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What is neonatal resuscitation ?
Assessment of the fetus at birth
Identification of the babies requiring resuscitation
Initial steps of resuscitation
Termination of resuscitation
•Series of actions, used to assist
newborn babies who have difficulty
with making the physiological
‘transition’ from the intrauterine to
•Most newborns are vigorous at birth.
•Approximately 10% will require some
assistance at birth to begin breathing.
•Less than 1% will require extensive
• General: Resuscitation bed, over head
warmer (servo-controlled infrared heater),
towel, stethoscope, pulse oximeter
• Airway Mangement: 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)
• Breathing support: Facemask; PPV device,
O2 gas, feeding tube,
• Circulation support: UVC kit, iv kit, io
• Drug and fluids:
Adrenaline(1;10000/0.1mg/ml), NS, Blood
Assessment of the newborn at birth
• In the compromised newborn, the optimal
timing of cord clamping remains unknown
• The more severely compromised the
newborn the more likely it is that
resuscitation measures need to take
priority over delayed cord clamping
Initial Assessment: APGAR score
• Assesses neonatal well-being &
1-min score Acidosis and Survival
5-minute score Neurologic outcome.
• Each variable must be evaluated at 1
and 5 minutes.
Sign 0 1 2
Body pink ,
Absent < 100/min > 100/min
Absent Grimace Cough ,
None Some flexion
(Respiratory Effort) Absent Slow , Good , crying
APGAR Score 8-10
• Achieved by 90% of
• Nothing is required,
-nasal and oral
-drying of the skin
APGAR Score 5-7
• Suffered mild asphyxia
just before birth.
over the face.
Apgar Score 3-4
• These Neonates are moderately
depressed at birth.
• They are usually cyanotic and have poor
• But they usually respond to BMV,
breath, and become pink.
Apgar Score 0-2
Which babies need resuscitation?
Newborn rapidly assessed for
● Term gestation? ●Crying or Breathing?
● Good muscle tone?
If “yes,” for all 3 questions
Baby does not need resuscitation and
should not be separated from mother.
• If “no,” for of any of the assessment
• Infant should receive one or more of
the following action in sequence:
1. Initial steps in stabilization
3. Chest compressions
4. Administration of epinephrine
and/or volume expansion
(“the Golden Minute”)
• ≈60 sec for initial steps, reevaluating,
and beginning ventilation if required.
• The decision to progress beyond initial
steps is determined by simultaneous
▫ Respirations (apnea, gasping, or
labored or unlabored breathing)
▫ HR (whether < 100/min or > 100/min)
• HR is assessed by intermittently
auscultating the precordial pulse.
• When pulse detectable, umbilical pulse
palpation provide rapid estimate and is
more accurate than other sites.
• Pulse oximeter takes 1-2 min to apply,
• May not function during states of very
poor CO or perfusion
• Provide continuous assessment without
interruption of other resuscitation
• Once PPV or supplementary O2
administration begun, assessment consist
of simultaneous evaluation of:
▫ HR, Respirations, and State of
• The most sensitive indicator of a successful
response to each step ↑ in HR.
Anticipation of Resuscitation Need
•Anticipation, adequate preparation,
accurate evaluation, and prompt
initiation of support are critical for
successful neonatal resuscitation.
• At every delivery at least 1 person
required whose primary responsibility is
the newly born.
• This person must be capable of initiating
resuscitation, including administration of
PPV and chest compressions.
• Someone else promptly available have the
skills to perform a complete resuscitation,
including endotracheal intubation and
administration of medications.
• Majority of newborn who will need
resuscitation can be identified before birth.
• If a preterm delivery(<37weeks) is expected,
special preparations will be required.
Problems with preterm babies
1. Immature lungs- difficult to ventilate and
also more vulnerable to injury by PPV;
2. Immature blood vessels in the brain that
are prone to hemorrhage;
3. Thin skin & large BSA Rapid heat loss;
4. Increased susceptibility to infection;
5. ↑ risk of hypovolemic shock related to
small blood volume.
