• Neonatal resuscitation is the immediate

steps to optimize newborn airway,

breathing, circulation to prevent or limit
the majority of neonatal morbidity that
occur during the first few hours after
delivery.
• The Neonatal Resuscitation Program
focuses on optimal resuscitation
readiness and effective communication.
Resuscitation Steps

A) Prior to delivery
1. Anticipate problems: Good history taking (maternal risk factors, delivery
problems).
The answers to 4 prebirth questions assess perinatal risk. The questions are:

• What is the expected gestational age?

• Is the amniotic fluid clear?
• How many babies are expected?
• Are there additional risk factors?

2. Adequate personnel:
 The number of trained personnel depends on baby`s condition.
 A well-coordinated newborn resuscitation begins before the birth.
 A team with the appropriate skills must be assembled and briefed, supplies
and equipment must be checked, care is coordinated with the obstetric team,
and parents should be informed about the plan of care.
3. Equipment: Newborn resuscitation supplies and
equipment are checked for presence and function
before every birth, preferably by using a checklist.
- A radiant warmer, pulse oximetry, cardiac monitor.
- Suction machine, meconium aspirator(not used)
- Oxygen delivery equipment (bag and mask, airways,
flow meter)
- Intubation equipment (laryngoscopes, tubes)
- Stethoscope, umbilical catheter tray and syringes.
4. Medication:
- Epinephrine, volume expanders (saline),
- NaHCO3 and naloxone.(not used)
pulse oximetry, and a cardiac monitor.
B) Post delivery
First, prevent heat loss by placing the baby under a
heated warmer, dry thoroughly with a pre-warmed
towels and discard the wet linens.
Assessment to;
(FT or PT), (breathing, crying or apniec), (pink lips or
cyanosed), (good tone or flaccid)
Quick evaluation by APGAR score at 1 min, 5 min
• The basic steps for resuscitation = ABC as the
majority of newborn who require resuscitation have
a healthy heart.
• A: Airway:
• B: Breathing
• C: Circulation
 APGAR score
0 1 2
Appearance Pink body, blue
(color) blue or pale all Pink Body,
extremi es
over extremi es
(acrocyanosis)

Pulse (HR) absent

< 100 beats / > 100 beats /
min min
Grimace no response to grimace on
cry , sneezing
(reflex) s mula on suc on
Ac vity flexed arms and
(tone) None, flaccid some flexion legs , resist
extension
Respira on Absent, apnea
weak, irregular, Strong cry,
gasping regular
Open the airway (A):- put the baby on his back
with head in midline position with the neck
slightly extended (avoid hyper or under
extension).
Suction mouth first then nose if there is obvious
obstruction or the baby require PPV. (babies
are obligatory nasal breathers). Avoid deep
oral suction (any touch of the posterior
pharynx may cause vagal stimulation causing
apnea and bradycardia).
• Reevaluate within 20 sec
The baby should be assessed by posing
three basic ques ons

