Neonatal Resuscitation

Dr. Ankit Yadavendra,

M. D. Paediatrics Resident,
Bombay Hospital Institute of Medical Sciences,
Mumbai.
 REFERENCE
• American Academy of Pediatrics. Textbook of
Neonatal Resuscitation. 7th edition. 2016
• Eric C. Eichenwald, Anne R. Hansen, Camila R.
Martin, Ann R. Stark, Cloherty and Stark’s Manual
of Neonatal Care, 8th Edition, Wolters Kluwer
• Richard J. Martin, Avroy A. Fanaroff, Michele C.
Walsh, Fanaroff and Martin’s Neonatal and
Perinatal Medicine Diseases of the Fetus and
Infant, 4th Edition, Saunders Elsevier
What is a neonate (newborn)?
• Chronological age ≤ 28 days
What is a preterm?
Infant classification by GA:
Preterm: < 37 wkGA (258 days).
• Extremely preterm: < 28 wkGA (195 days)
• Early preterm: 28 0/7 - 33 6/7 wkGA (195-237
days)
• Late preterm: 34 0/7 - 36 6/7 wkGA (238-258
days)
Term: 37 0/7 - 41 6/7 wkGA (259-293 days)
• Early term: 37 0/7 - 38 6/7 wkGA (259-272
days)
Postterm: ≥ 42 wGA (294 days)
What is low birth weight?
Birth weight classification.
• Normal birth weight (NBW): 2,500-4,000 g
• Low birth weight (LBW): < 2,500 g
• Very low birth weight (VLBW): < 1,500 g
• Extremely low birth weight (ELBW): < 1,000 g
What is resuscitation?
• Resuscitation: efforts at delivery
designed to help the newborn make
the respiratory and circulatory
transitions that must be accomplished
immediately after birth
• Incidence: 10% neonates require some
assistance, < 1% require extensive
resuscitation
Goals of Rususcitation?
Primary goal: To ensure an adequate
airway and respiration
Other goals:
• Minimising immediate heat loss
• Establishing normal respiration and lung
expansion
• Increasing arterial pO2
• Supporting adequate cardiac output
Indications to be ready for
resuscitation?
• Evidence of nonreassuring fetal status
1. sinusoidal pattern or absent fetal heart rate
variability with late decelerations, recurrent
variable decelerations, or bradycardia
2. H/o an acute perinatal event (e.g., placental
abruption, cord prolapse or abnormal fetal
testing, or a scalp pH ≤ 7.20)
3. H/o decreased fetal movement, diminution in
growth, or abnormalities of umbilical vessel
Doppler flow studies
Evidence of fetal disease or potentially
serious conditions:
• Meconium staining of the amniotic fluid
• Prematurity, postmaturity (> 42 wkGA),
anticipated LBW (< 2.0 kg), or HBW (> 4.5 kg)
• Major congenital anomalies diagnosed
prenataly
• Hydrops fetalis
• Multiple gestation
Labor and delivery conditions
• Significant vaginal bleeding
• Abnormal fetal presentation
• Prolonged or unusual labor
• Concern about a possible shoulder dystocia
What are the necessary
equipments?
• Radiant warmer with procedure table or
bed.
• Delivery room temperature=26℃
• Plastic wrap for preterms
• A blended oxygen source (adjustable
between 21-100%) with adjustable
flowmeter and adequate length of
tubing.
• Pulse oximeter
• Flow-inflating bag with adjustable pop-
off valve or self-inflating bag with
reservoir.
• Face mask(s) of appropriate sizes
• Reservoir
• A bulb syringe or mucous extractor
• Stethoscope
• Laryngoscope with no. 00, 0 and no. 1
blades, with extra batteries
• Uniform diameter ET tubes (2.5-, 3.0-,
and 3.5-mm internal diameters), two of
each
• ETT stickings
• Umbilical catheterization tray with 3.5
and 5 French catheters
• Syringes (1.0, 3.0, 5.0, 10.0, and 20.0
mL), needles (18 to 25 G), T-connectors,
and stopcocks
• Drugs, including Epinephrine (1:10,000),
and NaCl 0.9% (Normal saline).
• Transport incubator with battery-
operated heat source and portable
blended oxygen supply should be
available if delivery room is not close
to the nursery.
 Universal precautions
• Exposure to blood or other body fluids
is inevitable in the delivery room.
• Universal precautions must be practiced
by wearing caps, goggles or glasses,
gloves, and impervious gowns until the
cord is cut and the newborn is dried
and wrapped.
What questions should you ask
before every birth?
❶ What is the expected gestational age?
❷ Is the amniotic fluid clear?
❸ How many babies are expected?
