for an appropriate receiving hospital.
• In rural Victoria, proceed to the nearest base hospital (or hospital with maternity services) and contact PIPER via
the Clinician.
U

Transport
• Where available, MICA assistance should be sought early when preterm birth is considered a possibility.
B

• Expeditious Tx to the nearest most appropriate hospital should occur without delay.
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Emergency contacts
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Paediatric Infant Perinatal Emergency Retrieval (PIPER)

(formerly known as NETS, PETS and PERS)
for all advice and assistance in newborn care and Mx
contact via Clinician or 1300 137 650
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The Newborn Baby: Definitions and Contacts CPG N0101 271

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The Newborn Baby: Normal Values CPG N0101

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Weight:
• Average full term weight = 3.5 kg

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Normal blood volume:
• 80 mL/kg

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Heart rate:
• 120 – 160 bpm

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• HR is the most important indicator for resuscitation.
Respiration:

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• 40 – 60 breaths per min
Skin:

N
• Colour - may be dusky and peripherally cynanosed in the first few minutes after birth. Blue-ish / purple hand
and feet are normal in the first 24 hr after birth and are not an indication for supplemental O2.
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• It may take 7 – 10 min post birth for SpO2 to reach > 90% and for colour to become centrally and peripherally
pink.
Conscious state:
U

• Active motion, grimace and/or crying.

Temperature:
B

• Aim for normothermia (36.5 – 37.5ºC per axilla).

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• Newborns lose heat via the large surface area of the head and by evaporation from their wet bodies once
outside the uterus.
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BGL:
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• 2.6 – 3.2 mmol/L

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The Newborn Baby: General Care CPG N0101

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Body temp:
• Maintain normothermia (per axilla temperature of 36.5 – 37.5ºC). Place the newborn naked, skin to skin

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with the mother to maintain warmth and cover them both with warm blankets if the newborn is vigorous and
not requiring ongoing resuscitation.

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• If resuscitation is required, place the newborn on a warm, flat surface, cover with bubble wrap and warm
wraps. Place a woollen hat or the corner of a warm blanket on the newborn’s head to maintain warmth.
• Following birth, preterm infants < 28 weeks gestation should be placed immediately (without drying body)
into a polyethylene (Glad™ zip lock) bag with the head (dried) outside. If AV arrive after the birth, dry the

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infant, cover the head with a hat or the corner of a warm blanket and cover the body with bubble wrap and
warm blankets.

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Cutting the cord:

N
• Cutting the cord in the vigorous newborn is not urgent. Apply general care and cut the cord when it stops
pulsating.
LA
• The cord must be cut in the non vigorous newborn earlier to allow effective resuscitation. This would usually
be after initial basic tactile efforts and commencement of IPPV.
U
B
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The Newborn Baby: General Care CPG N0101 273

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The Newborn Baby: Airway CPG N0101

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Position:
• Place head and neck in a neutral position avoiding neck flexion and head extension.

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Suctioning:
• The vigorous newborn does not require suctioning unless born through meconium stained amniotic fluid. They

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usually clear their own airway very effectively.
• Newborns who are not vigorous at birth (not breathing and poor muscle tone) only require airway suctioning if
born through meconium stained amniotic fluid or if the infant has obvious blood in the oropharynx.

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• The mouth should be suctioned followed by the nose. The newborn is a nasal breather and may gasp
pharyngeal fluid if the nose is cleared first.

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• Intubation and suction of the trachea (if a person with the expertise to intubate is present) should follow where
necessary in Mx of the non vigorous newborn.

N
• Pharyngeal suctioning can cause laryngospasm and bradycardia through vagal stimulation, thus suctioning
must be gentle and brief (5 – 6 sec) to avoid compromising the newborn further.
LA
• A 10 or 12 FG catheter is the recommended size for suctioning the oropharynx of a newborn.
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Newborn Resuscitation: Advanced Airway CPG N0201

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OPA:
• size 00, 0

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• May be useful if there is an airway abnormality or the infant's tongue is large and impeding effective BVM ventilation.
• Not recommended for routine use in newborns with a normal airway as it can cause obstruction and

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vagal reactions.
Laryngoscope blade:
• Straight Miller blade. Size 1 for term. Size 00 preterm

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LMA:

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• Portex size 1 for newborn > 2000 g or 34 weeks gestation
• Indicated for failed BVM and failed intubation.

