NEONATAL

RESUSCITATION
PRESENTED BY
DR FIDHA FIRDOWS
DNB RESIDENT

MODERATED BY : DR UMAKANTHA ADIGA

 CONTENTS
1.What is neonatal resuscitation ?

2.Assessment of the fetus at birth

3.Identification of the babies requiring

4.resuscitation Initial steps of resuscitation

5.Pulmonary resuscitation

6.Vascular Resuscitation

7.Termination of Resuscitation
 1A.NEONATAL
RESUSCITATION?

DEFINITION
Series of actions, used to assist newborn babies
who have difficulty with making the physiological
‘transition’ from the intrauterine to extrauterine
life.
 Most newborns are vigorous at birth.

 Approximately 10% will require some

assistance at birth to begin breathing.

 Less than 1% will require extensive

resuscitation.
 1B. RESUSCITATION EQUIPMENTS
1.General:
1. Resuscitation bed, over head
warmer (servo-controlled
infrared heater)
2. towel
3. stethoscope
4. pulse oximeter
2.AIRWAY MANGEMENT:

1.SUCTION DEVICE WITH SUCTION CATHETER

BULB SYRINGE
2.LARYNGOSCOPE WITH BLADES (SIZE 00 AND 0)
3. ETT (SIZE 2.5, 3.0, 3.5)
4.ETCO2 DETECTOR
5. LMA (SIZE 1)
• Breathing support: Facemask; PPV device,
O2 gas, feeding tube,

• Circulation support: UVC kit, iv kit, io

needle,

• Drug and fluids:

Adrenaline(1;10000/0.1mg/ml), NS, Blood
2. ASSESSMENT OF THE NEWBORN AT
BIRTH
 INITIAL ASSESSMENT: APGAR SCORE
Assesses neonatal well-being & resuscitation.
1-min score : Acidosis and Survival
5-minute score: Neurologic outcome.

Each variable must be evaluated at 1 and 5

minutes.
Virginia Apgar
APGAR SCORE
1.APGAR SCORE 8-10
• Achieved by 90% of
neonates
• Nothing is required,
except
-nasal and oral
suctioning
-drying of
the skin
-maintenance of
normal body
2. APGAR SCORE 5-7

• Suffered mild asphyxia

just before birth.
-Respond to
vigorous stimulation
-Oxygen blown
over the face.
3.APGAR SCORE 3-4
• These Neonates are moderately
depressed at birth.

• They are usually cyanotic and have poor

respiratory efforts.

• But they usually respond to BMV,

breath, and become pink.
4.APGAR SCORE 0-2
• These
neonates
severely
asphyxiated
and require
immediate
resuscitatio
n
3.WHICH BABIES NEED RESUSCITATION

Newborn rapidly assessed for

1. Term gestation 2.Crying or 3.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 questions

• Infant should receive one or more of the
following action in sequence:
 Initial steps in stabilization
 Ventilation
 Chest compressions
 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 assessment
of:
 ▫ 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 is detectable, umbilical

pulse palpation provide rapid estimate
and is more accurate than other sites.
NEWBORN RESUSCITATION ALGORITHM
INITIAL
STEPS
1. To provide warmth by placing the baby
under a radiant heat source,
2. Positioning the head in a “sniffing”
position to open the airway,
3. Clearing the airway if necessary with a
bulb syringe or suction catheter,
4. Drying the baby, and
5. 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.
 CLEARING THE AIRWAY
When Amniotic Fluid Is Clear
• Deep Suctioning is avoided
• However, suctioning in the presence of
secretions can decrease respiratory
resistance.

• 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)
PULMONARY RESUSCITATION
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
• 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.
PPV
• If newborn apneic or gasping, or if the HR
< 100/min after the initial steps
Start PPV.

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.
 LARYNGEAL MASK AIRWAYS
• LMA are effective for ventilating newborns
weighing > 2000 g or delivered ≥ 34 weeks
gestation.
• 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.
• 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.
• Other clinical indicators of correct
endotracheal tube placement are
▫ Condensation or mist in the ETT,
▫ Chest movement,
▫ Presence of equal breath sounds
bilaterally,
▫ 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
Fistula.

• Failure to adequately ventilate the lungs

at birth may make hypoxemia worse and
lead to CNS damage or even death.
VASCULAR RESUSCITATION
 CARDIAC MASSAGE
• 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
volume,
▫ to measure blood gase, pH and
arterial BP,
• Provide continued vascular access until an
alternative route is established
RESUSCITATION DRUGS
• 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
• 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.
 VOLUME
EXPANSION
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.
 POSTRESUSCITATION
CARE
• 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
• Temperature
• Neurological
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
DISCONTINUING
• ItRESUSCITATION
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
 WITHHOLDING
RESUSCITATION
• 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.
LETS GIVE OUR NEWBORN A
GOOD START!

Thanks……..
RISK FACTORS FOR NEONATAL
RESUSCITATION
Fetal
Maternal Intrapartum
•Multiple gestation •Non reassuring FHR
• PROM (> 18 hours)
•gestation (< 35 wks; >41 patterns on CTG
• Bleeding in 2nd or 3rd
wks) •Abnormal presentation
trimester •Large for dates •Prolapsed cord
• PIH •IUGR •Prolonged labour
• Substance abuse •Alloimmune haemolytic •APH(e.g. abruption,
• Drug disease placenta praevia, vasa
• Diabetes mellitus •Polyhydramnios and praevia)
• Chronic illness oligohydramnios •Meconium in the amniotic
•Reduced fetal
• Maternal pyrexia fluid
movement •Narcotic administration to
• Maternal infection
before onset of mother within 4 hours of
• Chorioamnionitis labour birth
• Heavy sedation •Congenital abnormalities •Forceps birth
• Previous fetal or which may effect breathing, •Vacuum-assisted
neonatal death cardiovascular function or (ventouse) birth
other aspects of perinatal •Maternal GA
transition
REFERENCES