PEDIATRICS II

Saint Louis University School of Medicine MMXXII

P.01D FOUNDATIONS OF NEONATAL RESUSCITATION III. FETAL PHYSIOLOGY
(Part 1&2) A. IN THE FETUS
Dr. Balud | 01/17/2021 • Alveoli is filled with lung fluid instead of air, and therefore no
gas exchange happens between the fetal lung and
OUTLINE pulmonary circulation. Instead, oxygen is transferred from
I. Neonatal Resuscitation the maternal circulation to the fetal circulation via the
II. Why do newborns require different approach to placenta
resuscitation? • Fetus are adapted to low po2 (20 mmHg)
III. Fetal Physiology • In utero, fetus dependent on placenta for gas exchange
IV. After Baby’s Birth • Pulmonary arterioles are constricted
V. Normal Transition o Since the alveoli are filled with fluid, the
VI. What can go wrong during transition? surrounding pulmonary capillaries, arterioles and
VII. Signs of A Compromised Newborn venules are constricted
VIII. In Utero or Prenatal Compromise • Pulmonary blood flow is diminished
IX. Resuscitation Flow Diagram o Because of the constricted pulmonary arterioles,
X. Pre-resuscitation Preparation there is marked decrease in blood flow into the
XI. Neonatal Resuscitation lungs
• Blood flow is diverted across the patent ductus arteriosus:
OBJECTIVES: o Because of this hypertensive state, blood that is
• Importance of resuscitation skills supposed to flow to the lungs is then diverted into
• Physiologic changes during and after birth the aorta via the patent ductus arteriosus, diluting
• Neonatal Resuscitation Flow diagram format further the oxygen concentration of the blood in the
• Communication and teamwork skills used by effective aorta
resuscitation teams
I. NEONATAL RESUSCITATION FROM THE ATTACHED VIDEO CLIP:
NEONATAL DEATHS • Because of the constricted blood vessels in the lungs, most of
• 45% of under-five deaths in 2015 the blood bypasses the lungs, and instead passes into the
• 35% of under-five deaths in 2015 aorta via the ductus arteriosus

WHY LEARN NEONATAL RESUSCITATION?

• Birth asphyxia 23% of approximately 4M neonatal
deaths/year worldwide
• For many NB appropriate resuscitation not readily available
o Improved by more widespread use of resuscitation
techniques

WHICH BABIES REQUIRE RESUSCITATION?

• ALL newborns (NB) require assessment
• ~10% of NB requires some assistance to begin breathing at
birth
• <1% need extensive resuscitative measures to survive
Figure 1: Fetal Circulation Anatomy
II. WHY DO NEWBORNS REQUIRE DIFFERENT APPROACH TO
RESUSCITATION?
A. ADULT CARDIAC ARREST
IV. AFTER BABY’S BIRTH
• Most often a complication of trauma or existing heart disease
A. LUNGS AND CIRCULATION AFTER DELIVERY
o A sudden arrhythmia → ineffective heart
• Fetal lung fluid leaves alveoli
contraction → decreased cardiac output and most
o At birth, as the newborn takes the first few breaths,
importantly, brain circulation → loss of
several changes occur, whereby the lungs take over
consciousness → stops breathing
the lifelong function of respiration.
o During the arrest, O2 and CO2 in the blood are
o Following birth, the lungs expand as they filled with
usually normal
air. The fetal lung fluid gradually leaves the alveoli.
o Chest compressions are needed to be started
§ Hematogenous
immediately in order to maintain circulation until
§ Lymphatics
electrical defibrillations or medications restore
§ Aspiration
cardiac functions
§ Vaginal squeeze
§ Expelled
B. NEWBORNS NEEDING RESUSCITATION
• Most newborns requiring resuscitation have a healthy heart
• Lung expands with air
• Newborns requiring resuscitation have a problem in
o It is important that the baby takes the initial
respiration, in contrast to adults whose main problem is
respiration immediately for a more efficient clearing
cardiac→ inadequate gas exchange
of the alveolar fluid from the baby’s lungs.
o Respiratory failure may occur before or during birth
o Otherwise, fluid will be retained and may cause
o Placenta responsible for in utero respiration
unwanted complications such as transient
NOTE:
tachypnea or worse, persistent pulmonary
In utero respiration: Placenta
hypertension of the newborn.
Respiratory failure: may occur before or during the birth process
FROM THE ATTACHED VIDEO CLIP:
• Fluid in the alveoli is absorbed into the lung tissue, and
replaced by air. The oxygen in the air diffuses into blood
vessels that surround the alveoli.