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EtCO2:
• An EtCO2 detector (Pedi- Cap™) is recommended to verify successful tracheal intubation in
LA
the newborn.
• Paediatric EtCO2 is to be continuously monitored via the paediatric MRx attachment where available.

ETT size mm Lip length ETT suction NG

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(wt in kg + 6 cm) catheter tube

<1 kg or < 28 weeks

B

2.5 6 – 7 cm 6 FG 6 FG
‘extremely preterm’
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1 – 3 kg or 28 – 36 weeks
3 8 – 9 cm 6 FG 8 FG
‘moderately preterm’
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> 3 kg or > 36 weeks

3.5 9 – 1 0 cm 6 FG 8 FG
‘term or near term’
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Newborn Resuscitation: Ventilation CPG N0201

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Ventilation:
• The majority of newborns needing resuscitation at birth are apnoeic and bradycardic but rarely asystolic.

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Hypoxia eventually depresses respiratory drive and causes bradycardia. Effective ventilation is the key to
newborn resuscitation. Pulmonary pressure changes are integral in effecting necessary fetal circulation

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changes.
• Prompt improvement in HR > 100 bpm (assessed using a stethoscope over the apex of the heart)
is the primary indicator of adequate ventilation.
• Increased pressure may be required for initial breaths.

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Ventilation rate:

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• 40 - 60 inflations per min.
Tidal volume:
• 5 -10 mL/kg initially with room air.

N
• If HR remains < 100 bpm after at least 30 sec of effective BVM ventilation on room air, supply high
LA
concentration O2.
PEEP:
• Where available use a 5 cm H2O PEEP valve attached to BVM during IPPV.
U

• PEEP is important in improving lung vol and establishing and maintaining FRC particularly in preterm
newborns.
B
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Newborn Resuscitation: Ventilation CPG N0201 277

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Newborn Resuscitation: Circulation CPG N0201

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Chest compressions:
• Chest compressions are rarely required unless the HR is below 60 bpm despite effective ventilation for at least

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30 sec.
• The first min of resuscitation should not compromise airway techniques and ventilation where the HR < 100

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bpm.
• If after 30 sec of effective BVM ventilation the HR remains < 60 bpm, compressions should be commenced.
CPR:

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• 3:1 compression:ventilation ratio.
• Achieve 90 compressions and 30 ventilations per min with 0.5 sec pause in ventilation (120 events per min or

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two per sec). There is no pause post intubation.
HR:

N
• Reassess every 30 sec until HR > 60 bpm where compressions may be ceased.
• Continue IPPV / APPV until HR >100 bpm and the newborn is breathing effectively.
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Cardiac monitor:
• Attaching electrodes for routine cardiac monitoring of preterm newborns may result in damage to the fragile
dermis of the skin. ECG electrode attachment should be reserved for emergency resuscitation circumstances.
U

• Pulseless VT and/or VF are unlikely to be observed in the resuscitation of a newborn. Should these rhythms be
observed defibrilate as for other age children using 4 J/kg at 2 min intervals as required.
B

Pulse oximeter:
• Where available, attach newborn O2 saturation probe to right hand (pre-ductal) to allow continuous evaluation of
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heart rate and SpO2. This negates need to stop chest compressions to evaluate the HR.
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Newborn Resuscitation: Circulation CPG N0201

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Compression method:

Hand encircling 2 thumb method Alternative 2 finger method

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E
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N
• The 2 thumb method is preferred in the 2 rescuer setting.
• The 2 finger alternative preferred in single rescuer situations to minimise transition time.
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Compression Depth:
• 1/3 depth of chest diameter.
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Newborn Resuscitation: Circulation CPG N0201 279

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Newborn Resuscitation CPG N0201

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? Status 8 Assess
• Birthed • Is the newborn crying or breathing?
• Is the newborn moving?

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? Breathing present – moving or crying ? Not breathing – not moving or crying

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• Vigorous newborn • Non-vigorous newborn
 Action  Action

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• Routine care • Clear airway only if needed (see airway)
• Dry (especially the head) • Stimulate by drying (then maintain warmth)
• Keep warm (skin to skin with mother)
• Clear airway only if needed (see airway)
N • Place head and neck into a neutral position
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• Assess HR, breathing, colour
• Assess APGAR at 1 min and 5 min post birth
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8 Assess
B

By 30 sec • Is the newborn breathing?

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• Is the HR > 100 bpm?

