1. Resuscitation In Newborns
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Approximately 10% of newborns require some
assistance to begin breathing at birth.
Approximately 1% require extensive resuscitative
measures.

3. APNEA
• Primary – deprivation of oxygen → rapid
breathing → resp stop →HR↓ → apnea
*** will re- establish breathing with oxygen and
stimulation
• Secondary –If asphyxia continues →deep gasping
resp → HR ↓ & BP ↓ →last gasp →apnea
*** unresponsive to oxygen and stimulation →PPV
must be started

5. • Always assume infant has secondary Apnea &
commence Resuscitation

6. Resuscitation Assignments
• Team Leader- Airway
• Second Rescuer- Pulse Check (HR)
Chest Compression
• Third Rescuer- Medications
Equipment

7. Core Knowledge and Skills
• Airways - Establish Clear Airway
• Breathing- Ventilation & Oxygenation
• Circulation- Adequate Cardiac Output
• Drugs
• Environment - Reduce Heat Loss

8. Steps in Resuscitation - ABCDE
• Airway – open & clear airway
– Suction mouth and then nose , trachea if
needed
– No more than 5cms & no longer than 5 secs
– Mechanical suction - vacuum does not
exceed 100 mmHg (5litres)
– Airway tube / ET tube
• If nose cleared first the infant may gasp and aspirate
secretions in the pharynx

9. Airway
DO NOT SUCTION IF AIRWAY IS CLEAR
– Positioning
• Supine or lateral
• Head in neutral or slightly extended
position - Avoid overextension or flexion

10. CLEARING THE AIRWAY OF MECONIUM
Current recommendations No longer advise
routine intrapartum oropharyngeal and
nasopharyngeal suctioning for infants born
to mothers with meconium staining of
amniotic fluid

11. Suction
• Suction - Bulb syringe
DeLee mucus trap
Suction catheters (6F, 8F, 10F)
Feeding tube with syringe
Meconium aspirator

12. Steps in Resuscitation - ABCDE
• Breathing -Initiate breathing
- Tactile stimulation
- PPV – bag & mask
– bag & ET tube
• Assessment of respiratory effort and color

13. Tactile Stimulation
• Drying
• Suctioning
• Slapping or flicking the soles of the feet
• Rubbing the back gently
• Do not waste time continuing tactile stimulation
if there is no response after 10 - 15 seconds.

14. Harmful actions
• Slapping back
• Squeezing rib cage
• Forcing thigh onto abdomen
• Dilating anal sphincter
• Using hot or cold compression or bath
• Blowing cold air onto face
• Burning placenta

15. Use of oxygen during
neonatal resuscitation
• Indications for oxygen administration
– Cyanosis
– Respiratory distress
- Give free flowing oxygen 5L/min
• Use – 100% supplemental oxygen
• If oxygen unavailable - use room air to deliver
positive-pressure ventilation

16. Steps in Resuscitation - ABCDE
Indications for PPV / Bag-Valve-Mask Ventilation
• Apnoeic
• Gasping respiration
• HR < 100 bpm
• Persistent central cyanosis despite 100% O2
• 40-60 breaths/min
• No response

17. Bag-Valve-Mask Ventilation
• NeutralPosition of Head
• Tight Mask Seal
• Avoid Pressure on Trachea
•Assisted rate= 40 to 60 bpm

18. Bag-Valve-Mask Ventilation
• Signs of Adequate Ventilation:
- Bilateral Chest Expansion
- Bilateral Breath Sounds
- Adequate Heart Rate & Color

19. Bag and mask
Ventilate for 30 seconds:
Rate: 40-60 /min
Pressure: Visible rise and fall of chest
HR < 60 HR >100
HR > 100 bpm:
Continue ventilation Check for spontaneous
Initiate chest compression respirations
Consider intubation

20. Bag and mask the most important tool in newborn resuscitation

21. ENDOTRACHEAL TUBE PLACEMENT
• ET intubation - indicated at several points during
neonatal resuscitation:
1. Tracheal suctioning for meconium
2. Bag-mask ventilation is ineffective / prolonged
3.When chest compressions are performed
4.When ET administration of medications is required
5.Congenital diaphragmatic hernia or extremely low
birth weight (<1000 g)

22. Place a pillow under the
head and neck but NOT
under the shoulders
This allows a straight line
of vision from the mouth to
the vocal cords
The laryngoscope is
introduced into the right
hand side of the mouth (it
is held by the left hand

23. • The tongue is swept to the left
and the tip of the blade is
advanced until a fold of skin /
cartilage is visualised at twelve
o’ clock
• This is the epiglottis, and this
sits over the glottis (the
opening of the larynx) during
swallowing

24. • The tip of the blade is advanced to the
base of the epiglottis, known as the
vallecula, and the entire laryngoscope is
lifted upwards and outwards
• This flips the epiglottis upwards and
exposes the glottis below
• An opening is seen with two white
vocal cords forming a triangle on each
side

