Neonatal resuscitation

Definition

Neonatal resuscitation is defined as the set of interventions at

the time of birth to support the establishment of breathing
and circulation
Components (TABC)
• T- Temperature

Provide warmth
Dry the baby
Remove wet linen
Components (TABC)
• A : Airway

Position the infant

Clear the airway
Wipe baby’s mouth and nose
Suctioning
ET intubation if indicated
Components (TABC)
• Breathing

Tactile stimulation
PPV bag & mask/ bag & ET
Components (TABC)
• C – Circulation

Chest compression
Medications
© 2020 American Heart Association, Inc., and American Academy
of Pediatrics
 ADULT vs. NEONATAL RESUSCITATION

 The sequence of resuscitation in adults is C-A-

B
 But in newborns the sequence remains
A-B-C as the etiology of neonatal compromise
is nearly always a breathing difficulty
 AIRWAY(position and clear)
 BREATHING (stimulate to breathe)
 CIRCULATION (assess HR and oxygenation)
BEFORE
BIRTH
 Oxygen supply by placental
membranes
No role of lungs. Fluid filled
alveoli and constricted
arterioles due to low Po2 in
fetal blood.
 Low Po2 
constricted
arterioles
 increased
pulmonary vascular
resistance 
shunting of blood
from Pulmonary
Artery  Ductus
Arteriosus 
AFTER BIRTH
 Baby cries  takes first breath  air enters
alveoli
 alveolar fluid gets absorbed  increased Po2

relaxes pulmonary arterioles  decreased PVR
 Umbilical arteries constrict
+ clamp cord  closure of
Umbilical Arteries and
Umbilical Vein  increased
SVR
 Decreased PVR +
Increased SVR 
functional closure of
Ductus Arteriosus 
increased blood flow into
lungs  oxygenation 
supply to body through
WHAT CAN GO
WRONG
Compromise ?
of uterine or placental blood flow 
deceleration of FHR (1st clinical sign)
 Weak cry  inadequate ventilation to push the
alveolar fluid
 In utero hypoxia  Meconium passage may block
the airways
 Fetal blood loss (abruption)  Systemic Hypotension
 Fetal Hypoxia/ischemia  poor cardiac
contractility & fetal bradycardia  Systemic
Hypotension
 Asphyxi
a
• Occur prior to the birth or can occur
immediately following birth in a compromised
baby requiring resuscitation

• Perinatal asphyxia is a lack of blood flow or

gas exchange to or from the fetus during
antepartum intrapartum, or in the early post-
natal period.
 If oxygen deprivation continues,
When newborn first becomes deprived of
Secondary Apnea ensues. The heart
oxygen, an initial period of rapid breathing is
rate continues to fall, and the blood
followed by Primary Apnea which can be
pressure falls.
resolved by Tactile stimulation
Assisted ventilation must be
provided.
 RESPONSE OF THE BABY TO AN INTERRUPTION IN NORMAL TRANSITION
--secondary apnoea

•Poor muscle tone due to insufficient oxygen supply to brain, muscles and
other organs
• Depression of respiratory drive from insufficient oxygen supply to the
brain
• Bradycardia - Insufficient delivery of oxygen to heart, muscle or brain
stem
• Low Blood pressure -Poor myocardial contractility or blood loss
• Tachypnoea --- failure to absorb lung fluid
• Cyanosis --- insufficient oxygen in blood
1) Antenatal Counseling,
Equipment check
2) Routine care
3) Initial steps
4) PPV
5) Alternate
airway/Intubation
6) Chest Compression
7) Medication
 Antenatal
Counseling
 Meeting with parents before the birth of an
extremely
preterm baby is very important
– Parents
– Medical Providers

 Need both national and local outcome data and to

understand the limitations of each
– If necessary consult with specialists at your regional
referral
center to obtain up to date information
 Antenatal Counseling
 Best to consider multiple factors
Gestational Age
– Estimated Fetal Weight
– Gender
– Singleton or Multiple
– Has mother received antenatal steroids
• Team briefing & role assignment
 2. Adequate preparation
• Radiant warmer is turned on,& is heating
• Oxygen source is open with adequate flow
through the tubing
• Suction apparatus tested, functioning
properly
• Laryngoscope is functional with bright
light
• Resuscitation bag & mask demonstrates an
adequate seal & generation of pressure
 Oral
mucussucker

SuctionCatheter

Radiant
warmer
TRANSP
ORT
INCUBAT
OR
 Evaluation, algorithm based
• Rapid assessment of
neonate clinical status
• 1) Is the infant full term?
• 2) Is the infant breathing or
crying?
• 3) Does the infant has good
muscle tone.