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Saint Louis University School of Medicine
Figure 2: Constricted Blood Vessels and Fluid-filled Alveoli
Figure 3: Infant’s First Breath with Fetal Lung Fluid
Figure 4: Infant’s Second Breath with Air
Figure 5: Infant’s Subsequent Breaths with Air
Figure 6: Dilated Blood Vessels After Birth with Oxygen in
Alveoli
• Blood oxygen levels rise
o Since the lungs now take over the function of the
placenta for gas exchange, the pulmonary blood
now will be increasingly oxygenated.
• Pulmonary blood vessels relax
• Ductus arteriosus now constricts
o The increase in the oxygen concentration on the
blood will now cause a constriction of the ductus
arteriosus, which will usually be completed by the
10th day of life
• Blood flow through the lungs to pick up oxygen
o There will now be increased blood flow through the
lungs to pick up oxygen for peripheral circulation.
FROM THE ATTACHED VIDEO CLIP:
• As blood levels of oxygen increase and pulmonary blood
vessels relax, the ductus arteriosus begins to constrict.
• Blood previously diverted through the ductus arteriosus, now
flows through the lungs where it picks up more oxygen to
transport to tissues throughout the body.
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Figure 7: Fetal Lung and Circulation Before Birth
Figure 8: Fetal Lung and Circulation After Birth
• Pulmonary arterioles dilate
• Pulmonary vascular resistance decreases
• Pulmonary blood flow increases
o As a consequence of the clearance of the alveolar
fluid leaving the alveoli, the pulmonary vessels now
relax, and thus allows increase in pulmonary blood
flow.
Figure 9: Alveoli Before and After Birth
V. NORMAL TRANSITION
• The following 3 major changes take place within seconds after
birth:
o Alveolar fluid is absorbed into lung tissue and
replaced by air
o Umbilical arteries and vein constrict thus increasing
blood pressure - Umbilical arteries and veins are
clamped, removing the low resistance placental
circuit and increasing systemic blood pressure.
o Blood vessels in the lungs relax, increasing
pulmonary blood flow.
VI. WHAT CAN GO WRONG DURING TRANSITION
• Lack of ventilation of the newborn’s lungs → sustained
constriction of the pulmonary arterioles → prevents systemic
arterial blood from being oxygenated → cyanosis
• Prolonged lack of adequate perfusion and oxygenation →
damage to brain, damage to other organs, or death
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 PEDIATRICS II
Saint Louis University School of Medicine
• A baby may encounter difficulty before labor, during labor, or
after birth. Some of the problems that may disrupt normal
transition are:
o The baby may not breathe sufficiently to force fluid
from the alveoli, or foreign material such as
meconium that may prevent air from entering the
alveoli.
o Excessive blood loss may occur, or there may be
inadequate cardiac contractility, or bradycardia
from hypoxia and ischemia.
VII. SIGNS OF A COMPROMISED NEWBORN
• The compromised baby may exhibit one or more of the
following clinical findings:
o Poor muscle tone
o Depressed respiratory drive due to insufficient
oxygen reaching the brain
o Bradycardia
o Low blood pressure
o Tachypnea (rapid respirations)
o Cyanosis (blue color)
• Words of caution: Other conditions, such as infection,
hypoglycemia, or depressant drugs given to the mother
before birth, may also cause these symptoms.
VIII. IN UTERO OR PRENATAL COMPROMISE
A. PRIMARY APNEA
• When a fetus/newborn first becomes deprived of oxygen, an
initial period of attempted rapid breathing occurs, followed by
primary apnea with dropping of heart rate. This improves with
TACTILE STIMULATION.
• When babies are deprived of oxygen (in utero or after
delivery), they undergo a well-defined sequence of events
that starts with cessation of respiration.
• During primary apnea, the newborn responds to stimulation.
• Instruction Tip: Initiate resuscitation immediately.
Resuscitation may be inappropriately delayed if the health
care provider does not recognize the need for neonatal
resuscitation. Any delay in transferring a compromised
newborn to the resuscitation team is unacceptable practice.
B. SECONDARY APNEA
• Continued O2 deprivation → secondary apnea + continued fall
in heart rate and blood pressure
• Secondary apnea CANNOT be reversed by tactile stimulation;
assisted ventilation must be provided
• If oxygen deprivation continues, deep gasping respirations
develop, the heart rate continues to decrease, and the blood
pressure decreases
• An important point is that, during secondary apnea,
stimulation will not restart the baby’s breathing. Assisted
ventilation must be provided to reverse the process triggered
by oxygen deprivation. If a baby doesn’t begin to breathe
immediately after being stimulated, he or she is likely in
secondary apnea and will require positive-pressure
ventilation.
• Instructor Tip: Quickly achieve and maintain oxygenation in
full-term and post-term newborns after perinatal hypoxia-
ischemia because they are especially prone to persistent
pulmonary hypertension.
• Initiation of effective POSITIVE PRESSURE VENTILATION
during secondary apnea usually results in RAPID
IMPROVEMENT IN HEART RATE
