NRP- 2010 guidelines

1. Dr Anagha Anand

2.  Neonatal Resuscitation is intervention after a
baby is born to help it breathe and to help its
heart beat.
 Of the 25 million infants born every year in
India, 3-5% experience asphyxia at birth
 Neonatal resuscitation skills are essential for
all health care providers who are involved in
the delivery of newborns

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

4.  Anticipation
 A radiant heat source ready for use
 All resuscitation equipments immediately
available & in working order
 At least 1 person skilled in neonatal
resuscitation

7. Neonatal Resuscitation Supplies & Equipments
-Suction Equipment
Mechanical suction
Suction catheters 10,12, or 14 F
Meconium aspirator
-Bag and Mask Equipment
Neonatal resuscitation bags ( self limiting)
Face-masks ( for both term & preterm babies)
Oxygen with flow meter and tubing
-Intubation Equipment
Laryngoscope with straight blades no.0 (preterm)& no.1 (term)
Extra bulbs & batteries ( for laryngoscope)
Endotracheal tubes ( int diameter 2.5, 3, 3.5 & 4)

8. Medications
Epinephrine
Normal saline or Ringer Lactate
Naloxone hydrochloride
Miscellaneous
Linen, shoulder roll, gauze
Radiant warmer
Stethoscope
Syringes 1,2,5,10,20,50 ml
Feeding tube 6 F
Umbilical catheters 3.5, 5 F
Three way stopcocks
Gloves

9.  Based primarily on 3 signs
 Respiration
 Heart rate
 Color

11.  Performed at 1min & again at 5 min after birth.
 But resuscitation must be initiated bfr 1 min score
is assigned
 Not used to guide resuscitation
 But can reflect how well the baby is responding to
resuscitative efforts
 Should be obtained every 5 min for upto 20 min,
if the score is < 7

13. Term / Preterm ?
 Term: smooth transition
 Preterm : stiff, under-developed lungs,
insufficient muscle strength, can’t maintain
temperature
Breathing/Crying ?
 Watch baby’s chest
 Gasping is a series of deep, single or stacked
inspirations that occur presence of
hypoxia/ischemia. Treated as apnea.

14. Good tone ?
 Term: flexed extremities
 Preterm/sick: flaccid/limp,
extended extremities

15.  Provide warmth : Radiant warmer, don’t cover with
blankets or towels.
 Position head and clear airway if necessary
 Placed on her back or side with neck slightly
extended.
 Brings post pharynx, larynx & trachea in line
 Place a rolled blanket or towel under the shoulders,
elevating them 3/4th or 1 inch off the mattress.

17.  Suction mouth first, then nose
 “M” before “N”
 To prevent aspiration of mouth contents
 If copious secretions present → head should
be turned to one side
 Never insert catheter too deep in mouth or
nose for suction → stimulation of post
pharynx → vagal response → bradycardia or
apnea
 Max time limit – 15 sec

19.  For non-vigorous babies initial steps are
modified as:
 Place under radiant warmer. Postpone drying &
suctioning to prevent stimulation
 Remove residual meconium in the mouth & post
pharynx by suctioning under direct vision using
laryngoscope
 Intubate & suction out meconium from the lower
airway

20.  Dry, Stimulate and Reposition
 Stimulate : Flicking the soles/ drying & rubbing
the back

21.  Respirations
 Heart rate: Best is auscultation, alternatively
pulsations at base of cord is felt. Count for 6s and
“x”10
 Color- look at tongue, mucous membranes & trunk

22.  If baby has good breathing, HR>100/min, no
cyanosis →no additional intervention
 If baby has laboured breathing or persistent
cyanosis
-preterm babies → CPAP
-term babies→ supplemental oxygen
 If baby is apneic, has gasping breathing or HR <
100/min → PPV is needed

23.  PPV – using a self-inflating bag & face mask

24. Indications:
 Gasping/apnea
 HR < 100/min
 Persistent central cyanosis despite
administration of 100% free flow oxygen
Contraindications:
 Diaphragmatic hernia
 Non vigorous babies born through MSL, B & M
ventilation carried out only after tracheal
suctioning

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

26. When n/l rise of chest is observed start ventilating.
Ventilation should be carried out at a rate of 40-60
breaths per min, following a ‘squeeze, two, three’
sequence

27.  PPV may cause abd distension as gas escapes
into the stomach via oesophagus.
↓
Presses on diaphragm & compromises the
ventilation
 So orogastric tube should be inserted & left
open to decompress the abdomen

28. Rhythmic compression of the sternum
→compress heart against spine → ↑se
intrathoracic pressure → circulate blood to
the vital organs
 Always accompanied by BMV so that only
oxygenated blood is circulated

29. Indications :
 HR <60/min even after 30 sec of effective
PPV
 Once HR>60/min CC should be discontinued.

30.  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.

31.  A positive breath should follow every third
chest compression
 In 1 min 90 compressions & 30 breaths are
administered
 To determine the efficiency of CC, the carotid
or femoral pulsations should be checked
periodically

32.  After 30 sec HR is checked:
 HR<60 → CC should continue along with B &
M ventilation. In addition medications have to
be given
 HR>60 → CC should be discontinued. BMV
should be continued until the HR > 100/min
& the infant is breathing spontaneously

34.  When tracheal suction is required ( non
vigorous babies born through MSL)
 When prolonged BMV is required
 When BMV is ineffective
 When diaphragmatic hernia is suspected

35.  Laryngoscope with extra blades and bulbs
 Straight blades
 Term – 1
 Preterm – 0

37.  Infant’s head should be in midline & neck
slightly hyper extended.
 Laryngoscope is held in left hand b/w thumb
& the first three fingers, with the blade
pointing away from oneself
 Stand at the head end, the blade is
introduced in the mouth & advanced to just
beyond the base of tongue

39.  Once the glottis & vocal cords are visualized,
he ET is introduced from the right side of the
mouth
 Its tip is inserted into the glottis until the
vocal cord guide is at level of the glottis

40. 1. Epinephrine (1:1000)
Indication :HR< 60/min after 30 sec of effective
PPV & CC.
Effects: Inotropic, chronotropic, peripheral
vasoconstrictor
Dose: 0.1-0.3ml/kg
Route: i.v, through umbilical vein, directly into
tracheobronchial tree through ET

41.  NS, RL
Indication: Acute bleeding with hypovolemia
Effects: increase intravascular volume, improves
perfusion
Dose: 10ml/kg
Route: umbilical vein

42.  Naloxone (0.4mg/ml)
Indication: Respiratory depression with maternal
history of narcotic use within 4 hr of birth
Effects: Narcotic antagonist
Dose: 0.25ml/kg(0.1mg/kg)
Route: i.v preferred, delayed onset of action with
i.m use, administer only after restoring ventilation