1- Full term?
2- Good muscle tone?
3- Breathing spontaneously or crying?
1- If the answer to all questions are YES:
Provide routine care:
-Dry the baby.
-Provide warmth (wrapping).
-Position the head and neck to open the airway.
-The infant should be placed on the maternal
chest or abdomen.
-The cord clamped and divided after 60 seconds
have passed.
-IM Vitamin K
-Continue evaluation.
Breathing (B): Normal RR 40-60 breath/minute.
1- If the answer to ANY of these questions is NO: Start the
initial steps of resuscitation:
-Dry the baby.
-Provide warmth (wrapping-warmer-plastic bags for preterm
with wormed blanket).
-Position the head and neck to open the airway.
- Clear secretions if needed (mouth then nose).
- Tactile stimulation for compromised breathing by flicking of
the soles of the feet or rubbing the back.
- If breathing does not start after two tactile stimulation (10
seconds), the baby is in secondary apnea and initiate
respiratory support by Neopuff. Proper mask size, partially
extended neck, start by rate 40-60 /min then reevaluate after
15-20 sec for RR, HR, color
Apply correctly sized
mask over infants mouth
and nose with apex of
mask over bridge of nose
 Apnea /Gasping
Or
Heart rate < 100 bpm
 1- NO- Breathing spontaneous with HR >
100 but labored breathing or cyanosis
 Position airway and clear secretions if needed.
 Attach pulse oximeter to right hand to monitor Spo2.
 Supplement oxygen as needed. If oxygen is required
during resuscitation start with room air as initial
concentration for babies ≥ 35 W and 21% to 30% for
babies <35 W ,increase gradually to keep Spo2 lies
within the minute specific reference range advised by
NRP.
 Consider CPAP.
 Post resuscitation care for all cases requiring
resuscitation.
2- YES- There is Apnea or Gasping or HR
> 100 bpm
 Call for help.
 Ensure the baby is dry, warm and the airway is
patent.
 Spo2 and ECG monitor.
 Consider CPAP.
 Provide PPV. Begin with inspiratory pressure of 20-
25 cm H2O at rate of 40-60 breath per minute for 30
seconds. Use T- piece resuscitator (Neopuff).
 The most important indicator of successful PPV is a
rising heart rate.
Neopuff
 Indications for PPV
• Apnea or gasping.
• Heart rate<100 bpm.
• Oxygen saturation below the target range
despite free flow oxygen or CPAP.
When indicated. PPV should be started
within 1 minute of birth.
-Check chest movements with PPV.
-If chest is not moving do ventilation corrective
steps:
1- Mask adjust.
2- Reposition airway.
3- Suction mouth and nose.
4- Open mouth.
5- Pressure increase.
6- Alternative Airway: Place an endotracheal
tube or laryngeal mask.
- Continue PPV (via endotracheal tube or
laryngeal mask if needed)
 HR is increasing
↓
Continue PPV and do your second
assessment of the baby's HR after another
15 seconds
↓
HR at least 100 bpm
↓
Continue PPV 40-60 breath per minute
until spontaneous effort
Consider CPAP
Post resuscitation care
If HR < 60 bpm
Start Chest compression
• It`s rhythmic compressions of the
sternum to compress the heart against
the spine, squeezing blood to vital
organs.
• After 30 seconds of PPV ,& HR<100.
Or if initial HR< 60/min after 15
seconds of PPV that inflate the lungs as
evident by chest movement with
ventilation.
done by one of 2 methods:
• Hand-encircling technique: Using the 2
thumbs of both hands while the hands
encircle the thorax.
• Two fingers technique: With the tips of the
index and middle finger of one hand.
• Depth: 1-1.5 cm posterior about one third
of antero-posterior diameter of the chest
• Rate: HR:RR= 3:1/ min 3 compressions and
1 ventilation every 2 seconds(90
compression and 30 ventilation per minute.
• Continue PPV via endotracheal
tube with 100% oxygen.
• ECG monitor.
 1 minute a er star ng effec ve chest
compression and ven la on
HR remain < 60 bpm HR> 60 bpm and rising so stop cardiac
massage and continue PPV till
spontaneous respiration is regained

• Insert umbilical
venous catheter and:
• Send sample for PH,
blood gases, Hb and
glucose.
• Give Epinephrine
• Epinephrine is indicated if the baby,s HR remain
below 60 bpm after:
- At least 30 seconds of chest compressions
coordinated with PPV that inflates the
lungs(moves the chest).
And
- Another 60 seconds of chest compressions
coordinated with PPV using 100% oxygen.
• Dose: 0.1- 0.3 ml/kg of 1:10000 solution(equal to
0.01 to 0.03 mg/kg)
• Route: Intravenous or intra osseous, endotracheal
route is less effective so dose 0.5 to 1 ml/kg.
Circulation (C)
- Detect HR by (Moitor) stethoscope or umbilical pulse,
Count in six seconds &multiply by 10.
• If HR 60-100 /minute, start PPV.
• - If heart rate is less than 60/min., start chest compressions
with PPV immediately.
• Epinephrine is indicated if the baby,s HR remain below 60
bpm after:
• At least 30 seconds of chest compressions coordinated with
PPV that inflates the lungs(moves the chest).
And
• Another 60 seconds of chest compressions coordinated with
PPV using 100% oxygen.
 1 minute a er epinephrine and con nued
chest compression and ven la on
Improvement
If no improvement (HR < 60 bpm) • continue PPV and compression
till HR stabilize > 60 bpm.
• MV or assisted ventilation.
• Repeat epinephrine every • Post resuscitation care.
3 to 5 minutes.
• Consider hypovolemia,
pus 10 ml/kg saline IV (or
O- backed RBCs if
perinatal blood loss
suspected or Hb % is low.
• Consider pneumothorax.
• If there is confirmed absence
of HR after 10 minutes of
resuscitation, it is reasonable
to stop resuscitation effort, or
decision is individualized
Endotracheal intubation
• Indications; if prolonged PPV is required or
if bag and mask ventilation are ineffective.
• Tracheal suction of thick meconium.
• If diaphragmatic hernia is expected
Medications
Given through ETT or IV.( umbilical venous
catheter).
1. Epinephrine
Indications: If HR< 80 despite a minimum of
30 seconds of PPV and chest chest
compressions).
2. Volume expanders
Indication: if hypovolemia or acute blood
loss. Give normal saline or ringer lactate
3.Naloxone Hydrochloride
 Clinical Changes

Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscita on. Elk Grove Village, IL: American Academy of Pediatrics.