• Most babies in secondary apnea will respond to effective
ventilation with a rapid improvement in heart rate.
• The longer a baby has been in secondary apnea, the longer it
will take for spontaneous breathing to resume.
• If heart rate does not improve rapidly with effective
ventilation, myocardial function may be compromised and
chest compressions and/or medications may be required.
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IX. RESUSCITATION FLOW DIAGRAM
• Initial Assessment:
o Determine if the baby can remain with the mother
or should be moved to a radiant warmer for further
evaluation
• Airway:
o While doing the initial steps of resuscitation,
Perform the initial steps to establish an open airway
and support spontaneous respiration
• Breathing:
o Positive pressure ventilation is provided to assist
breathing for babies with apnea or bradycardia
o Other interventions (CPAP: Continuous Positive
Airway Pressure or oxygen) maybe appropriate
§ if baby is breathing spontaneously but
has low oxygen saturation (oxygen is
supplemented) or labored breathing
(CPAP is provided)
• Circulation:
o If severe bradycardia persists despite assisted
ventilation, circulation is supported by performing
chest compressions, coordinated with PPV (Positive
Pressure Ventilation)
• Drugs:
o If severe bradycardia persists despite assisted
ventilation and coordinated chest compressions,
the drug EPINEPHRINE is administered as PPV
and chest compressions continue
X. PRE-RESUSCITATION PREPARATION
FOCUS ON TEAMWORK
• Poor teamwork and communication were the most
common root causes for potentially preventable infant deaths
in the delivery room
• Therefore, one of the emphasis also of the neonatal
resuscitation program, whether it be the AAP or NRPh+
version is the planning on how the team will be contacted,
who will be responding. And that before entering any
resuscitation calls or codes, each team members need to
understand his role and tasks he or she will be assigned.
PERSONNEL AND EQUIPMENT
• ALL deliveries should be attended by at least 1 person whose only
responsibility is the baby and who is capable of initiating
resuscitation. Either that person or someone else, who is available
immediately, should have the skills required to perform a complete
resuscitation
• Prepare necessary equipment:
o Turn on radiant warmer
o Set delivery room temperature to 26°C
o Check the equipment
PRE-RESUCITATION BRIEFING
• Planning how the team will be contacted and who will respond
• Each team member needs to understand his role and the tasks
he or she will be assigned. You try to identify the role of each
member of the resuscitation team. Who will be there during
the catch, and where will the help be contacted and how.
• Assess perinatal risk factors so that you will know what to
anticipate.
• Identify a team leader
• Delegate tasks: assign who is responsible to do the initial
steps of resuscitation and positive pressure ventilation, who
will be doing the chest compressions, where will these people
be positioned with respect to the baby, who will document all
the things going on during the resuscitation, who will be the
timer, who will be the nurse who is responsible for the
supplies and equipment, are all the equipment already within
reach? If not, then identify which are not available and make
sure to replenish them even before the delivery is called, on
when and how to and the proper way of substituting the chest
compressor. It would also be best if you already perform a
mock code to orient you on how to go about during the actual
resuscitation.
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 PEDIATRICS II
Saint Louis University School of Medicine MMXXII
• Identify who will document events as they occur • Quick debriefing immediately after the event and a more
• Determine what supplies and equipment will be needed comprehensive debriefing may be scheduled afterward
• Identify how to call for additional help • Debriefings do not have to find major problems to be effective
o May identify series of small changes that result in
TEAM LEADER significant improvements in your team’s performance
• Mastery of the Neonatal Resuscitation Program (NRP) Flow
Diagram
• Effective leadership skills – good communication skills
o Clear directions: clear, direct and audible enough
o Share information with other members of the team,
for example, he should mention to the members of the
team that they should be wearing gloves for their
protection because the mother is a diagnosed case of
HIV; he should not be withholding such information from
the members of the team or else he will lose their trust.
o Delegate responsibilities ensuring coordinated
care
o Maintaining professional environment
• Remain aware of entire clinical situation, not only about how
long the duration of the resuscitation is going on.
• Maintain view of big picture (not distracted by single activity)
• The leader should also be aware of other circumstances like
knowing that the baby is a precious child, wherein the mother
is already in her mid 40s and may not be able to conceive a
child anymore should this baby being resuscitated will not
make it, and other sensitive information.

