About 10% of all newborn require some assistance to begin breathing after birth, and 1% require extensive resuscitation efforts. Newborn resuscitation cannot always be anticipated in time to transfer the mother before delivery to a facility with specialized neonatal support. Therefore, every hospital with a delivery suite should have an organized, skilled resuscitation team and appropriate equipments available.

2.  Series of actions, used to assist, newborn
babies who have difficulty with making the
physiological ‘transition’ from the intrauterine to
extrauterine life.

3.  About 10% of all newborn require some assistance to
begin breathing after birth, and 1% require extensive
resuscitation efforts.
 Newborn resuscitation cannot always be anticipated
in time to transfer the mother before delivery to a
facility with specialized neonatal support. Therefore,
every hospital with a delivery suite should have an
organized, skilled resuscitation team and appropriate
equipments available.

4.  Normal transitional events at birth begin with initial lung
expansion, generally requiring large negative
intrathoracic pressures, followed by a cry. Umbilical
cord clamping accompanied by a rise in systemic blood
pressure and massive stimulation of the sympathetic
nervous system. with onset of respiration and lung
expansion, pulmonary vascular resistance decreases
followed by gradual transition from fetal to adult
circulation, with closure of the foramen ovale and
ductus arteriosus.

5.  The asphyxiated newborn undergoes an abnormal
transition. Acutely with asphyxiation the fetus
develops primary apnea, during which spontaneous
respirations can be induced by appropriate sensory
stimuli. If the asphyxial insult persist about another
minute, the fetus develop deep gasping for 4-5
minutes, followed by a period of secondary apnea,
during which spontaneous respiration cannot be
induced by sensory stimulation.

6.  Death occurs if secondary apnea is not reversed
by vigorous ventilatory support within several
minutes. Because one can never be certain
whether an apnoeic newborn has primary or
secondary apnea, resuscitative efforts should
proceed as though secondary apnea is present.

7.  Preparation for a high risk delivery is often the key
to a successful outcome. Cooperation between the
obstrtic, anesthesia and paediatric staff is
important. Knowledge of potential high risk
situations and appropriate interventions is
essential. It is useful to have an estimation of
weight and gestational age, so that drug doses can
be calculated and appropriate endotracheal tube
and umbelical catheter size can be chosen.

8.  While waiting for the infant to arrive it is potential
problems, steps that may be undertaken to
correct them, and which member of the team will
handle each step. Provided there is both time and
opportunity, resuscitative measures should be
discussed with the parents. This is particularly
important when the fetus is at the limit of viability
or when life threatening anomalies are
anticipated.

9.  Radiant warmer.
 Stethoscope.
 Pulse oximeter.
 Compressed air and oxygen source.
 Oxygen blender.
 Suction source, suction catheter, and
meconium aspirators.

10.  Nasogastric tubes
 Apparatus for bag and ventilation.
 Ventilation mask
 Laryngoscope
 Endotracheal tubes
 Epinephrine
 Volume expanders
 Clock
 Syringes
 Equipments for uvc
 Warm blankets

14.  The APGAR score is assigned at 1, 5 and
occasionally, 10-20 min after delivery. It gives fairly
a retrospective idea of how much resuscitation a
term infant required at birth and the infants
response to resuscitative efforts. During
resuscitation , simultaneous assessment of
respiratory activity and heart rate provides the
quickest and most accurate evaluation of the need
for continuing resuscitation.

15. Sign 0 1 2
Color
(Appearance)
Blue
Pale
Body pink,
Extremities
blue
Completely
pink
Heart Rate
(Pulse)
Absent < 100/min > 100/min
Reflex Irritability
(Grimace)
Absent Grimace Cough,
Sneeze
Muscle Tone
(Activity)
None Some flexion
of extremities
Active
movement
Respiratory
Effort
Absent Slow Good, crying

16.  Achieved by 90% of neonates, nothing is
required, except
› Nasal and oral suctioning
› Drying of the skin
› Maintenance of normal body temperature.

17.  Suffered mild asphyxia just
before birth.
› Respond to vigorous
stimulation.
› Oxygen blown over the face.

18.  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.

19.  These neonates severely asphyxiated and
require immediate resuscitation.

20.  The baby should be positioned on the back with
the neck slightly extended in the neutral position.
 Clear air way-By suctioning oro-pharyngeal and
nasal secretion by using suction catheter if there
are sign of air way obstruction. Introduce the
catheter about 5cm into the mouth and 3cm into
the nose.

21.  If liquor is meconium stained and baby is non
vigorous give suction of oral cavity and tracheal
suctioning after intubation before drying.
 While clearing airway in meconium stained the
suction pressure should be at 100mmHg, suction
should not be more than 10 seconds at a time.