• To provide warmth by placing the baby
under a radiant heat source,
• Positioning the head in a “sniffing”
position to open the airway,
• Clearing the airway if necessary with a
bulb syringe or suction catheter,
• Drying the baby, and
• Stimulating respiration.
•The baby dried, placed skin-to-skin
with the mother, and covered with dry
linen to maintain temperature.
•Observation of breathing, activity, and
color should be ongoing.
•VLBW (<1500 g)
preterm babies are
likely to become
the use of traditional
decreasing heat loss.
Additional warming techniques :
• Prewarming the delivery room to 26°C,
• Covering the baby in plastic wrapping
(food or medical grade, heat-resistant
• Placing the baby on an exothermic
• Placing the baby under radiant heat .
Clearing the Airway
When Amniotic Fluid Is Clear
• Deep Suctioning is avoided
▫ nasopharynx bradycardia during
▫ trachea in intubated babies receiving MV at
NICUdeterioration of pulmonary
compliance, oxygenation and ↓ CBF.
• However, suctioning in the presence of
secretions can decrease respiratory
• Suctioning immediately following birth
should be reserved for babies who have
obvious obstruction to spontaneous
breathing or who require PPV.
When Meconium is Present
• Meconium-stained depressed infants
are at increased risk to develop
Meconium Aspiration Syndrome(MAS)
• Tracheal suctioning has not been
associated with reduction in the
incidence of MAS or mortality in these
• “Pea soup" or particulate meconium
should be removed from the lung
before breathing is established to
improve the survival of neonates with
• Thin, watery meconium does not
• Chest physical therapy and postural
drainage done every 30 min for 2 hrs
and hourly thereafter for the next 6 hrs
may help remove residual meconium
from the lung.
• All neonates born after meconium
aspiration should be observed for 24 hrs
because they can develop Persistent
Fetal Circulation syndrome.
•In the absence of randomized,
controlled trials, there is insufficient
evidence to recommend a change in
the current practice of performing
endotracheal suctioning of
nonvigorous babies with meconium-
stained amniotic fluid.
Assessment of oxygen need
• PaO2 uncompromised babies generally do
not reach extrauterine values until ≈10
min following birth.
• SpO2 may normally 70% -80% for several
minutes following birth Cyanosis.
• Optimal management of oxygen is
important because either insufficient or
excessive oxygenation can be harmful
• Meta-analyses comparing room air versus
100% oxygen showed increased survival
when resuscitation was initiated with air.
• Escrig R et al found that in preterm,
initiation of resuscitation with a blend of
oxygen and air resulted in less hypoxemia
or hyperoxemia than with either air or
100% oxygen followed by titration.
•If the baby is bradycardic
(HR<60/min) after 90 seconds of
resuscitation with a lower
concentration of oxygen, oxygen
concentration should be
increased to 100% until recovery
of a normal HR.
• If newborn apneic or gasping, or if the HR
< 100/min after the initial steps Start
Initial Breaths and Assisted Ventilation
• Initial inflations following birth, either
spontaneous or assisted, create FRC.
• The primary measure of adequate
initial ventilation is prompt
improvement in HR.
• Chest wall movement should be
assessed if HR does not improve.
• An initial peak inflation pressure of 20 cm
H2O is effective, but 30-40 cm H2O may be
required in some term babies.
• If pressure is not being monitored, the
minimal inflation required to achieve ↑ in
HR should be used.
• Assisted ventilation @40-60 breaths/min to
promptly achieve or maintain >HR 100/min.
• Recommended in preterm newborn
who are breathing spontaneously, but
• Starting infants on CPAP, ↓ the rates of
intubation and MV, surfactant use, and
duration of ventilation, but ↑ rate of
PEEP versus no PEEP
• Although PEEP is beneficial and used
routinely during MV of neonates in NICU,
there have been no studies specifically
examining PEEP versus no PEEP when PPV
is used during establishment of an FRC
• PEEP is likely to be beneficial and should
be used if suitable equipment is available .
