Approximately 10% of newborns require some assistance breathing at birth, while less than 1% require extensive resuscitation. The American Heart Association and American Academy of Pediatrics have updated neonatal resuscitation guidelines. Proper equipment, positioning, suctioning, stimulation, ventilation, chest compressions, and medications may be required to resuscitate non-vigorous or depressed newborns. Ongoing assessment of respiration, heart rate, and color determine if further intervention is needed.

1. Presented by:
Moninder Kaur
M.Sc. Nsg. 1st year

2.  Approximately 10% of newborns require some
assistance to begin breathing at birth. Less
than 1% require extensive resuscitative
measures. Although the majority of newly
born infants do not require intervention to
make the transition from intrauterine to
extra-uterine life, because of the large total
number of births, a sizable number will
require some degree of resuscitation.

3.  The American Heart Association(AHA) and the
American Academy of Pediatrics(AAP) have
recently updated the resuscitation guidelines
that are being propagated world wide
through the Neonatal Resuscitation
Program(NRP).

4.  Suction equipment:
 Meconium aspirator
 Mechanical suction
 Suction catheters, 10F or 12F
 Feeding tube 6F and 20 ml syringe
 Bag and mask equipment:
 Neonatal resuscitation bags
 Face masks, newborn and premature size
 Oxygen with flow meter and tubing

5.  Intubation equipment:
 Laryngoscope with straight blade no.
0(preterm) and no. 1(term)
 Extra bulbs and batteries for laryngoscope
 Endotracheal tubes 2.5, 3, 3.5, 4 mm ID
 Stylet
 Scissors
 Medications:
 Epinephrine
 Naloxone hydrochloride
 Sodium bicarbonate
 Sterile water

6.  Miscellaneous:
 Watch with seconds hand
 Linen, shoulder roll
 Radiant warmer
 Stethoscope
 Adhesive tape
 Syringes 1,2,5,10,20,50 ml
 Gauze
 Umbilical catheters 3.5F, 5F
 Three way stopcocks
 Gloves

7.  T- Maintenance of temperature
 A-Establish an open Airway
 B-Initiate breathing
 C-Maintain circulation

9.  Clear of meconium?
 Term gestation?
 Crying or breathing?
 Good muscle tone?
 Color pink?

10.  If the answer to all 5 of these questions is
“yes,” the baby does not need resuscitation and
should not be separated from the mother.
The baby should be 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.

11. If the answer to any of these assessment
questions is “no,” the infant should receive
one or more of the following 4 categories of
action in sequence:
 Initial steps in stabilization (provide warmth,
clear airway if necessary, dry, stimulate)
 Ventilation
 Chest compressions
 Administration of epinephrine and/or volume
expansion

12.  Approximately 60 seconds (“the Golden
Minute”) are allotted for completing the initial
steps, reevaluating, and beginning ventilation
if required. The decision to progress beyond
the initial steps is determined by
simultaneous assessment of 2 vital
characteristics: respirations and heart rate.

13.  Positioning
To maintain the correct position, one may
placed a rolled blanket or towel under the
shoulders, elevating them ¾ or 1 inch off the
mattress(sniffing position). If the infant has
secretions from the mouth, keep head turned
to the side.
 Purpose of position: to make adequate
alignment.

14. The mouth and nose should be suctioned. One
should not insert the catheter very deep in
mouth or nose for suction because it can
cause severe bradycardia or apnea. For
suctioning, the size of suction catheter
should be 12 or 14 Fr. The suction pressure
should be kept around 80 mmhg (100 cm
water) and not exceed 100 mmhg (130 cm
water).

15. After suctioning, the baby should be dried
adequately using pre- warmed linen to
prevent heat loss. The wet linen should be
removed from the baby.
 Methods of stimulation: A brief tactile
stimulation in form of flicking the soles or
rubbing the back may be provided in case of
no- establishment of good respiratory
efforts.

16. If the baby continues to be depressed, provide
free flow of oxygen using a facemask held
over the face loosely or by a cupped hand.
The flow of oxygen should be 5-6 liters per
minute.

17.  Appropriate steps must be taken during and
immediately after delivery to reduce the risk
of serious consequences resulting from
aspiration of the meconium.
 When head is delivered, a thorough
suctioning of mouth, nose and posterior
pharynx should be carried out using a 12 or
14 F catheter in all cases.