22.  In 1974 Gregory and associates were among the
first to show that endotracheal suctioning at birth
was beneficial.
 More recently the American Heart Association and
American Academy of Paediatrics recommended
endotracheal suctioning when meconium is
present in amniotic fluid and infant is non
vigorous.
 Clinical judgement is always Important in
deciding whether or not aggressive endotrachel
suctioning is necessary.

23. Harmful Action
 Slapping the back
 Squeezing the rib cage
 Holding upside down
and shaking
Consequences
 Bruising
 Fractures,
pneumothorax, death.
 Intraventricular
bleeding, brain
damage.

24.  Most infants can be adequately ventilated with a
bag and mask provided that the mask is the
correct size with a close seal around the mouth
and nose and there is an appropriate flow of gas
to the bag.

25.  Position of resuscitator should be at the baby’s side
or head to use a resuscitation device effectively.
 Both positions leave the chest and abdomen
unobstructed for visual monitoring of the baby, for
chest compressions and for vascular access via
umbilical cord.
 Position of the baby’s head: The baby’s neck
should be slightly extended (but not over extended
non flexed) into the “sniffing position” to maintain
an open airway.

26.  Place the mask on the face so that it covers the
nose and mouth and tip of the chin rests within the
rim of the mask.
 Use four fingers to ensure sealing: Thumb and ring
finger to encircle the upper stiff part of the mask to
keep the mask firmly apposed on face, middle
finger resting on the rim at chin and little finger at
the jaw to maintain neutral position.

27.  Once positioning and sealing are done start
bagging and observe whether chest rises with
each squeeze. Continue BMV at the rate of 30-40
breaths/min.
 Be sure that chest rises with each squeezing.
 If chest does not rise with squeezing:
Repositioning
Check the mouth, oro-pharynx and nose for
secretions, suction the mouth and nose if
necessary.
Reapplying mask with mouth open and
ensuring better seal.

28.  Continue effective ventilation for one minute at
the rate of 40 breaths/min.
 To help a rate of 40 breaths/min try saying to
yourself as you ventilate the newborn..
 One thousand… one… one thousand… two…
(Squeeze) (Release) (Squeeze)
(Release)

29.  Improvement is indicated by the signs
› Improving color
› Breathing well
› Improving muscle tone.
 If spontaneous regular breathing
established reduce rate of BMV and
discontinue.

30.  If heart rate <60 b/min, continue effective BMV till
spontaneous regular breathing is established
along with assessment for signs of improvement
every 30 seconds.
 When the heart rate stabilizes above 100
b/minutes and no spontaneous regular
respirations, reduce the rate and pressure of
assisted ventilation until effective spontaneous
respirations.

31.  If heart rate remains below 60 b/min
despite one min of effective ventilation,
proceed to the next step of chest
compressions.
 If physiologic improvements still cant be
achieved, Endotracheal intubation may
be done if possible.

32.  Insert an oro-gastric tube and left in place.
 The problems related to gastric/abdominal
distention and aspirations of gastric contents
can be reduced by inserting an oro-gastric
tube, suctioning gastric contents and leaving
the gastric tube in place and uncapped to act
as a vent for stomach gas throughout the
reminder of the resuscitation.

33.  The American Heart Association and American
Academy of Paediatrics recommended that
blended gas be used for positive pressure
ventilation and oxygen concentration be
adjusted to meet the preductal pulse oxymetry
goals based on the age after birth.

34. Age SPO2
 1 min 60-65%
 2 min 65-70%
 3 min 70-75%
 4 min 75-80%
 5 min 80-85%
 10 min 85-95%

35.  The chest compressions should be started when
the heart rate is <60 b/min and baby is not
breathing at all or
 Gasping after giving several cycles of effective
bag mask ventilation .
 The person performing chest compressions must
have access to the chest and be able to position
his or her hands correctly.
 The person assisting ventilation will need to be
positioned at the baby’s head to achieve an
effective mask –face seal and watch for effective
chest movement.

36.  Two techniques:
 1. The two thumb encircling hand technique:
› Two thumbs are used to depress the sternum, while
the hands encircle the torso and the fingers
support the spine.
› Hands should be positioned on the lower third of
the sternum in the midline.
› The thumbs can be placed side by side or on small
baby, one over the other.
› The thumbs should be fixed at the first joint and
pressure applied vertically to compress the heart
between the sternum and the spine.