25. • The tip of the ET tube is advanced through the
vocal cords and once the cuff has passed
through, one stops advancing The tube is
secured at this level and the cuff inflated

26. ET tube sizes
GA Weight ET tubes Size
• <28weeks <1Kg 2.5cm
• 28-34 1-2Kg 3 cm
• 34-38 2-3Kg 3-3.5 cm
• >38 >3 Kg 3.5- 4cm

27. Steps in Resuscitation - ABCDE
• Circulation
• Assessment of heart rate
• Umbilical arteries pulsation
• Chest Compressions

28. Steps in Resuscitation - ABCDE
Indication for Chest Compressions
1. HR < 60 bpm despite adequate vent with 100%
O2 for 30 seconds
2. Heart Rate 60 to 80 but not Increasing (±) -
controversial

29. 2 techniques
• 2 thumb
(preferred)
• 2 finger
• 3:1 ratio
• 1/3 of AP
diameter

30. Chest compression
1.Thumb technique:
- Place thumbs side by side or one
over the other above xyphoid - other
fingers provide support for the back
- Depress the sternum to a depth of
1/3 of the anterior/posterior diameter of the
chest
- Your thumbs should remain in
contact with the chest at all times
- Rate - 3:1

31. Drugs needed for
Newborn Resuscitation

32. Steps in resuscitation - ABCDE
Drugs
• Adrenaline
• Volume Expanders
• Naloxone
• Sodium bicarbonate (0.5 mEq/mL)

33. Drugs
1.Adrenaline
• HR < 60 /min after 30 seconds of adequate
ventilation and chest compressions
• Give via ETT, UVC, IV
• Repeat dose if no response after 60 seconds
• IV or ET dose - 0.1 to 0.3 mL/kg of 1:10,000
(0.01 to 0.03 mg/kg) repeated every 3 to 5
/min
• ET: 0.3 to 1.0 mL/kg of 1:10,000
• No different dose for premature infants

34. Steps in resuscitation - ABCDE
• Volume expanders
• Not given routinely
• Useful in hypovolemia
– Suspected where there is a pale tachycardic
infant
• Normal saline - 10mL/kg over 5-10 min
• Route - UVC, IV
• Blood or packed red cells - If haemorrhagic
shock is suspected

35. Drugs
• Naloxone
• Inadequate spontaneous respiratory effort
• Mothers who received narcotics within 4 hrs
of delivery
• Dose - 0.1mg/kg of a 0.4 mg/mL solution
• Route - ETT, IV, UVC, IM, SC

36. Steps in resuscitation- ABCDE
• Environment
– Turn on radiant warmer
– Warm blankets/cap/plastic wrap for
preterms
– Shut doors and windows
– Heat Lamps

37. :
Equipments Prepare for birth
• Two clean towels for thermal protection
• Warm delivery room > 25oC
• A radiant heater / warmer
• Clean delivery kit for cord care, gloves
• an additional set of equipment in reserve for
multiple births or in case of failure of the first
set

38. Equipments
- Oxygen supply
- Bag and mask, face mask, oral airway (Guedel
airway)
- Intubation –
Laryngoscope (0 and 1 sized blades)
ET tubes, (2.5-4)
Scissors ,gloves
Extra bulbs and batteries
Stethoscope

39. Fluids
- IV catheters (22 g)
- Tape and sterile dressing material
- D10W
- Isotonic saline solution
- T-connectors
- Syringes (1-20 mL)

40. Rapid assessment - 5 characteristics
• Full-term gestation?
• Amniotic fluid clear of meconium ?
• Breathing or crying?
• Good muscle tone?
• Color pink?

41. If the answer to any of these
assessment is "no"
• Initial steps in stabilization ( warmth, position, clear
airway, dry, stimulate)
• Ventilation
• Chest compressions
• Administration of epinephrine and/or volume expansion

42. Resuscitation Priorities
- Drying, Warming, Positioning
- Suctioning, Stimulation
- BVM Vent
- Oxygen
- Chest Compressions
-Intubation
-Medications

44. • BIRTH
↓
Clear of meconium?
Breathing or crying?
Good muscle tone? YES Routine care
Colour pink? -Warmth
Term gestation? -Clear airway
-Dry the baby
NO
• Provide warmth
• Position and clear airway*-suction
• Dry, stimulate, reposition
• Give oxygen

45. • Evaluate:-
Breathing Supportive care
HR>100
pink
Apnoea or HR <100
Provide positive pressure ventilation* by ambu bag
→Breathing
HR >100
pink
↓
Ongoing care

46. IF
• HR<60
• Provide positive pressure ventilation*
• Administer chest compression
↓
• HR<60
• Administer Epinephrine
***ET may be considered at several steps

47. Discontinuing resuscitation efforts
• After 10 minutes of continuous and adequate
resuscitative efforts, discontinuation of
resuscitation may be justified if there are no
signs of life (no heart beat and no respiratory
effort)

48. Thank you
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Medical Post [ www.themedicalpost.net ]