NEONATAL RESUSCITATION

DEPARTMENT OF PAEDIATRICS
FEDERAL TEACHING HOSPITAL, IDO-EKITI
DR E. O. ADEYEMI
 OUTLINE
• INTRODUCTION

• PHYSIOLOGIC CHANGES AT BIRTH

• RESUSCITATION FLOW DIAGRAM

• ENDOTRACHEAL INTUBATION

• MEDICATION USED FOR RESUSCITATION

 INTRODUCTION
• Most newly born babies are vigorous
• Only about 10% of newborns require some
assistance
• Only 1% need major resuscitative measures
(intubation, chest compressions, and/or
medications) to survive
• The steps in resuscitation follows the ABCs o f
resuscitation.
 PHYSIOLOGIC CHANGES AT BIRTH
• Fetal physiology-
 Alveoli filled with lung fluid
 In utero, fetus dependent on placenta for gas
exchange
 Pulmonary arterioles constricted
 Pulmonary blood flow diminished
 Blood flow diverted across ductus arteriosus
PHYSIOLOGIC CHANGES AT BIRTH cont.

• Lungs and Circulation

After Delivery
 Fluid in alveoli absorbed; air enters lungs
 Blood vessels in lung relax
 Pulmonary blood flow increases
 Umbilical arteries and vein constrict thus
increasing blood pressure
 What Can Go Wrong During Transition
• Lack of ventilation of the newborn’s lungs results in
sustained constriction of the pulmonary arterioles,
preventing systemic arterial blood from being
oxygenated
• Prolonged lack of adequate perfusion and
oxygenation to the baby’s organs can lead to brain
damage, damage to other organs, or death


p. 1-6
Signs of a Compromised Newborn
• Poor muscle tone Good tone
with
• Depressed respiratory cyanosis
drive
• Bradycardia
• Low blood pressure
• Tachypnea
Bad tone
• Cyanosis with
cyanosis

p. 1-7
 In Utero or Perinatal Compromise
Primary Apnea
• When a fetus/newborn first becomes deprived of
oxygen, an initial period of attempted rapid
breathing is followed by primary apnea and
dropping heart rate that will improve with tactile
stimulation

p. 1-8
 Secondary Apnea
• If oxygen deprivation
continues, secondary apnea
ensues, accompanied by a
continued fall in heart rate
and blood pressure QuickTime™ and a
Sorenson Video 3 decompressor

• Secondary apnea cannot be

are needed to see this picture.

reversed with stimulation;

assisted ventilation must be
provided

Click on the image to play video


p. 1-8
Three Levels of Post-resuscitation Care

p. 1-18
 RESUSCITATION FLOW DIAGRAM
• All newborns require
initial assessment to
determine whether
resuscitation is
required
 RESUSCITATION FLOW DIAGRAM cont.
• Provide warmth
• Position head and clear
airway as necessary*
• Dry and stimulate the baby
to breathe

*Consider intubation of the

trachea at this point (for
depressed newborn with
meconium-stained fluid
Potentially Hazardous Forms of Stimulation

• Slapping back or buttocks

• Squeezing rib cage
• Forcing thighs onto abdomen
• Dilating anal sphincter
• Hot or cold compresses or baths
• Shaking

p. 2-12
2-13
 RESUSCITATION FLOW DIAGRAM cont.

After these initial steps, further actions are

based on evaluation of
• Respirations
• Heart rate
• Color
You have approximately 30 seconds to achieve a
response from one step before deciding to go on
to the next
 RESUSCITATION FLOW DIAGRAM cont.
Initial steps: meconium present
• Newborn is not vigorous: Suction the baby’s trachea
before proceeding with any other steps

• Newborn is vigorous: Suction the mouth and nose

only.

• In suctioning, positioning on back or side, slightly

extending neck to a “Sniffing” position which aligns
posterior pharynx, larynx, and trachea.
Opening the Airway
 RESUSCITATION FLOW DIAGRAM cont.
If Apneic or HR < 100
bpm:
• Provide positive-
pressure ventilation
• If breathing, and heart
rate is >100 bpm but
baby is cyanotic, give
supplemental oxygen. If
cyanosis persists,
provide positive-
pressure ventilation
 RESUSCITATION FLOW DIAGRAM cont.

If heart rate <60 bpm despite adequate

ventilation for 30 seconds:
• Provide chest compressions as you continue
assisted ventilation
• Then evaluate again. If heart rate <60 bpm,
proceed to Block D
 RESUSCITATION FLOW DIAGRAM cont.
Chest Compressions:
• Temporarily increase circulation
• Must be accompanied by ventilation
• Should use 100% oxygen
• 1. Thumb Technique (Preferred)
– Less tiring
– Better control of compression depth
• 2.Finger Technique
– Better for small hands
– Provides access to umbilicus for medications
 RESUSCITATION FLOW DIAGRAM cont.

