definition, indications, articles procedure and algorithm of neonatal resuscitation

1. NEONATAL
RESUSCITATION
Kiran Kaur
Lect. CON
PGIMS, Rohtak

2. Cardio pulmonary Resuscitation
It is a technique of basic life support for the patient
who is not breathing and has no pulse. It involves a
series of steps used to establish artificial ventilation
and circulation.

3. Neonatal Resuscitation
Resuscitation of newborn child with birth asphyxia is called neonatal
resuscitation.
It is a series of actions used to assist newborn babies having difficulty in
making physiological transition from intrauterine life to extra uterine
life.

4. Purposes
• To maintain open and clear airway.
• To maintain breathing by artificial ventilation.
• To maintain blood circulation by external cardiac massage.
• To save life of neonates having weak or no respiratory efforts.
• To provide basic life support till medical and the advanced life support
arrives.

5. Indications
• Birth asphyxia
• Meconium aspiration syndrome
• Preterm birth with least respiratory efforts
• Fetal distress

6. Articles
Suctioning Articles
• Bulb syringe
• De lee mucus trap with No-10 Fr catheter or mechanical suction
• Suction catheters 6,8,10 Fr
• Feeding tube 6 and 8Fr
• 10&20 ml syringe

7. • Bag & Mask articles
• Infant resuscitation bag (C pressure release value or pressure gauge
with reservoir capable of delivering 90-100% oxygen)
• Face Mask- newborn and premature size (with cushioned rim)
• Oral airways
• Oxygen with flow meter & tubing
• Intubation articles
• Laryngoscope with straight blades No. 0,1
• Extra bulb & batteries
• Endotracheal tubes size – 2.5, 3.0, 3.5 & 4.0 mm
• Stylet

8. • Medications
• Epinephrine (1:10,000)
• Naloxone hydrochloride
• Volume expanders (5% albumin solution, Normal saline, Ringer
lactate)
• Sodium bicarbonate
• Dextrose 10%
• Sterile water

9. Miscellaneous
• Radiant warmer
• Stethoscope
• Adhesive tape, bandage, scissor
• Syringe 1ml, 2ml, 5ml, 10ml &
20ml
• Needles no. 21,22,26 G
• Umbilical catheter 3.5, 5 F
• Three-way stopcock
• Umbilical cord clamp
• Gloves, Warm dry towels
• Watch with second hand
• Linen, Shoulder roll

10. Algorithm of neonatal resuscitation

11. Principle of neonatal resuscitation
T= Temperature
• Receive the baby in a prewarmed linen.
• Keep the baby under radiant warmer.
• Dry the baby immediately.
• Remove the wet linen.
• Maintaining room temperature 25 + 20 C
• Cover head of the baby.

12. A=Airway
Positioning:
Place the baby on its back.
•Position the head so that it is slightly extended to open the
airway.
•Place a folded piece of cloth under the shoulder of baby to
help to maintain the position. The folded cloth under the
baby’s shoulder should not be too thick or thin that may lead to
overextension or flexion of airway.

13. Suctioning:
• Suction first the MOUTH & then the NOSE with the help of bulb syringe or
mechanical suction.
• Do suction gently by introducing the suction tube 5cms in baby’s mouth
until the 5cms mark is at baby’s lips.
• Use suction while withdrawing the tube.
• Next introduce the suction tube upto 3 cms into each nostril.
• Suction for less than 15 seconds. If the infant has copious secretions from
the mouth, the head should be turned to the side.
• The size of suction catheter should be 6,8 or 10 F.
• The suction pressure should be kept 40-60 mm Hg for pre-term infant and
60-80 mm Hg for term neonate.

14. B= Initiating Breathing
• Tactile stimulation:
• Both drying & suctioning the infant produces stimulation, which is for many infants is enough to
induce respiration.
• If respiration is inadequate, tactile stimulation is given by slapping or flicking the soles & rubbing
the newborn’s back, trunk or extremities. These slaps/flicks should be given once/twice.
• If the infant remains apneic, positive pressure ventilation should be started
• PPV if necessary
• Positive pressure ventilation: Bag and mask ventilation is indicated if after tactile stimulation
• The infant is apneic or gasping.
• HR< 100 bpm
• Persistent central cyanosis despite of administration of 100% free flow oxygen.
• PPV should be given with self-inflating bag and face mask. The resuscitation bag should have a
capacity of 240-750 ml. If the bag is attached to an oxygen source (at 5-6 Liter/min.) & a reservoir
which delivers 90-100% oxygen.