37.  2.The two finger technique
› The tip of the middle finger and either the index
finger or ring finger of one hand are used to
compress the sternum, while the other hand is used
to support the baby’s back.
› Position two fingers perpendicular to the chest and
press with the finger tips.
› The 2 thumbs encircling hands technique is
recommended for performing chest compression in
newborn as it generates higher peak systolic and
coronary perfusion pressure than two finger
technique.

38. Two techniques for performing chest compression
The required pressure to compress the chest:
Use enough pressure to depress the sternum to a
depth of approximately 1/3rd of the anterior posterior
diameter of the chest and then release the pressure
to allow the heart to refill. One compression consist
of the downward stroke plus the release. The actual
distance compressed will depend on the size of the
baby.

39.  During cardiopulmonary resuscitation ,chest
compressions must always be accompanied by
positive pressure ventilation, with one interposed
after every third compression for a total of 30
breaths and 90 compressions per minute.
 One cycle of events(CPR Cycle) will consist of 3
compressions plus 1 ventilation(these 4 events
should be administered in 2 seconds)
 If the heart rate <60 bpm after several cycles of
CPR then consider the use of drugs.

41.  Before initiating drug treatment, one should
check the following:
› Whether the air way is open
› Whether the chest inflates with each ventilation
› Whether chest compression given properly.
› If the newborn does not respond even after the
airway is open the chest moves easily with
ventilation,and effective chest compressions
has been given, only then the drugs may help.

42.  Intravenous adrenaline 1:1000;1ml mixed with 9ml
of distilled water to make a 1:10000 dilution.0.1-
0.3 ml/kg I/V and 0.5-1ml/kg can be given in ET
Tube.
 Volume expander: when blood loss in known or
suspected (Pale skin, weak pulse, poor perfusion
and heart rate not responding adequately to the
other resuscitative measures) an isotonic
crystalloid solution or blood 10ml/kg is
recommended which may need to be repeated.

43.  Volume expanders should be infused very slowly
to the premature babies. If infused rapidly that
may cause hypertension & Intra ventricular
hemorrhage.
 Intravenous glucose administration should be
considered as soon as after resuscitation with the
goal of avoiding hypoglycemia.

44.  Sodium bicarbonate:
Sodium bicarbonate is usually not useful during
the acute phase of neonatal resuscitation.
Without adequate ventilation and oxygenation it
will not improve the blood pH and may worsen
cerebral acidosis. After prolong resuscitation
sodium bicarbonate may useful in correcting
documented metabolic acidosis.

45.  Atropine and Calcium:
Although previously used during resuscitation of
the asphyxiated newborn, atropine and calcium
are no longer recommended by the American
Academy of Paediatrics and American Health
Association during the acute phase of neonatal
resuscitation. These medications are used
sometimes in special circumstances in
resuscitation.

46.  Temperature regulation: Regulation of
temperature specially for preterm neonates, who
have thin skin, decrease stores of body fat &
increased body surface area. Heat loss may be
prevented by the following measures-
› Dry the infant thoroughly immediately after
delivery.
› Maintain a warm delivery room.
› Place the infant under pre warmed radiant
warmer.

47.  Previous protocol of resuscitation by BSMMU was
after 20minute of continuous and adequate efforts if
there are no signs of life(no heart rate, no
respirations),discontinue resuscitative efforts.
 Newer protocol by American Academy of Paediatrics
and American Heart Association state that if there is
no heart rate after 10minute of adequate resuscitation
efforts, discontinuation of resuscitation may be
adequate.

48.  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.

49.  Oxygen saturation(SpO2)
 Heart rate
 Respiratory rate and pattern
 Blood glucose measurement
 Blood gas analysis
 Fluid balance and nutrition
 Blood pressure
 Temperature
 Neurological

50.  Talk with the parents about resuscitation, answer any
question they may have.
 Counsel parents about hospital admission for post
resuscitation care.
 Encourage mother to keep the baby warm.
 Explain that there are some risks of infection, feeding
problem and convulsions. Advise them to come
promptly if any medical problem arises.

53.  No respirations, no cry, gasping respirations with
long pause in between pale or blue color, heart rate
absent or <100 b/min- Go for resuscitation.
 Early diagnosis and early interventions results good
outcome.
 Proper technique of resuscitation can give a good
start of a newborn.
 Proper counseling and advice can aware parents
about post resuscitative consequences.
 Early assessment and coordinated team work can
minimize the neonatal death ratio.

54. › Neonatology by Gomella Cunninghum
Eyal (7th edition)
› Text book of neonatal resuscitation (7th
edition)
› BSSMU Guidelines for neonatology
› American academy of paediatrics
› https://www.ncbi.nlm.nih.gov/pubmed/293
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