PPV delivery devices
• T-piece device is preferred. PIP for term @30
cm H2O; Preterm @20-25 cm H2O; PEEP: 5-8
cm H2O; Max pressure relief valve: 50cm H2O
• Self inflating bag: Pressure release valve@
≈40 cm H2O; cannot effectively deliver CPAP,
PEEP or sustained inflation breaths
• Flow inflating (or anaesthetic) bag
Laryngeal Mask Airways
• LMA are effective for ventilating newborns
weighing > 2000 g or delivered ≥ 34 weeks
• limited data on the use of these devices in
small preterm infants(<2000g; <34 wk).
• LMA should be considered if facemask
ventilation is unsuccessful and tracheal
intubation is unsuccessful or not feasible.
Endotracheal Tube Placement
• Initial endotracheal suctioning of non
vigorous meconium stained newborns.
• If BMV is ineffective or prolonged.
• Newborns born without a detectable HR
• Expected need for continued or prolonged
• For special resuscitation circumstances, such
as CDH and ELBW.
• An appropriate size ETT should be
inserted and the tip of the tube placed 1
to 2 cm below the vocal cords.
• Distance from the tip of the tube to the
gums is 7, 8, 9, or 10 cm in 1-, 2-, 3-, and
4-kg infants, respectively.
• A small gas leak should be present between
the ETT and trachea when ventilation
pressure is 15-25 cm H2O.
Appropriate size of the tube
• 2.5 mm tube for neonates weighing < 1.5 kg,
• 3.0 mm tube for 1.5-2.5 kg,
• 3.5 mm tube for > 2.5 kg.
• Prompt ↑ HR is the best indicator that the
tube is in the tracheobronchial tree and
providing effective ventilation.
• Exhaled CO2 detection is the recommended
method of confirmation of ETT placement.
• Poor or absent pulmonary blood flow may
give false-negative results (ie, no CO2
detected despite ETT in the trachea).
• Other clinical indicators of correct
endotracheal tube placement are
▫ Condensation or mist in the ETT,
▫ Chest movement,
▫ Presence of equal breath sounds
▫ Improvement in skin color and SpO2.
• Because the chest is small, breath sounds
are well transmitted within the thorax.
• A difference in breath sounds between the
two sides of chest should raise suspicion of
pneumothorax, atelectasis, or a congenital
anomaly of the lung.
• Presence of loud breath sounds over the
stomach suggest Tracheoesophageal
• Failure to adequately ventilate the lungs
at birth may make hypoxemia worse and
lead to CNS damage or even death.
• If the PaO2 > 70-80 mm Hg or SaO2 >94%,
FiO2 (if higher FiO2 is used) should be
reduced untill SaO2 and PaO2 are normal
for age. (normal SaO2 ≈87-95%, which is
associated with a PaO2 of 55-70 mm Hg)
• Retinopathy of prematurity can occur in
premature neonates(<34 wks gestation)
with a PaO2 of ≈150 mm Hg for 2-4 hrs.
Administration of Surfactant
• Its use resulted in significant improvement in
the outcome of preterms.
• The incidences of pulmonary gas leaks, HMD
deaths, BPD, and pulmonary interstitial
emphysema are lower after surfactant use.
• Administered as liquid (Survanta@4mL/kg;
email@example.com/kg into trachea at birth).
• indicated when HR < 60/min despite
adequate PPV with O2 for 30 seconds.
• Rescuers should ensure that assisted
ventilation is being delivered optimally
before starting chest compressions because
▫ ventilation is the most effective action and
▫ chest compressions are likely to compete
with effective ventilation,
• Compressions should be delivered on the
lower third of the sternum to a depth of
≈1/3rd of the AP diameter of the chest.
