Management session on

neonatal resuscitation
Presented by : Dr Abdifatah H (MI)
Dr Anfal A (MI)

Moderators : Dr Mekdes Pediatrician

Dr Ready GP
• Case presentation
• Contents
• Introduction
• Risk factors of NP
• Steps of newborn care
• Positive pressure ventilation
• Chest compressions
• Medications
• Volume expedures
• When to stop resuscitations
• Pitfalls
• Demonstration
 Case report
• Name x
• Sex F
• Age 5 minutes
c.c failure to initiate breathing after birth
• HPI : this is 5 minutes old female neonate born from para II mother
whose LNMP was on 5/3/15 Making a gestational age of 38 + 2days
• The mother had a regular ANC followup at AMGH and the pregnancy
was uneventful through out and she completed Iron and folic intake ,
her TT vaccines were up todate .
• The mother gave birth through emergency ceserean delivery after total
duration of labor of 7hrs and Rupture of membrane of 1 hr and Umblical
cord prolapse of 10 minutes duration to affect the delivery of singleton
alive female neonate weighing 3500 with an Apgar score of 2 and 3 at 1st
and 5th minute
• The umblical cord was clumped and cut , the neonate was put
on Infant radiant warmer dried secretion sucked and
stimulated for about 1 min but no response and was then
transferred to neonatal resuscitation room for better
management .
• Perinatal Risk Assesment
- Term Newborn
- Clear AF
- Cord Prolapse
- Fetal Bradycardia for the Last 5 minutes
- Tone floppy and not breathing
• Upon arrival To Neonatal Resuscitation Room
V/S PR 74 RR 3 SPO2 63% and T 35.3 RBS 70
The newborn was pale with cold and cyanotic extremities There
was respiratory grunting
Flaccid limbs and all reflexes were affected
• With this the Infant was dried thoroughly and placed under
Radiant warmer and was put on intranasal 02 .
• Repetetive back rubs and Infants mouth and nares suctioned
with bulb syringe for a period of 1 Minute.
After 1 minute - HR 70 chest not moving PPV was started at rate
of 40 breath per minute with o2 pressure of 21%
At 15 seconds - HR 76 chest not moving all MR – SOPA steps
were applied except Endotracheal tubewas not available by time
At 45 seconds – HR 101 chest started moving but baby was not
breathing in adequate rate .
• The infant was further resuscitated with PPV
after 4 minutes of PPV PR 122 RR 36 and Spo2 of 88 % was
reached and Infant was then Put on 1l IN02 and was then
Transferred To Neonatal ICU for further Management .
Introduction
Definition: neonatal resuscitation is prevention of death or injury to
new born.

Goals of Neonatal resuscitation are to:

• Re-establish adequate spontaneous respirations
• Obtain adequate cardiac output, and
• Prevent the morbidity and mortality associated with hypoxic-ischemic
tissue (brain, heart, kidney) injury.
Epidemiology
• Most newborns make the transition to extrauterine life without
intervention. Within 30 seconds after birth, approximately 85% of
term newborns will begin breathing.
• An additional 10% will begin breathing in response to drying and
stimulation to successfully transition,
• Approximately 5% of term newborns will receive positive-pressure
ventilation(ppv) 2% of term newborns will be intubated.
• 1 to 3 babies per 1,000 births will receive chest compressions or
emergency medications.
Physiology of fetus before and after birth
Before birth
• The fetus is dependent on the placenta as the organ of gas exchange
• Air sacs are filled with fetal lung fluid.
• Arterioles are constricted.
• Pulmonary blood flow is diminished.
• Blood flow is diverted across ductus arteriosus.
After birth
• Lungs expand with air.
• Fetal lung fluid leaves alveoli.
• Pulmonary arterioles dilate and blood flow increases.
• Ductus arteriosus constricts and blood flows through lungs to pick up
oxygen.
Preparation for neonatal resuscitation
Steps of newborn care
How do you evaluate the newborn
immediately after birth?
1) Does the baby appear to be term,
2) Does the baby have good muscle tone, and
3) Is the baby breathing or crying?
Initial steps of newborn care
• Provide warmth
• Dry
• Stimulate
• Position the head and neck
• Clear secretions if needed.
How do yo u provide the initial steps for
non-vigorous and preterm newborns?
Provide warmth
• Bring the baby to a radiant warmer
• Drying thoroughly
• Removing wet towels
• Raise environment temperature
• Cover with clear plastic sheeting
The goal temperature for a newborn undergoing resuscitation is
between 36.5°C and 37.5°C.
Dry.
• Wet skin increases evaporative heat loss. Place the baby on a warm
towel or blanket and gently dry any fluid.
• Drying is not necessary for very preterm babies less than 32 weeks'
gestation.
• they should be covered immediately in polyethylene plastic.
Stimulate.
• Drying the baby will frequently provide enough stimulation to initiate
breathing.
• Gently rub the newborn's back, trunk, or extremities.
• Overly vigorous stimulation is not helpful and can cause injury.
• Never shake a baby.
Position the head and neck to open the airway.
• Position the baby on the back ( supine) with the head and neck
neutral or slightly extended and the eyes directed straight upward
toward the ceiling in the «sniffing the morning air" position. This
position opens the airway and allows unrestricted air entry.
lf needed, clear secretions from the airway.
• Routine suction for a crying, vigorous baby is not indicated.
• Clear secretions from the airway if the baby is
• not breathing,
• gasping,
• poor tone,
• if secretions are obstructing the airway,
• having difficulty clearing their secretions,
• or if you anticípate starting PPV
Secretions may be removed from the upper airway by suctioning gently with a
bulb syringe
• If the newborn has copious secretions coming from the mouth, turn
the head to the side. This will allow secretions to collect in the cheek
where they can be removed.
• Suction the mouth before the nose to ensure there is nothing for the
baby to aspirate if the baby gasps when the nose is suctioned. You can
remember «mouth before nose" by thinking «M" comes before «N" in
the alphabet.
• Stimulation of the posterior pharynx during the first minutes after
birth can produce a vagal response leading to bradycardia or apnea.
Positive-Pressure Ventilation
• Indicated if the baby is:
• not breathing, OR
• gasping, OR
• heart rate is less than 100 bpm.
Types of resuscitation devices
How do you prepare to begin positive-pressure ventilation?
Evaluate the baby's response to PPV
• Within 15 seconds of starting PPV, the baby's heart rate should be
increasing.
• within 30 seconds of starting PPV, the baby's heart rate should be
greater than 100 bpm.
• If the baby's heart rate is not increasing after the first 15 seconds, ask
your assistant if the chest is moving.
• If the chest is moving, continue PPV
• If the chest is NOT moving, Perform the ventilation corrective steps
The ventilation corrective steps (MR. SOPA)
Indications for endotracheal intubation
• if the baby's heart rate remains less than 100 bpm
• and is not increasing after positive-pressure ventilation (PPV) with a
face mask or laryngeal mask
• before starting chest compressios.
• if the trachea is obstructed by thick secretions,
• for surfactant administration,
• for stabilization of a newborn with a suspected diaphragmatic hernia.
• If PPV is prolonged
Chest compression
• Chest compressions are indicated when the heart rate remains less than 60 bpm
despite at least 30 seconds of PPV that inflates the lungs (chest movement).
• To administer chest compressions, place your thumbs on the sternum, in the
center, just below an imaginary line connecting the baby's nipples. Encircle the
torso with both hands.
• Support the back with your fingers. Your fingers do not need to touch each
other.
• Use enough downward pressure to depress the sternum approximately one-
third of the anterior-posterior (AP) diameter of the chest.
• The compression rate is 90 compressions per minute and the breathing rate is
30 breaths per minute.
• If the heart rate is 60 bpm or greater, discontinue compressions and
resume PPV at 40 to 60 breaths per minute. adjust the oxygen
concentration to meet the target oxygen saturation guidelines.
Medications
• Epinephrine is indicated if the baby's heart rate remains less than 60
bpm after:
A. At least 30 seconds of PPV that inflates the lungs as evidenced by
chest movement and
B. Another 60 seconds of chest compressions coordinated with PPV
using 100% oxygen.
C. In most cases, ventilation should have been provided through a
properly inserted endotracheal tube or laryngeal mask
Dose and route
1. Intravenous or intraosseous = 0.02 mg/kg (0.2 mL/kg)
• May repeat every 3 to 5 minutes
• Range = 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg)
• Rate: Rapidly-as quickly as possible
• Flush: Follow intravenous or intraosseous dose with a 3-mL saline
flush
Endotracheal = 0.1 mg/kg (1 mL/kg)
• Range = O.O5 to 0.1 mg/kg (0.5 to 1 mL/kg)
• If no response, recommend intravenous or intraosseous for
subsequent doses
Volume expanders
Indicated if the baby is:
• not responding to the steps of resuscitation and there are signs of
shock or a history of acute blood loss.
Volume expansion recommendations
a. Solution: Normal saline (NS) or type O Rh-negative blood
b. Route: Intravenous or intraosseous
c. Preparation: 30- to 60-mL syringe (labeled NS or O- blood)
d. Dose: 1O mL/kg
e. Rate: Over 5 to 1 O minutes
When to stop resuscitation
• If there is a confirmed absence of heart rate after all appropriate
steps of resuscitation have been performed, cessation of resuscitation
efforts should be discussed with the team and family. A reasonable
time frame for considering cessation of resuscitation efforts is around
20 minutes after birth; however, the decision to continue or
discontinue should be individualized based on patient and contextual
factors.
 Pitfalls
• Wether pre Anticipations for Neonatal Resuscitation were made or If
the team were communicated prior to delivery is not mentioned.
• Orogastric tube Use is not documented For the prolonged PPV .
• Signifant Delay in transfer to Neonatal Resuscitation room .
• Shortage in equibments and Absence of cardiac monitoring Devices .
References
• American Academy of Pediatrics, text book of Neonatal Resucitation,
8th edition.
• Gomella's neonatology, 8th edition.
• Guideline for the management of common childhood illness, WHO,
chapter 3(3.1-3.2).
• NICU training participants manual, Chapter 5, 2021 edition.
Thank you