• One cycle of 3 compressions and 1 breath

takes 2 seconds
• The breathing rate is 30 breaths per minute
and the compression rate is 90 compressions
per minute. This equals 120 “events” per
minute
 RESUSCITATION FLOW DIAGRAM cont.

If heart rate <60 bpm despite adequate

ventilation and chest compressions:
• Administer epinephrine as you continue
assisted ventilation and chest compressions
 Important Points in the Neonatal
Resuscitation Flow Diagram
• Heart rate <60 bpm → Additional steps
needed
• Heart rate >60 bpm → Chest compressions
can be stopped
• Heart rate >100 bpm and breathing →
Positive-pressure ventilation can be stopped
• Time line: if no improvement after 30 seconds,
proceed to next step
 Preparation for Resuscitation:
Personnel and Equipment
• Every delivery should be attended by at least 1
person whose only responsibility is the baby and who
is capable of initiating resuscitation. Either that
person or someone else who is immediately available
should have the skills required to perform a complete
resuscitation.

• When resuscitation is anticipated, additional

personnel should be present in the delivery room
before the delivery occurs

• Prepare necessary equipment

– Turn on radiant warmer
– Check resuscitation equipment
Preparation for Resuscitation: Risk Factors

Antepartum factors: Intrapartum factors:

• Ruptured membranes • Excessive bleeding
• Breech presentation
over 18 hours • Meconium
• Pre-eclampsia & • Abnormal fetal heart
Eclampsia tones
• Maternal infection – • Prolapsed or nuchal
Malaria, HIV, etc. cord
• Rapid, hard labor
• Premature labor • Foul smelling fluid
• Multiple births • Prolonged labor
• Others • Shoulder dystocia
 Why Are Premature Newborns at Higher
Risk?
• Possible surfactant deficiency
• Decreased drive to breathe
• Rapid heat loss, poor temperature control
• Possible infection
• Susceptible to brain hemorrhage
• Susceptible to hypovolemia secondary to blood loss
• Weak muscles make spontaneous breathing difficult
• Immature tissues may be damaged by excessive
oxygen
Types of Positive-Pressure Devices

• Self-inflating bag
• Flow-inflating bag
• T-piece resuscitator

This course will be discussing

only the self-inflating bag.

p. 3-5
 General Characteristics of Resuscitation
Devices
• Appropriate-sized mask (cushioned,
anatomically shaped mask preferred)
• Variable oxygen capability up to 90% to 100%
• Size of bag (200-750 mL)
• Safety features to prevent high pressure
delivery

p. 3-10, 3-11
 Self-inflating Bag
Advantages:
• Always refills after being squeezed
• Inflates without a compressed gas source
• Pressure release (pop-off) valve makes over-
inflation less likely


p. 3-7
 Self-inflating Bag
Disadvantages:
• Bag will work without a gas source; ensure that
oxygen is connected
• Requires tight face-mask seal to inflate the lungs
• Requires oxygen reservoir to provide high
concentration of oxygen
• Cannot give free-flow oxygen through the mask
• Cannot be used for CPAP. No PEEP without special
valve

 p. 3-7
 Self-inflating Bag: Control of Oxygen
An oxygen reservoir must be
attached to deliver high
concentrations of oxygen using a
self-inflating bag

Without reservoir and oxygen

attached, the bag delivers only
about 40% oxygen, which may be
insufficient for neonatal
resuscitation
Click on the image to play video


p. 3-45
 Oxygen Concentration During Positive-
Pressure Ventilation
• The Neonatal Resuscitation Program (NRP) recommends use
of 100% oxygen when positive-pressure ventilation is required
during neonatal resuscitation. However, research suggests
that resuscitation with something less than 100% may be just
as successful.
• If resuscitation is started with less than 100% oxygen,
supplemental oxygen up to 100% should be administered if
there is no appreciable improvement within 90 seconds
following birth.
• If oxygen is unavailable, use room air to deliver positive-
pressure ventilation.

 p. 3-14
 Bag and Mask: Equipment
Face Mask Characteristics
• Rims
– Cushioned
– Non-cushioned
• Shape
– Round
– Anatomically shaped
• Size
– Small
– Large

p. 3-16
 Bag and Mask: Equipment
Mask should cover
• Tip of Chin
• Mouth
• Nose

p. 3-16
Insertion of Orogastric Tube: Technique

• Insert tube through mouth, rather than nose

(resume ventilation)
• Attach 20-mL syringe and aspirate gently
• Remove syringe and leave tube end open to
air
• Tape tube to newborn’s cheek

p. 3-28
 Insertion of Orogastric Tube
Measuring correct length

p. 3-27
 ENDOTRACHEAL INTUBATION
INDICATION:
• To suction trachea in presence of meconium when
the newborn is not vigorous
• To improve efficacy of ventilation after several
minutes of bag-and-mask ventilation or ineffective
bag-and-mask ventilation
• To facilitate coordination of chest compressions
and ventilation
• To administer epinephrine while IV access is being
established
Endotracheal Intubation: Special Indications

• Extreme Prematurity
• Surfactant Administration
• Suspected Diaphragmatic Hernia

A person experienced in endotracheal

intubation should be immediately available to
assist at every delivery. 