• Two techniques:
▫ compression with 2 thumbs with fingers
encircling the chest & supporting the back
▫ compression with 2 fingers with a second
hand supporting the back.
• The 2 thumb–encircling hands
technique may generate higher
peak systolic and coronary
perfusion pressure than the 2-
finger technique, So
recommended in newborns
• Compressions and ventilations should be
coordinated to avoid simultaneous delivery.
• The chest should be permitted to reexpand
fully during relaxation, but the rescuer’s
thumbs should not leave the chest.
• compressions to ventilations ratio 3:1 (i.e.
≈120 events/min to maximize ventilation at
90 compressions and 30 breaths
• Thus each event will be allotted ≈1/2sec,
with exhalation occurring during the first
compression after each ventilation.
• A 3:1 compression to ventilation ratio is used
where ventilation compromise is the
primary cause, but rescuers should consider
using higher ratios (eg, 15:2) if the arrest is
believed to be of cardiac origin.
• Respirations, HR and oxygenation should be
reassessed periodically, and coordinated
chest compressions and ventilations should
continue until the spontaneous HR ≥60/min.
• Avoid frequent interruptions of
compressions, as they will compromise
artificial maintenance of systemic perfusion
and maintenance of coronary blood flow.
• If the neonate's condition does not
improve rapidly with ventilation and
tactile stimulation, an umbilical artery
catheter should be inserted.
• Most preterm neonates weighing < 1250
gram at birth and 1-3% of term
neonates require an umbilical artery
catheter during resuscitation.
Umbilical venous catheter (UVC)
• Most rapidly accessible intravascular route
▫ to administer drugs (Adrenaline);
▫ for fluid administration to expand blood
▫ to measure blood gase, pH and arterial
• Provide continued vascular access until an
alternative route is established
• Bradycardia is usually the result of
inadequate lung inflation or profound
hypoxemia, and establishing adequate
ventilation is the most important step.
• if the HR remains < 60/min despite one
minute of adequate ventilation and chest
compressions with100% O2,adrenaline or
volume expansion or both are indicated
• IV is the preferred route: UVC is
preferable to intraosseous
• Recommended IV dose is 0.01-0.03
mg/kg/dose; rapid bolus followed
by 1ml of 0.9% NS flush
•Intratracheal dose is higher(0.05 to
0.1 mg/kg); 1:10,000 (0.1 mg/mL);
may be considered while IV access
is being obtained; Follow with PPV –
Flush not recommended
•Can be repeated every 5 minutes, if
HR remains < 60/min.
Detection of Hypovolemia
• measuring the arterial BP and
• by physical examination (i.e. pale skin color,
have poor capillary refill time, poor skin
perfusion, extremities are cold, and pulses
(radial and posterior tibial) are weak or
absent, and temperature).
• CVP measurements are helpful in detecting
hypovolemia and in determining the
adequacy of fluid replacement.
• Normal CVP in neonates is 2-8 cm H2O.
• If CVP < 2 cm H2O, hypovolemia suspected.
Treatment of Hypovolemia
• The key is intravascular volume expansion.
• Best be done with blood and crystalloids
• If hypovolemia is suspected at birth, Rh-
negative type O PRBCs should be available in
delivery room before neonate is born.
• Crystalloid and blood should be titrated in 10
mL/kg and given slowly over 10 minutes.
• At times, >50% of the blood volume (85
mL/kg in term; and 100 mL/kg in preterm)
must be replaced, especially when the
placenta is transected or abrupted.
• In most cases, <10-20 mL/kg of volume
restores mean arterial pressure to normal.
• Care should be taken to avoid giving volume
expanders rapidly, because rapid infusions of
large volumes have been associated with
hypertension and IVH.
• Hypertension may disrupt the intracerebral
vessels and cause intracranial hemorrhage if
cerebrovascular autoregulation is absent.
• Babies who require resuscitation are at risk
for deterioration after their vital signs have
returned to normal.
