ITISMITA Biswal

MSC, NURSING 2NDYEAR

MEANING-
Neonatal Resuscitation means to revive or
restore life of a baby from the state of
asphyxia.
DEFINITION
Series of actions, used to assist newborn
babies who have difficulty with making the
physiological ‘transition’ from the
intrauterine to extrauterine life
 Others 7%
Diarrhoea 3%
Tetanus 7%
Preterm
27%
Congenital 7%

Asphyxia Sepsis &

23% pneumonia
26%

4 million neonatal deaths: When? Where? Why?

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.
 Preterm delivery
 Delivery other than normal
 Mal presentations
 Multiple pregnancy
 Fetal distress
 Meconium staining
 Severe IUGR
 Antepartum haemorrhage
 Antenatal diagnosis of fetal abnormalities
Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required Always needed
Dry, stimulate to breathe

Give supplemental oxygen, as required

Assist ventilation with positive Needed less

pressure frequently

Intubate the trachea

Provide chest
compressions
Rarely needed

Medications
 Anticipate
 Be Prepared
 Know what to do
 In what order
 Be able to work quickly in coordination
RESUSCITATION PLACE
 FLAT SURFACE
 Warm and clean
 Room temperature 26 degree celsius
 Radiant warmer/heater/a 200 watt bulb
 Keep heat source on before delivery
 2 pre warmed towels to receive the baby
 General: Resuscitation bed, over head
warmer (servo-controlled infrared heater),
towel, stethoscope, pulse oximeter
 Airway Management: Suction device with
Suction catheter ; Bulb syringe, laryngoscope
with blades (size 00 and 0); ETT (size 2.5, 3.0,
3.5); EtCO2 detector; LMA (size 1)
 Oral mucus sucker

SuctionCatheter

Radiant warmer
 Breathing support: Facemask; PPV device,
O2 gas, feeding tube

 Circulation support: UVC kit, iv kit,

 Drug and fluids:

Adrenaline(1;10000/0.1mg/ml), NS, Blood
..
TRANSPORT
INCUBATOR
Delivery room resuscitation protocol following American Heart
Association and American Academy of Pediatrics and National
Neonatology Forum (NNF), India
PRINCIPLE OF NEONATAL
RESUSCITATION

TEMPERATURE
AIRWAY

BREATHING

CIRCULATION
Steps in Resuscitation - ABCD

Airway
• Clear airway if required
• Removal of secretions if present
• Suction mouth and nose

“M” before “N”

Positioning
• Supine or lateral
• Head in neutral or slightly extended position
 +········ ······-;
. ..,

, ·········· ..• Correct

········
.----

Incorrect Incorrect
(h y p e r e x t e n s i o n (flexion)
)
Acceptable methods of stimulation
If Apneic or HR < 100 bpm:
 Provide positive-pressure
ventilation,spo2 monitoring.
 If breathing, and heart rate is
>100 bpm but baby is cyanotic,
give supplemental oxygen,
spo2 monitoring. If cyanosis
persists, provide positive-
pressure ventilation
 If respiratory distress is
persistent , consider CPAP and
connect oximeter
 Free flow oxygen  Start with room air and
Oxygen mask increase to maintain
Flow inflating bag target SpO2
T- piece resuscitator
Time Target Spo2
Oxygen tubing held
1min 60-65%
close to baby’s nose
2min 65-70%
 CPAP provided with
3min 70-75%
Flow inflating bag
4min 75-80%
T-piece resuscitator
5min 80-85%
10min 85-95%
DEVICES USED
Self Inflating bag T-Piece Resuscitator

Flow Inflating Bag

 Ventilation of the lungs is the single most
effective step in newborn resuscitation.
Indications:
 Gasping/apnea
 HR < 100/min
 SpO2 remains below target values despite free
flow supplemental oxygen increased
to 100%.
Appropriate
Sizes
Mask should
Rest on Chin
Cover Mouth
& Nose
 Suction & Position

Light Pressure on
mask to create a
Cup the chin in seal
the mask and Anterior pressure
then cover the on posterior rim
nose of mandible
40 to 60 breaths per minute

Start With 21% ( higher in preterm's) oxygen and

increase according to target Saturation
Initial Pressure at 20mmH2O
 Corrective steps Action

M Mask Adjustment Ensure Good seal of mask

on face
R Reposition airway Sniffing Position

S Suction Mouth and nose If secretions present

O Open mouth Ventilate with baby mouth

slightly open and lift the
jaw forward
P Pressure increase Gradually increase the
pressure every few breaths

A Airway alternative Consider ET or Laryngeal

mask airway
 Indications :
 HR <60/min
despite at least
30 sec of
effective PPV

consider Endotracheal intubation at this point

as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions
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.
For small chests with
thumbs overlapped
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)
When to stop chest compressions?
 Reassess after 45-60 sec, if HR > 60/min stop
chest compressions and increase breaths to
40-60 per minute.
If HR is not improving…
 Insert an umbilical catheter and give IV
epinephrine
WHEN TO CONSIDER
INTUBATION?
Indications in resuscitation
Baby is floppy, not crying, and preterm
HR < 100/min, gasping/apnea
HR < 100/min inspite of PPV
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
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

 Wt Depth of
insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm

Add 6 to baby’s wt.

 Watching the tube passing between cords
Watching for chest movements
Listening for breath sounds ( Axilla and stomach)
Colourimeter/Capnography ( Can also be used for PPV
with mask or LMA
Improvement in HR and Spo2
Vapour Condensing inside tube
Additional resources , additional personnel,
additional thermoregulation strategy
▪ Portable warming pad
▪ Polyethylene Plastic wrap (< 29wk)
▪ Prewarmed transport incubator
Use of Oxymeter, blender to targetSpo2
85%- 95%

Consider giving CPAP

 Consider Surfactant
Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks.

Monitor for Apnea, bradycardia, BP,SPo2

&Urine output.
Monitor B. Sugars, electrolytes , Hematocrit ,
Platelets,ABG
Maintain adequate oxygenation & support
ventilation as needed
Delay feeds, Start IV fluids, consider
parenteral nutrition
Consider inotropes , fluid bolus
Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)
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.

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