• Yes: no resuscitation,
routine neonatal care
• No: needs
resuscitation
 Routine Care
• Early Skin to skin care- put baby on mother’s
abdomen
• Delayed cord clamping- 1-3 minutes at least for
30 second
• Gentle drying
• Suction if needed- routine suction and NG tube
insertion is not needed
• Early breast feeding initiation.
• Ongoing evaluation
 Will Likely Need Combination
of Strategies to Provide
Warmth
 For all newborns
• Environmental Temperature at least 25-
• 26°C
• Warm Blankets for Drying
• Hats
•For Newborns requiring resuscitation
• Radiant Warmer
• warm humidified gases
 For Preemies
– Polyethylene Occlusive wrapping
 Resuscitation: initial steps
• Provide warmth and
maintain normal
temperature
• Position airway-- “
sniffing position”
• Clearing secretion, if
necessary- 80- 100
mmHg
• Dry the baby
• Stimulation for
breathing
Suction mouth first,
then nose
“M” before “N”
To prevent aspiration
of mouth contents
 Initial
Steps
•Non-vigorous infants delivered through meconium stained
amniotic fluid (MSAF) do not routinely require intubation and
tracheal suction
• (A non-vigorous infant was defined as the presence of
poor respiratory effort, poor muscle tone, or heart rate <
100 beats per minute during the delivery room
provider's initial assessment.)

•MSAF remains a risk factor for abnormal transition, and teams

must ensure a member with advanced airway and resuscitation
skills is in attendance
http://www2.aap.org/nrp/docs/15535_NRP%20Guidelines%20Flyer_English_FIN
AL.pdf
• The new recommendation to no longer routinely suction
nonvigorous infants arose from an emphasis on
prevention of harm (ie, delays in providing bag-mask
ventilation and potential consequences of unnecessary
interventions) instead of the unknown benefit of the
intervention of routine tracheal intubation and
suctioning.
• PPV should be initiated if the infant is not breathing or the

heart rate is less than 100/min after the initial steps are

completed.
Stimulation
• The act of drying itself provides enough stimulation to initiate
breathing
• If poor resp effort additional tactile stimulation by

• Flicking the soles

• Rubbing the back gently
1) No Apnea, No Gasping, HR > 100 bpm, normal breathing - routine care
2) No Apnea, No Gasping, HR > 100 bpm, laboured breathing or cyanosis- O2
inhalation/CPAP
3) Apnea, Gasping, HR < 100 bpm- PPV, SPO2 monitoring, ECG monitoring
 SUPPLEMENTALOX
YGEN
• If HR is >100 but has labored breathing

Term infants start resuscitation with 21% O2,

Preterm less than 35 Weeks should be initiated with low oxygen (21%
to 30%) and the oxygen titrated to achieve preductal oxygen saturation
similar to that in healthy term infants.

• Initiating resuscitation of preterm newborns with high oxygen (65% or

greater) is not recommended.

• If HR is >100 but has labored breathing or Sp02 cannot be maintained

within target range despite 100% free-flow oxygen, consider a trial of
continuous positive airway pressure (CPAP).
 TARGETED PREDUCTAL SPO2
AFTERBIRTH
pulse oximeter

• 1 min 60%-65%
• 2 min 65%-70%
• 3min 70%-75%
• 4min 75%-80%
• 5min 80%-85%
• 10min 85%-95%
 PPV: Positive pressure ventilation
• Indications for PPV :
• Heart rate less than 100 bpm
• Having Ineffective respirations- Apnea & Gasping
• Persistent Cyanosis

• Initial PIP is suggested in the range of 20-25 cm H20.

• When PPV is administered to preterm infants, PEEP
should be used. Recommended starting PEEP is 5
cm H20.

• Rate of PPV is 40-60 / minute.

