step by step description of resuscitation in newborn for clinical year 2 medical students easier to understand and help revise for exam and osce examinations

1. May 2020

2. Preterm
27%
Sepsis &
pneumonia
26%
Asphyxia
23%
Congenital
7%
Tetanus
7%
Diarrhoea
3%
Others
7%
4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–
900

3. WHY TO LEARN NEWBORN RESUSCITATION ?
 Birth asphyxia ~25% neonatal mortality
 ~90% requiring little or no assistance
 10% of newborns need some assistance
 Only 1% require extensive resuscitation
 Always be prepared to resuscitate, even those
with no risk factors will require resuscitation.

4. Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as
required
Assist ventilation with
positive pressure
Intubate the trachea
Provide chest
compressions
Medications
Always
needed
Needed less
frequently
Rarely needed

6. BEFORE BIRTH
 Oxygen supply by placental
membranes
 No role of lungs. Fluid filled
alveoli and constricted
arterioles due to low Po2 in
fetal blood.

7. AFTER BIRTH
 Baby cries  takes first breath  air enters
alveoli  alveolar fluid gets absorbed 
increased Po2  relaxes pulmonary arterioles 
decreased PVR

8.  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 aorta.

9.  Low muscle tone
 Respiratory depression
(apnoea / gasping)
 Tachypnea
 Bradycardia
 Hypotension
 Cyanosis

12.  Provide warmth : Radiant warmer,
don’t cover with towels.
 Position head and clear airway as
necessary
 Dry and stimulate the baby to
breathe, reposition

13.  Suction mouth first, then
nose
 “M” before “N”
 To prevent aspiration of
mouth contents

14. Stimulate :
Flicking the
soles/ drying &
rubbing the back
Evaluation

15.  Ventilation of the lungs is the
single most and 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%.

16. Appropriate Sizes
 Mask should
Rest on Chin
Cover Mouth
& Nose

17.  Gently pull infant’s jaw forward to mask
 Use a “C-grip” to hold mask to infant’s face,
using the 3rd finger to hold jaw up to mask

18. 40 to 60 breaths per minute
Start With 21% ( higher in preterm's) oxygen
and increase according to target Saturation
Initial Pressure at 20mmH2O

19.  Most Important sign is the rising of HR
 Improvement in Oxygen Saturation
 Equal and adequate breath sounds B/L
 Good Chest rise

20. If heart rate <100 bpm
despite adequate
ventilation for 30
seconds,

21. 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

22. If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,

23. Indications :
 HR <60/min
despite at least 30
sec of effective
PPV
Strongly consider Endotracheal intubation at this point
as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions

24. Rationale:
 HR<60/min despite PPV indicates
very low O2 levels and significant acidosis 
depressed myocardium  no blood in lungs
to get oxygenated(supplied by PPV)
 Chest compressions + effective ventilation
(ET/PPV)  oxygenation of blood 
recovery of myocardium to function
spontaneously  HR increases  O2 supply
to brain increases

25. 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.

26.  Thumb technique is
preferred as
 Better control of depth of
compression
 Can provide pressure
consistently
 Superior in generating peak
systolic and coronary arterial
perfusion pressure.

27. For small chests with
thumbs overlapped

29. 2- finger

30.  Depth : 1/3rd of the
anteroposterior
diameter of chest.
 Duration of
downward stroke
should be shorter
than the duration of
release
 Do not lift the
fingers off the chest

31. 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)

32. 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

33.  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

34.  Special conditions
 Extreme Prematurity
 Surfactant administration
 Suspected diaphragmatic hernia

35. Mechanism of action :
 Increases systemic vascular resistance
 Increases coronary artery perfusion pressure
 Improves blood flow to myocardium and
restores depleted ATP
Indications :
 If HR remains < 60/min even after 30 sec of
effective ventilation preferably after
intubation and at least another 45-60 sec of
coordinated chest compressions and
effective ventilation

36. Administration :
 Intravenous (recommended)
 Endotracheal
Preparation and dosage:
 Adrenaline vial 1ml = 1mg (1:1000 solution)
 Dilute with NS to make 1:10,000 solution
(1ml = 100 mcg)
 IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
 ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
 Give rapidly – as quickly as possible
 Can repeat every 3-5 minutes

37. Indications:
 Bradycardia not improving with adrenaline
Volume Expanders:
 Normal saline (recommended)
 Ringer lactate
 Dosage: 10 ml/kg
 Route : Umbilical vein
 Rate: over 5-10 min , rapid infusion may
cause IVH in <30 weeks babies

38.  Additional resources , additional personnel,
additional thermoregulation strategy
 Portable warming pad
 Polyethylene Plastic wrap (< 29wk)
 Prewarmed transport incubator
 Use of Oxymeter, blender to target Spo2 85%- 95%
 Use Lower PIP 20-25 cm of H2O during PPV
 Consider giving CPAP
 Consider Surfactant

39.  Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and
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

40.  Delay feeds, Start IV fluids, consider
parenteral nutrition
 Consider inotropes,fluid bolus
 Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)

41.  Choanal atresia – oral Airway
 Pierre Robin : place prone , 12F Et through
nose with tip in post pharynx
 Laryngeal web, cystic hygroma, Cong.
Goiter- ET/tracheostomy
 Pneumothorax : Percutaneous needle
aspiration
 Pleural effusion : Percutaneous needle
aspiration
 Congenital Diaphragmatic hernia

42.  Can we differ resuscitation?
 Can we to stop resuscitation?

43. THANK YOU