❹ Are there any additional risk factors?
What personnel should be
present at delivery?
• Every birth should be attended by at least
1 qualified individual
• If risk factors are present, at least 2
qualified people should be present solely
to manage the baby.
 Behavioural skills
• Know your environment.
• Use available information.
• Anticipate and plan.
• Clearly identify a team leader.
• Communicate effectively.
• Delegate workload optimally.
• Allocate attention wisely.
• Use available resources.
• Call for additional help when needed.
• Maintain professional behavior.
• Which image shows the correct way to
position a newborn’s head to open the
airway?
Pressure of suction catheter=80-100 mmHg
Indications for Pulse Oximetry
• When resuscitation is anticipated
• To confirm your perception of persistent central
cyanosis
• When supplemental oxygen is administered
• When positive-pressure ventilation isrequired
• Which images show the correct way to
give free-flow oxygen to a baby?
Free-flow Oxygen Delivery Devices
1. oxygen tubing
2. oxygen mask
3. flow-inflating bag and mask
4. T-piece resuscitator and mask
5. open reservoir (“tail”) on a self-inflating bag
 What do you do if the baby has
labored breathing or persistently
low oxygen saturation?
 Does the presence of
meconium-stained amniotic
fluid change the approach to the
initial steps?
 • Meconium-stained fluid and a vigorous
newborn: Simply use a bulb syringe to
gently clear meconium-stained secretions
from the mouth and nose.
• Meconium-stained fluid and a non-
vigorous newborn:
1. Use a bulb syringe to clear secretions
from the mouth and nose.
2. If the baby is not breathing or the HR<100
bpm after the initial steps are completed,
proceed with PPV. Routine intubation for
tracheal suction is not suggested.
What is positive pressure
ventilation (PPV)?
• Peak inspiratory pressure (PIP): The highest
pressure administered with each breath
• Positive end-expiratory pressure (PEEP): The
gas pressure maintained in the lungs between
breaths
• Continuous positive airway pressure (CPAP):
The gas pressure maintained in the lungs
between breaths when a baby is breathing
spontaneously
• Rate
• Inspiratory time (IT): The duration of the
inspiratory phase
Indications for Positive-Pressure Ventilation:
• Apnea (not breathing)
• Gasping
• Heart rate less than 100 bpm
• Oxygen saturation below the target range despite
free-flow oxygen or CPAP
The valves are usually set to release at 30 to 40
cm H2O pressure
What concentration of oxygen should be
used to start positive-pressure ventilation?
• ≥ 35 wkGA: 21% oxygen
• < 35 wkGA 21% to 30% oxygen
• Rate in flowmeter=10 L/minute
Breaths should be given at a rate of 40 to 60
breaths per minute.
Which of these devices is a self-inflating bag, a
flow-inflating bag, a T-piece resuscitator?
Which is correct application of mask?
Measure the distance from the bridge of the nose to the
earlobe and from the earlobe to a point halfway between
the xiphoid process (the lower tip of the sternum) and the
umbilicus.
 Resuscitation with positive-
pressure ventilation using an
endotracheal tube
How much time should be allowed for an intubation
attempt?
What are the indicators that the tube is in
the trachea?
• Audible and equal breath sounds near both
axillae during PPV
• Symmetrical chest movement with each breath
• Little or no air leak from the mouth during PPV
• Decreased or absent air entry over the stomach
• Rapidly increasing HR
• Exlaled CO2
How deeply should the tube be inserted within
the trachea?
Which illustration shows the view of the oral cavity
that you should see if you have the laryngoscope
correctly placed for intubation?
Chest compressions?
Indications for Chest Compressions:
• Chest compressions are indicated when the
heart rate < 60 bpm after at least 30 seconds of
PPV that inflates the lungs, as evidenced by
chest movement with ventilation.
• In most cases, you should have given at least 30
seconds of ventilation through a properly
inserted endotracheal tube or laryngeal mask.
Where you would apply chest compressions?
• What oxygen concentration should be
used with positive-pressure ventilation
during chest compressions?
• Ans: 100%
• When should you check the baby’s heart
rate after starting compressions?
• Ans: after 60 sec
• When do you stop chest compressions?
• Ans: when HR > 60/min
Medications?
Epinephrine dose:
• Intravenous or intraosseous: 0.1 to 0.3
mL/kg (equal to 0.01 to 0.03 mg/kg).
• Endotracheal: 0.5 to 1 mL/kg (equal to
0.05 to 0.1 mg/kg).
For how long should you
continue?
• If there is a confirmed absence of heart
rate after 10 minutes of resuscitation, it is
reasonable to stop resuscitative efforts.
Thank You!