5-37
ENDOTRACHEAL INTUBATION cont.
• Select tube size based on weight and gestational age
• Consider shortening tube to 13 to 15 cm
• Stylet optional.

Tube Size (mm) Weight Gestational Age

(inside diameter) (g) (wks)
2.5 Below 1,000 Below 28
3.0 1,000-2,000 28-34
3.5 2,000-3,000 34-38
3.5-4.0 Above 3,000 Above 38
 Endotracheal Intubation:
Tube Location in Trachea
Tip-to-lip measurement
Weight (kg) Depth of insertion
(cm from upper lip)
1* 7

2 8

3 9

4 10

 p. 5-20
5-39
ENDOTRACHEAL INTUBATION cont.
ENDOTRACHEAL INTUBATION cont.
STEP 1:
• Stabilize the newborn’s
head in the “sniffing”
position
• Deliver free-flow oxygen
during the procedure
ENDOTRACHEAL INTUBATION cont.
STEP 2:
• Slide the laryngoscope over right side of the
tongue
• Push tongue to left side of mouth
• Advance blade until the tip lies just beyond
the base of the tongue
ENDOTRACHEAL INTUBATION cont.
STEP 3
• Lift the blade slightly
• Raise the entire blade, not just the tip
• Visualize pharyngeal area
• Do not use rocking motion
ENDOTRACHEAL INTUBATION cont.
STEP 4:
• Look for landmarks. Vocal
cords should appear as
vertical stripes on each
side of the glottis or as an
inverted letter “V”
• Applying downward
pressure on cricoid may
help bring glottis into view
• Suction, if necessary, for
visualization
ENDOTRACHEAL INTUBATION cont.
• STEP 5:
• Insert the tube into the right
side of the mouth with the
curve of the tube lying in the
horizontal plane
• If the cords are closed, wait
for them to open
• Insert the tip of the
endotracheal tube until the
vocal cord guide is at the
level of the cords
• Limit attempts to 20 seconds
ENDOTRACHEAL INTUBATION cont.
• STEP 6:
• Hold the tube firmly
against the baby’s
palate while removing
the laryngoscope
• Hold the tube in place
while removing the
stylet if one was used
ENDOTRACHEAL INTUBATION cont.
• Suctioning Meconium via
Endotracheal Tube
 Connect endotracheal tube to
meconium aspirator and suction
source
 Occlude suction port to apply
suction
 Gradually withdraw
endotracheal tube
 Repeat intubation and suction
as necessary until newborn’s
heart rate indicates that
positive-pressure ventilation is
needed
ENDOTRACHEAL INTUBATION cont.
Signs of correct tube position
• Improved vital signs (heart rate, color, and
activity)
• Breath sounds over both lung fields but
decreased or absent over stomach
• No gastric distention with ventilation
• Vapor in the tube during exhalation
• Chest movement with each breath
MEDICATION USED FOR RESUSCITATION
• Epinephrine, a cardiac stimulant, is indicated
when the heart rate remains below 60 beats
per minute despite

• 30 seconds of assisted ventilation followed by

• 30 seconds of coordinated compressions and
ventilation
_____________
Total = 60 seconds 
Medication Administration via Umbilical Vein

• Dilute 1:1000
concentration to
1:10,000
 Poor Response to Resuscitation:
Hypovolemia
Indications for volume expansion
• Baby is not responding to resuscitation AND
• Baby appears in shock (pale color, weak
pulses, persistently low heart rate, no
improvement in circulatory status despite
resuscitation efforts)
• There may be a history of a condition
associated with fetal blood loss (eg, extensive
vaginal bleeding, abruptio placentae, placenta
previa, twin-to-twin transfusion, etc)
 Blood Volume Expansion: Dose and
Administration
Recommended solution = Normal saline

Acceptable solution = Ringer’s lactate, or O Rh-negative blood

Recommended dose = 10 mL/kg

Recommended route = Umbilical vein

Recommended preparation = Correct volume drawn into large

syringe

Recommended rate = Over 5 to 10 minutes

 CONCLUSION
Although the majority of babies undergo a
smooth physiologic transition and breathe
effectively after delivery, the goals of neonatal
resuscitation are to prevent the morbidity and
mortality associated with hypoxic-ischemic
tissue injury and to reestablish adequate
spontaneous respiration and cardiac output.
 REFERENCES
• Neonatal Resuscitation Program Slide by
American Heart Association
• Nelson peadiatrics textbook 20th edition
THANK YOU