18.  After delivery, it is important to identify
whether the baby is vigorous ( good
respiration; good muscle tone; heart rate
>100/min.) or non- vigorous( absence of
any single important signs). The vigorous
baby does not require any tracheal suctioning
and the usual initial steps are provided.

19.  Place the baby under radiant warmer.
Postpone drying and suctioning to prevent
stimulation.
 Residual meconium in the hypopharynx
should be removed by suctioning under
direct vision using a laryngoscope.
 The trachea should then be intubated and
meconium suctioned from the lower airway.

20.  Tracheal suctioning is best done by applying
suction directly to an ET. Once ET tube has
been inserted, continuous suction is applied
to the tube as it is withdrawn with the vaccum
set to approximately 100 mmhg (130 cm of
water).
 Tracheal suctioning can be repeated if the
previous suctioning revealed meconium and
baby has not developed significant
bradycardia.

21.  After providing initial steps, the baby should
be evaluated for three signs: respiration( by
chest movements), heart rate( by auscultation
or by palpating the umbilical pulsation),
color( by looking tongue and mucus
membrane).

22.  Indications: BMV is indicated if the infant is
apneic or gasping and respiration is
spontaneous but heart rate is below 100b/m.
 Positive-Pressure Ventilation (PPV): PPV may
be attempted in the spontaneously breathing
infant who remains cyanotic despite
administering 100% free flow of oxygen. In
non- vigorous babies born through MSL, bag
and mask ventilation is carried out only after
tracheal suctioning.

23.  The infant’s neck should be slightly extended
to ensure an open airway. Position yourself at
head end or at the side of the baby to have an
unobstructed view of infant’s chest and
abdomen. The appropriate facemask should
cover mouth and nose but not eyes of the
infant. Compress bag with using your fingers.
Observe for an appropriate rise of the chest.

24. Action Condition corrected
1.Reapply mask
2.Reposition infant’s head
3.Check for secretions, suction, if
present
4.Ventilate with mouth slightly
open
5.Increase pressure slightly
Inadequate seal
Blocked airway
Blocked airway
Blocked airway
Inadequate pressure

25. Bag
 Adult------1600 ml.
 Child-------500 ml.
 Infant-------500 ml.
Mask
 Adult------Size 4
 Child------Size 2
 Infant------Size 1
Reservoir
 Adult------suitable for 1600 ml. bag
 Child / Infant---Suitable for 500 ml. bag
Tubing
 Having suitable connectors at both ends for easy and
safe connections

27. Heart rate Action
Above 100
60-100
Below 60
If spontaneous respiration is
present, discontinue ventilation
gradually. Provide tactile
stimulation, and monitor heart
rate, respiration and color.
Continue ventilation
Continue to ventilate. Begin chest
compressions

28.  Chest compressions are indicated if HR is
below 60 b/m even after 30 sec. of positive
pressure ventilation with 100% oxygen.
 Once the HR is 60bpm or more, chest
compressions should be discontinued.

29.  Thumb technique( preferable): Two thumbs
are used to depress the sternum, with the
hands encircling the torso and the fingers
supporting the back.
 Two finger technique: the tips of the middle
finger and either the index finger of one hand
are used to compress the sternum. The other
hand is used to support the infant’s back,
unless the infant is on a very firm surface.

30.  One-third the depth of the chest is
recommended.
 3 compressions are performed and a pause
for ventilation left in place of the 4th
compression.
 This gives an effective rate of 90
compressions and 30 ventilations per minute.

31.  The heart rate should be re-evaluated every
30 seconds while compressions are being
performed.
 If the heart rate is less than 60 b/m after 30
seconds of chest compressions with effective
ventilation, then drug therapy will be
necessary

32.  Endotracheal intubation is required for
suctioning the trachea in the case of
meconium-stained amniotic fluid in a
depressed infant.
 Other indications are to provide prolonged
ventilation, to ventilate an infant in whom
positive-pressure ventilation has been
ineffective, and to ventilate an infant
suspected of having a diaphragmatic hernia.