• Once adequate ventilation and circulation
have been established, the infant should be
maintained in, or transferred to an
environment where close monitoring and
anticipatory care can be provided.
Monitoring required may include:
• Oxygen saturation(SpO2)
• Heart rate and ECG
• Respiratory rate and pattern
• Blood glucose measurement
• Blood gas analysis
• Fluid balance and nutrition
• Blood pressure
Role of Glucose
• Newborns with lower blood glucose levels
are at ↑ risk for brain injury so maintain
BGL >2.5 mmol/L.
• If the blood glucose concentration is low,
bolus of glucose (0.5 to 1.0 mL/kg of 10%
dextrose) and constant infusion of 5-7
mg/kg/min intravenously is given .
Induced Therapeutic Hypothermia
• Infants born ≥36 weeks gestation with
evolving moderate to severe hypoxic-
ischemic encephalopathy should be offered
therapeutic hypothermia (33.5-34.5⁰C).
• The treatment according to the studied
protocols include commencement within 6
hrs following birth, continuation for 72 hrs,
and slow rewarming over at least 4 hours.
Guidelines for Withholding and
• It is based on the physician's experience and
desires of the parents.
• In making the decision, the physician must
consider the probability of neurologic
damage and chances of a productive, useful
life are poor, consideration should be given
to discontinuing all resuscitative efforts.
• It may be considered reasonable, when there
have been conditions with poor outcome
(i.e. gestation, birth weight, or congenital
anomalies are associated with almost certain
early death or unacceptably high morbidity
is likely among the rare survivors) and
opportunity for parental agreement, (eg <23
wk gestation; BW<400g; trisomy 13)
• conditions with ↑rate of survival, acceptable
morbidity (with ≥ 25 wks gestation and with
most congenital malformations, resuscitation
is always indicated.
• Conditions with borderline survival, high
morbidity rate and uncertain prognosis,
parental desires concerning initiation of
resuscitation should be supported.
Discontinuing Resuscitative Efforts
• In a newly born baby with no detectable
HR, resuscitation are discontinued if the
HR remains undetectable for 10 min.
• resuscitation efforts beyond 10 min with
no HR should be considered if presumed
etiology of the arrest, gestation of the
baby, and the parental desire.
Risk factors for neonatal resuscitation
• PROM (> 18 hours)
• Bleeding in 2nd or 3rd
• Substance abuse
• Diabetes mellitus
• Chronic illness
• Maternal pyrexia
• Maternal infection
• Heavy sedation
• Previous fetal or
•gestation (< 35 wks; >41
•Large for dates
•Reduced fetal movement
before onset of labour
which may effect breathing,
cardiovascular function or
other aspects of perinatal
•Non reassuring FHR
patterns on CTG
placenta praevia, vasa
•Meconium in the amniotic
•Narcotic administration to
mother within 4 hours of
Assists babies who fail to initiate or sustain regular breathing at birth.
2 vital characteristics.
Suctioning of the oropharynx before delivery of the shoulders was considered routine until a randomized controlled trial demonstrated it to be of no value Elective and routine endotracheal intubation and direct suctioning of the trachea were initially recommended for all meconium-stained newborns until a randomized controlled trial demonstrated that there was no value in performing this procedure in babies who were vigorous at birth
However, if attempted intubation is prolonged and unsuccessful, bag-mask ventilation should be considered, particularly if there is persistent bradycardia.
So skin colour is a poor indicator of resuscitation need in immediate neonatal period.
An initial peak inflation pressure of 20 cm H2O is effective, but 30-40 cm H2O may be required in some term babies without spontaneous ventilation.
The laryngeal mask has not been evaluated in cases of meconium-stained fluid, during chest compressions, or for administration of emergency intratracheal medications.
Drugs are rarely indicated in resuscitation of the newly born infant.
1-2 g/kg of 25% albumin, or 10 mL/kg of plasma.
Care must be taken not to overexpand the intravascular volume and cause hypertension, especially in preterm neonates.