2. Overview and Principles of Resuscitation
Initial steps of resuscitation
Positive – Pressure ventilation
Chest compressions
Endotracheal tube intubation and LMA
insertion
Medications
Special considerations
Resuscitation of Preterm babies
Ethics and Care at the end of life
4. Approximately 90% of newborns make
smooth transition from intrauterine to
extrauterine life requiring little or no
assistance
10% of newborns need some assistance
Only 1% require extensive resuscitation
We must always be prepared to resuscitate,
as even some of those with no risk factors
will require resuscitation.
5. Assess baby’s risk for requiring resuscitation
Providewarmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as required
Assist ventilation with positive
pressure
Intubate the trachea
Provide chest
compressions
Medications
Alwaysneeded
Needed less
frequently
Rarely needed
6. BEFORE BIRTH
Oxygen supply by placental
membranes
No role of lungs. Fluid filled
alveoli and constricted arterioles
due to low Po2 in fetal blood.
7. AFTER BIRTH
Baby cries takes first breath air enters alveoli
alveolar fluid gets absorbed increased Po2
relaxes pulmonary arterioles decreased PVR
16. 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 asapnea.
17. Good tone ?
Term: flexed extremities
Preterm/sick: flaccid/limp,
extended extremities
19. Provide warmth :
Radiant warmer, don’t
cover with towels.
Position head and
clear airway as
necessary
Dry and stimulate
the baby to breathe,
reposition
20. Suction mouth first, then
nose
“M” before“N”
Toprevent aspiration of
mouth contents
23. Respirations
Heart rate: Best is
auscultation, alternatively
pulsations at base of cord is
felt. Count for 6s and “x”10
Oxygenation by oximeter
24. If Apneic or HR < 100bpm:
Provide positive-pressure
ventilation,spo2 monitoring.
If breathing, and heart rate is
>100 bpm but baby is cyanotic,
give supplemental oxygen,
spo2 monitoring. If cyanosis
persists, provide positive-
pressure ventilation
If respiratory distress is
persistent , considerCPAPand
connectoximeter
25. Free flow oxygen
Oxygenmask
Flow inflating bag
T- piece resuscitator
Oxygen tubing held
close to baby’s nose
CPAP provided with
Flow inflating bag
T-piece resuscitator
Start with room air and
increase to maintain
targetSpO2
Time TargetSpo2
1min 60-65%
2min 65-70%
3min 70-75%
4min 75-80%
5min 80-85%
10min 85-95%
28. Ventilation of the lungs is the
single most and most effective
step in newborn resuscitation
Indications:
Gasping/apnea
HR < 100/min
SpO2 remains below target
values despite free flow
supplemental oxygen increased
to 100%.
30. Suction & Position
Cup the chin in
the mask and
then cover the
nose
Light Pressureon
mask to create a
seal
Anteriorpressure
on posterior rim
of mandible
31. 40 to 60 breaths per minute
StartWith 21% ( higher in preterm's) oxygen and
increase according to target Saturation
Initial Pressure at 20mmH2O
32. Most Important sign is the rising of HR
Improvement in OxygenSaturation
Equal and adequate breath sounds B/L
Good Chest rise
33. Heart rate
Oxygenation by
oximeter
If heartrate <100 bpm
34. Corrective steps Action
M MaskAdjustment Ensure Good seal ofmask
on face
R Repositionairway Sniffing Position
S Suction Mouth and nose If secretionspresent
O Openmouth Ventilate with baby mouth
slightly open and lift the
jaw forward
P Pressureincrease Gradually increase the
pressure every few breaths
A Airwayalternative Consider ET or Laryngeal
maskairway
35. Place an OG tube, Suction gastriccontents
and leave the end open.
36. If heart rate <60
bpm despite
adequate ventilation
for 30 seconds,
37. Indications :
HR <60/min
despite at least
30 sec of
effective PPV
Strongly consider Endotracheal intubation at this point
as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions
38. Rationale:
HR<60/min despite PPV indicates
very low O2 levels and significant acidosis
depressed myocardium no blood in
lungs to get oxygenated(supplied by PPV)
Chest compressions + effective ventilation
(ET/PPV) oxygenation of blood
recovery of myocardium to function
spontaneously HR increases O2 supply
to brain increases
39. Principle:
Rhythmic compressionsof
sternumthat
Compress the heart against the
spine
Increases intrathoracic pressure
Circulate blood to vital organs
Chest compressions
compresses heart & increased
Intrathoracic pressure blood
pumped into arteries
Pressure released bloodenters
heart fromveins
40. Positions :
Chest compressions are of
little value unless the lungs
are effectivelyventilated
2 persons are required
1 – chest compressions
provider should have accessto
the chest with his hands
positioned correctly
2 –Ventilation providershould
be at head end to maintain
effective mask-face seal or to
stabilize ET tube
41. Technique:
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.