 Self Inflating T-Piece
bag Resuscitator

240- 500 ml

DEVICES
Flow Inflating Bag
USED
Appropriate
Sizes
Size 0 for preterm with outer
diameter 35-50 mm
Size 1 term baby outer diameter
50-65 mm

Mask should Rest on

Chin Cover Mouth &
Nose
 Suction &Position

Light Pressure on
mask to create a
Cup the chin
seal
in the mask
Apply pressure
and then
on posterior rim
cover the
of mandible
nose
40 to60 breaths per
minute

Initial Pressure at
20mmH2O
 PPV EFFECTIVE OR NOT

•.
Rising of HR
PPV
Improvement in Oxygen Saturation EFFECTIVE
Equal and adequate breath OR NOT?
sounds B/L Good Chest rise
Heart rate- Auscultation
If heart rate <100
Consider ECG monitoring
bpm
Oxygenation by oximeter
 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
If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,
 WHEN TO CONSIDER INTUBATION ?
Indications in resuscitation
 Baby is floppy, not crying, and preterm
 HR < 100/min, gasping/apnea inspite of effective PPV

 HR > 100/min
 Requires prolonged PPV > 5 minutes

 HR < 60/min
 Intubation recommended before chest compressions
 To administer drugs
Endotracheal tube
 Advanced
airway

• Depth of insertion using

table or by measuring nasal-
tragus length (NTL) + 1 cm
Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation.
Elk Grove Village, IL: American Academy of Pediatrics
Laryngoscope with
extra blades and
bulbs
Straight blades
Term – 1
Preterm – 0
Extremely
preterm - 00
Non- Dominant Hand
 CRICOID
PRESSUR
E

SUCTIONIN
G
 LMA(Laryngeal mask airway)
• If intubation is not successful or feasible,
laryngeal mask airway (LMA) should be used
• Soft mask, fits over laryngeal inlet when
inflated, occludes the oesophageal opening
LM
A
1. Pulse oximeter
2. ECG monitoring
 Chest
Compressions
• The indication:-
• Heart rate less than 60 bpm
in spite of 30 seconds of
effective PPV.
• 100% oxygen continues to
be recommended when
administering chest
compressions.
• The 2-thumb technique is recommended and once the airway has been
secured, the team member administering compressions should switch to the
head of the bed and the team member providing PPV should move to side.
• Compress 1/3rd diameter of chest.
• Do not lift the fingers off the chest.

• 90 compressions to 30 ventilations/minute
(3:1- One & two & three & breathe & One & two & three & breathe…)

• Chest compressions should be continued for 60 seconds before

reassessment of heart rate.
• Electronic cardiac monitor preferred for assessment of heart rate.
 MEDICATIO
NS

1.Epinephrine
• Indicated if HR remains <60 bpm
after at least 30 secs of effective PPV
and another 60 seconds of chest
compressions using 100% oxygen
 MEDICATIO
NS
1.Epinephrine
• One dose may be given through ETT.
• If no response, give intravenous dose via emergency UVC or
IO access.
• Give rapidly.
• Concentration - 1:10,000 (0.1mg/ml) .
• ETT dose - 1 ml/kg i.e 0.1 mg/kg
• UVC / IV/ IO dose 0.2 ml/kg ,follow with a 3 ml flush NS .
• Can repeat every 3-5 minutes.
• Max 3 doses can be given.
Epinephrine dose
Available : 1:1000 ie, 1ml = 1mg
Make it 1:10,000 by adding 9ml NS
Then 1ml = 0.1mg

IV dose = .1ml/kg (.01mg/kg)

ET dose= 1ml/kg (0.1mg/kg)
2.OTHE
RS
• For treatment of hypovolemic shock, normal saline and blood
are the solutions of choice and the recommended volume is
10 ml/kg.
• Ringer’s lactate is no longer recommended.
• The routine use of NaHCO3 to correct metabolic acidosis is not
recommended.
• The use of naloxone to manage respiratory depression in
infants born to mothers with narcotic exposure in labour is
not recommended.
 Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and
E/O Acute perinatal HIE
 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)
 NNR : not indicated
• Conditions with certainly early death
• Extreme prematurity(GA<23 weeks)
• Birth weight<400g
• Anencephaly
• Chromosomal abnormality: Trisomy 13