EFFECTIVE COMMUNICATION
• Every team member shares responsibility for ongoing
assessment
• Share information: communicate with each other
• Direct request to a specific individual
• Call team member by name
• Make eye contact
• Speak clearly
• Ask receiver to report back as soon as the task is completed.

In order to have effective communication, again, every team

member shares responsibility for ongoing assessment. If you were
the one who took the history it is your responsibility to share what
pertinent information should be shared with each team member. Figure 11: Debriefing form.
For example, the mother is Hepatitis B positive, then this should be Where questions are asked about what was the best part of the
shared to each member of the team especially those that will handle resuscitation event, what was the most challenging part, what areas
anything with blood, so that they will have to take necessary precautions still need to be worked upon for improvement. (There are different
like wearing of gloves and goggles. Or if the mother is COVID suspect, available templates of debriefing form online, and your institution may
of has positive COVID swab, then every member of the team should be have its own debriefing form being used)
alerted to be able to wear the proper protective equipment. PART 2
It would be better if we put our name on our chest area so that we XI. NEONATAL RESUSCITATION: PREPARInG FOR
can call each other by name, and direct our request to a specific RESUSCITATION
individual. Make an eye contact when talking to your members, speak PERINATAL FACTORS INCREASING THE LIKELIHOOD OF
clearly, and ask the receiver to report back as soon as the task is NEONATAL RESUSCITATION
completed. For example, the leader orders: Gilbert, please administer It is ideal to know if there are any risk factors surrounding the birth
epinephrine 1:10,000 dilution, 0.5 mL via the umbilical catheter bolus of the baby so that the pediatric team would be ready, be able to
now. Then after Gilbert does his task, he echoes by saying epinephrine, organize a resuscitation team way before the birth of the baby, delegate
1:10,000 0.5mL given via umbilical catheter. task to each members of the team, check for the supplies and equipment
and their functionality. But often times, in the real world, there are
ACCURATE DOCUMENTATION instances when the mother arrives at the emergency room about to give
• Complete records are important for clinical decision making birth, giving the pediatric team insufficient time to fully organize a
and source for quality improvement data for the future resuscitation team, much less delegate a task or have a briefing.
• Events during resuscitation documented as they occur;
supplemented with retrospective narrative summary ANTENATAL RISK FACTORS
• Use single time reference to avoid confusion, especially when Gestational age <36 0/7 weeks Oligohydramnios
data is to be used for court cases Gestational age >41 0/7 weeks Fetal hydrops
• Recorder should not be responsible for other roles (assigned Preeclampsia or eclampsia Fetal macrosomia
to experienced team member) as she needs to focus and not Maternal hypertension Intrauterine growth restriction
be distracted as she documents the resuscitation Multiple gestation Significant fetal malformation or
• Use well designed forms that follow NRP / NRPH+ flow Fetal anemia anomalies
diagram for more rapid data entry Polyhydramnios No prenatal care
INTRAPARTUM RISK FACTORS
POST-RESUSCITATION DEBRIEFING Emergency cesarean delivery Intrapartum bleeding
• Reinforces good teamwork habits and helps team identify Forceps or vacuum-assisted Chorioamnionitis
areas of improvement for future resuscitations delivery