33. Tube size
Inner diameter(mm)
Weight
(g)
Gestational age
(weeks)
2.5
3.0
3.5
4.0
<1000
1000-2000
2000-3000
>3000
<28
28-34
34-38
>38

34.  Two people are needed—one to intubate and
ventilate, and one to assist in managing
equipment and confirming proper tube
placement by listening to the infant’s lungs.
 The infant should be positioned in the same
“sniffing” position as for positive pressure
ventilation.
 A laryngoscope with a straight blade, size
1(term) or 0 (preterm), should be tested and in
good working order

35.  The laryngoscope blade is introduced
between the anterior wall of the hypopharynx
and the epiglottis.
 The appropriately sized endotracheal tube is
inserted until the tip lies 1 to 2 cm beyond
the vocal cords.
 Many tubes have markings to indicate the
appropriate placement.

36.  Proper depth of insertion can also be
estimated by calculating the depth at the tip
according to the following formula:
weight in kilograms + 6 cm = insertion depth
at lip in cm

37.  Drugs are rarely used in neonatal
resuscitation, but may be needed for the
most critically depressed newborns and those
with significant anomalies.
 Note that all drug doses are calculated based
on the infant’s weight.
 Since the weight is not precisely known, the
physician must clinically estimate the baby’s
size to calculate the doses.

38.  It is given if the infant’s heart rate is less than
60 per minute after 30 seconds of cardiac
compressions combined with effective
ventilation, or if the infant’s heart rate is zero
at delivery.
 Epinephrine improves systemic and
pulmonary perfusion. The recommended
dose is 0.01 to 0.03 mg/kg and the I/V route
is preferred.

39.  Do not give the higher dose IV, as it has been
associated with hypertension and worse
myocardial and neurological function.
 Epinephrine may be repeated every five
minutes as needed.
 Chest compressions and ventilation should be
continued, and the heart rate should be re-
evaluated every 30 seconds.

40.  Volume expanders are reserved for situations
in which blood loss has occurred or the infant
is clinically hypovolemic.
 Isotonic crystalloid solution, such as normal
saline or Ringer’s lactate, is the volume
expander of choice.

41.  Albumin solutions are less frequently used
for initial volume expansion because of
limited availability and evidence that colloids
(albumin and others) do not decrease
mortality.
 If albumin is used during neonatal
resuscitation, the dose is 10 ml/kg
intravenously, given slowly over 5 to 10
minutes to avoid intraventricular hemorrhage.

42.  It is no longer recommended to give
naloxone (Narcan) as an initial step of
neonatal resuscitation for newborns with
respiratory depression.
 Naloxone should be given if there is
continued respiratory depression despite
positive pressure ventilation, and the mother
has been given narcotics within four hours of
delivery.

43.  The dose is 0.1 mg/kg of 1.0 mg/ml
naloxone solution, and the preferred route of
administration is I/V and I/M( very less).
 Naloxone should not be given to the infant of
a mother who is a known or suspected
chronic narcotic user, since giving this drug
to an addicted newborn may precipitate
seizures.

44.  Sodium bicarbonate has been given to correct
metabolic acidosis. For documented
metabolic acidosis, the dose of sodium
bicarbonate is 2 mEq/kg, given intravenously
over at least two minutes.

45.  It is an semi- objective measure of assessing
the infant’s respiratory, circulatory and
neurological status at birth.
 Normal babies have an APGAR score of more
than 8 at 1 and 5 min.
 APGAR score between 4-8 is moderately low,
while that less than 4 is very low. 5 min.
 APGAR scores are more important than 1 min.
APGAR scores.

46. Score 0 1 2
•Respiratory
effort
•Heart rate/
min.
•Color of the
body
•Muscle tone
•Reflex
stimulation
None
Absent
Blue/ pale
Flaccid
No response
Slow, irregular
<100
Body pink,
extremities blue
Some flexion
Grimace
Good, crying
>100
Pink
Actively moving
the extremities
Cries, coughs or
sneezes

47.  Immediate task
 Cut the umbilical cord about 2-3 cm and tie
it with sterile thread or disposable clip.
 Examine the baby completely
 Weight the baby
 Decide whether this is a normal, ‘ at risk’ or
sick neonate and accordingly decide the level
of care.
 Make a case record of the baby.

48.  If normal:
 Clothe the baby, transfer to mother
 Initiate breastfeeding within half hour
 Communicate with the mother
 Monitor the baby
 Provide immunization (BCG & OPV). Hepatitis
B immunization may also be initiated at birth.
 Give discharge advice.
 Plan follow up.