15. Procedure of giving PPV:
• Place the infant in neck slightly extended position to ensure open airway.
• Place the correct size mask on the baby's face so that it covers the baby's
chin, mouth and the nose.
• Make a seal between the mask and the baby's face.
• Hold the mask in place gently but firmly. Keep the head in position.
• Squeeze the bag attached to the mask with the thumb and two fingers so
as to cause adequate chest rise with each ventilation. Ventilate at a rate of
40-60 breaths/minute.
• Count out loud. SQUEEZE-count a loud' one hundred and one, SQUEEZE
one hundred and two, SQUEEZE one hundred and three, SQUEEZE……..'
and continue until you reach 'One hundred and twenty'(i.e. For 30
seconds).
• If the chest is not rise and there no audible breath sounds, the following
steps to be undertaken:

16. VENTILATION CORRECTIVE STEPS (MRSOPA)
Action Remedial steps
Inadequate seal Reapply Mask
Blocked airways Reposition the head in sniffing position
Blocked airway
Suction the airway
Open baby’s mouth and ventilate
Inadequate pressure
Increase Pressure by squeezing the bag with
more Pressure till a chest rise is visible
No improvement with
above steps
Consider endo tracheal intubation (Airway
maintain)

17. • Provide uninterrupted effective ventilation for 30 seconds and assess
for spontaneous
• breathing and heart rate. If spontaneous breathing present and heart
rate is 100 or more, then gradually discontinue PPV.
• After 30 seconds of bag and mask ventilation, reassess respiratory
efforts, heart rate every 30 seconds (oxygen saturation may be
monitored continuously if available) and look for the following signs
of improvement:

18. Response to ventilation should be seen by:



Improvement in baby’s color from blue to pink
Improved respiration
Heart rate >100 bpm.

19. FOLLOW-UP ACTIVITY FOR HEART RATE RESPONSE:
HR ACTION
Above 100
 STOP ventilation if spontaneous respirations are present;
provide tactile stimulation by gently rubbing the body, &
monitor HR, Respiration & color.
 If gasping or not breathing, continue ventilation
60 to 100 Continue bag and mask ventilation, take corrective steps
measures
Below 60 Begin chest compressions; Continue to ventilate

20. C= Maintain circulation
• Chest compressions: When the infant is hypoxic, there is diminished
blood and oxygen flow to the vital organs. Chest compressions are
used to temporarily increase circulation and oxygen delivery. Chest
compressions should be accompanied with 100% oxygen, so that the
blood being circulated during chest compressions gets oxygenated.

21. Indication of providing chest compressions:
•HR<60, even after 30 seconds of PPV.
•HR is between 60-80 but not increasing

22. PROCEDURE OF PROVIDING CHEST COMPRESSIONS:
• Techniques of providing chest compressions:
• Thumb technique
• Two-finger technique
• When chest compression is performed on a neonate, pressure is applied to the lower third of the
sternum. To locate the area, one should slide the fingers on the lower edge of thoracic cage and
locate xiphisternum. The lower third of sternum is just above it.
• Rate: In one minute, 90 chest compressions and 30 breaths are administered (a total of 120 events)
in a ratio of 3:1
• Thumbs or tips of fingers remain in contact with chest during compressions and release. Don’t lift
your thumb or fingers off the chest between compressions.
• To determine efficiency of chest compressions, the carotid or femoral pulsations should be checked
periodically.
• Evaluation: after a period of 30 seconds of chest compressions, the HR is checked.
• HR<60 bpm: Chest compressions should be continued with bag and mask ventilation. Endotracheal
intubation and Medications can be administered.

23. Thumb Technique Two Finger Technique

24. • Possible Complication
• Injury – to vocal cord, trachea, throat, ribs
• Bleeding
• Trauma
• Bronchospasm
• Infection

25. • Care after procedure
• Make sure that baby’s pulse rate & respiratory rate are normal.
• Remove all equipments from bed side.
• Provide oxygen if necessary & maintain normal saturation.
• Wash all articles.
• Wash hand to prevent infection.
• Record the procedure.