42. Thumb technique is
preferred as
Better control of depth of
compression
Can provide pressure
consistently
Superior in generating
peak systolic and coronary
arterial perfusion
pressure.
47. Depth : 1/3rd of the
anter0posterior
diameter of chest.
Duration of
downward stroke
should be shorter
than the duration
of release
Do not lift the
fingers off the
chest
49. Coordination of chest compressions and
ventilation:
Avoid giving compression and ventilation
simultaneously
1 breathe after every 3 compressions
Ratio is 1 : 3 or 30: 90 per minute
One cycle: 2 sec, 3Compresssions + 1 ventilation
1 minute : 30 cycles or 120 events (90 compressions +
30 breaths)
50. When to stop chest compressions?
Reassess after 45-60 sec, if HR > 60/minstop
chest compressions and increase breaths to
40-60 per minute.
If HR is not improving…
Insert an umbilical catheter and giveIV
epinephrine
51.
52. WHENTOCONSIDER INTUBATION?
Indications in resuscitation
Baby is floppy, not crying, and preterm
HR < 100/min, gasping/apnea
HR < 100/min inspite of PPV
HR < 60/min
No adequate chest rise and no clinical
improvement
If chest compressions are needed, intubation
provides better coordination and efficacy of PPV
Toadminister drugs
53. WHENTOCONSIDER INTUBATION?
Special conditions
Meconium aspiration if baby is depressed in
which it is the first step to be done
Extreme Prematurity
Surfactant administration
Suspected diaphragmatic hernia
54. Laryngoscope with extra
blades and bulbs
Straight blades
Term – 1
Preterm – 0
Extremely preterm - 00
58. Watching the tube passing between cords
Watching for chest movements
Listening for breath sounds ( Axilla and stomach)
Colourimeter/Capnography ( Can also be used for PPV
with mask or LMA
Improvement in HR andSpo2
Vapour Condensing insidetube
59. Mechanism of action :
Increases systemic vascular resistance
Increases coronary artery perfusion pressure
Improves blood flow to myocardium and
restores depletedATP
Indications :
If HR remains < 60/min even after 30 sec of
effective ventilation preferably after intubation
and atleast another 45-60 sec of coordinated
chest compressions and effective ventilation
60. Administration :
Intravenous (recommended)
Endotracheal
Preparation and dosage:
Adrenaline vial 1ml = 1mg (1:1000 solution)
Dilute with NS to make 1:10,000 solution (1ml =
100 mcg)
IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
Give rapidly – as quickly as possible
Can repeat every 3-5 minutes
61. Indications:
Bradycardia not improving with adrenaline
Placenta previa/Abruption
Volume Expanders:
Normal saline (recommended)
Ringer lactate
Dosage: 10 ml/kg
Route : Umbilical vein
Rate: over 5-10 min , rapid infusion may
cause IVH in <30 weeksbabies
62. Additional resources , additional personnel,
additional thermoregulation strategy
▪ Portable warming pad
▪ Polyethylene Plastic wrap (< 29wk)
▪ Prewarmed transport incubator
Use of Oxymeter, blender to targetSpo2
85%- 95%
Use Lower PIP 20-25 cm of H2O during PPV
Consider giving CPAP
ConsiderSurfactant
63. Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and E/O
Acute perinatal HIE
Monitor for Apnea, bradycardia, BP,SPo2
&Urine output.
Monitor B. Sugars, electrolytes , Hematocrit,
Platelets,ABG
Maintain adequate oxygenation & support
ventilation as needed
64. Delay feeds, Start IV fluids,consider
parenteralnutrition
Consider inotropes , fluid bolus
Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)
65. Choanal atresia – oralAirway
Pierre Robin : place prone , 12F Et through
nose with tip in post pharynx
Laryngeal web, cystic hygroma,Cong.Goiter-
ET/tracheostomy
Pneumothorax : Percutaneous needle
aspiration
Pleural effusion : Percutaneous needle
aspiration
Congenital Diaphragmatichernia
66. Meeting and discussing with parents and
documenting the conversation.
WhereGA ( < 23wks ), B.wt ( < 400g) and / or
Cong.Anomalies are associated with certainly
early death and unacceptably high morbidity
among rare survivors resuscitation is not
indicated
After 10 minutes of continuous and adequate
resuscitative efforts, discontinuation of
resuscitation may be justified if there are no
signs of life (no heart beat and no respiratory
effort).
67. Doing the simple things better is probably the
most cost-effectivepolicy.
Resuscitation can come as complete surprise
So be prepared for resuscitation.
It may take several hours to learn but it
should be implemented over seconds.
Practice makes one perfect.
68. Neonatal resuscitationTextbook 6th ed.
4 million neonatal deaths:When?Where?
Why? Lancet 2005; 365: 891–900
Park’sTextbook of Preventive andSocial
Medicine , K. park 21st Edition .