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? HR > 100 bpm and breathing adequately ? HR < 100 bpm and/or inadequate breathing
 Action  Action

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• Routine care • IPPV with room air @ 40 – 60 min until HR > 100 bpm
• Continue to observe HR, breathing, colour, tone, activity and breathing adequately

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• If centrally cyanotic after 7 – 10 min post birth • Reassess after 30 sec IPPV
- Commence O2 @ 2 L/min via nasal cannula until pink

8 Assess
By 60 sec

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• Evaluate HR and breathing

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? HR > 100 bpm and breathing adequately ? HR 60 - 100 bpm and inadequate breathing ? HR < 60 bpm and inadequate breathing

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 Action  Action  Action
• Cease IPPV  ontinue IPPV @ 40 – 60 min until HR >
• C • Commence CPR @ 3:1 ratio aiming for 90

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100 bpm and breathing adequately. Add compressions and 30 ventilations per min
• Observe HR, breathing, colour, tone and
supplemental high concentration O2 • IPPV with high-flow supplemental O2
activity closely

N
• Continue to reassess after 30 sec IPPV • Continue to reassess after 30 sec CPR
LA
8 Assess
By 90 sec
• Evaluate HR and breathing
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B

? HR > 100 bpm and breathing adequately ? HR 60 - 100 bpm and inadequate breathing ? HR < 60 bpm
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 Action  Action  Action

• Cease IPPV and ECC  ontinue IPPV @ 40 – 60 min until HR > 100
• C • Continue CPR with supplemental O2
© Ambulance Victoria 2013

bpm and breathing adequately. Continue high • Mx as CPG N0202 Newborn Advanced
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• Observe HR, breathing, colour, tone and

concentration O2 Resuscitation
activity closely
• Continue to reassess after 30 sec IPPV • Continue to reassess @ 30 sec intervals
• Cease high flow oxygen if centrally pink
and/or SpO2 > 90%
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Newborn Resuscitation CPG N0201 281

? Status Stop 8 Assess 8 Consider  Action  MICA Action
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Newborn Advanced Resuscitation CPG N0202

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? Asystole or severe bradycardia persists
 Action
• Continue CPR if pulseless or HR < 60 bpm
• Reassess every 30 sec

C
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? Asystole or severe bradycardia persists
 Action
• IV / IO Adrenaline 10 mcg/kg repeated @ 3/60 intervals

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? Asystole or severe bradycardia persists

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 Action
• Intubate

N
• If unable to obtain above vascular access
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- Adrenaline 100 mcg/kg ETT

? Asystole or severe bradycardia persists

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 Action
• Normal Saline 10 – 20 mL/kg IV or IO
B

- Repeat if necessary
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? If pulse returns
© Ambulance Victoria 2013

 Action
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• At early opportunity, assess BGL

• If BGL < 2.6 mmol/L, consult with PIPER for administration of
10% Dextrose or Glucagon
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Newborn Advanced Resuscitation CPG N0202

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Adrenaline 1:10,000:
• 10 mcg/kg IV or IO (100 mcg/kg via ETT).

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• Do not use 1:1,000 unless diluted to 10 mL.
Normal Saline:

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• 10 - 20 mL/kg IV or IO. Repeat if necessary.
If BGL < 2.6 mmol/L:
• Consult with PIPER for drug and dose administration advice for Mx using Dextrose 10% or Glucagon.

E
Sodium Bicarbonate:
• Not indicated / should not be administered.

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Atropine:
• Not indicated / should not be administered.
Naloxone:
N
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• Not indicated / should not be administered even in the setting of suspected opioid overdose.
It can lead to acute withdrawal and seizures in the newborn.
Sedation:
• Not usually required to maintain ETT. Consult PIPER for further advice if necessary.
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B
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Newborn Resuscitation CPG N0201 283

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Newborn Baby: APGAR scoring system CPG N0301

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APGAR scores should not be used as a guide for resuscitation. The time intervals used for resuscitation
are contained elsewhere within this CPG.

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The APGAR score should be conducted 1 min after delivery and repeated 5/60 until APGAR score > 7.

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A score of:

7 – 10 Satisfactory

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4 – 6 Moderate depression and may need ongoing respiratory support (IPPV)
0 – 3 Newborn requiring ongoing resuscitation (including ETT and drug therapy)

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0 points 1 point 2 points

Appearance Blue, pale

N Body pink, extremities blue Totally pink

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Pulse Absent < 100 > 100

Grimace None Grimaces Cries

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Activity Limp Flexion of extremities Active motion

Respiratory effort Absent Slow and weak Good strong cry

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