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Breech or other abnormal Narcotics administered to consulted this surgeon, who in turn will explain to
presentation mother within 4 hours of the parents what will be anticipated, whether they
delivery will do direct closure of the defect immediately at
Category II or III fetal heart Shoulder dystocia birth, or will they do a staged reduction of the
pattern intestines and perform the primary closure later.
Maternal general anesthesia Meconium-stained amniotic fluid • Identify team leader (based on the characteristics discussed
Maternal magnesium therapy Prolapsed umbilical cord before), discuss the possible scenarios that your team may
Placental abruption encounter, assign roles and responsibilities
o Who will perform initial assessment
o Who will stimulate the baby
WHAT QUESTIONS TO ASK BEFORE EVERY BIRTH o Who will start PPV if needed
There are at least 4 basic questions you need to ask the o Who will document events: it would be best to have
obstetrics provider before the birth of the baby to help you at least a prepared documentation form or template for
organize quickly and prepare. easier input of the data during the actual
resuscitation event.
• What is the expected gestational age? Anticipate RESUSCITATION SUPPLIES AND EQUIPMENT
whether this is pre-term or postmature. • Supplies and equipment should be prepared and checked if
o Preterm: then you will need equipment particularly for functional. And when in the delivery room, it is already laid out
thermoregulation, assisting the breathing of the baby, in such a way that when it is needed, it is already within reach
surfactant, umbilical venous catheter insertion and the and without the necessity to look for it first when asked by the
like. team leader.
o Postmature: then you will expect the baby to be • Most important thing to check will be the bag-mask apparatus,
possibly meconium-stained if not aspirated meconium be sure that it really works, and you are using the appropriate
already and that the baby might be born limp and will volume. The 200-mL bag is for the newborn, whereas the
require assistance in the initiation of breathing. 700 mL is for older infants and pediatric patients. Please
• Is the amniotic fluid clear? don’t interchange.
o A clear amniotic fluid would make the resuscitating • For the laryngoscope, make sure that the bulb has a strong
team at ease. But a meconium-stained fluid will light, batteries should be changed regularly.
keep them on their toes as they will now need to assess • The blade appropriate to use for newborns would be straight
if the baby, upon birth, is active or limp. compared to older children and adults where the curved blade
• How many babies are expected? is preferred. This is due to the peculiarity of the anatomy of their
o Knowing the answer to this will make the team prepare larynx, especially of the epiglottis. An extremely premature infant
or if not an additional team is required if we are , or those who are less than 28 weeks gestational age, would
expecting multiple pregnancy, as compared to when this require a blade double 0. Bigger preterm infants will require
is a singleton pregnancy. blade 0, whereas term infants would require blade 1.
• Are there any additional risk factors? SUCTION EQUIPMENT POSITIVE PRESSURE
o Does the mother have SLE? Was the baby antenatally VENTILATION EQUIPMENT
diagnosed to have congenital anomalies that will hinder Bulb syringe Device for delivering PPV
the normal transition process, does the baby need an
Mechanical suction and tubing Face masks, newborn & preterm
immediate surgical intervention upon birth, so that we
sizes
need the surgery team on stand by at the time the baby
Suction, catheters, 5F or 6F, 10F, Oxygen source
is delivered?
12F or 14F
8F feeding tube or large syringe Compressed air source
RESUSCITATION TEAM Meconium aspirator Oxygen blender to mix O2 & CA
• Every birth, those without risk factors, should be attended by with flowmeter & tubing
at least 1 qualified individual, skilled in the initial steps of Pulse oximeter with sensor &
newborn care and PPV, whose only responsibility is the cover
management of the newborn baby. Target O2 saturation table
o This individual should be skilled in performing the initial INTUMATION EQUIPMENT MEDICATIONS
steps of newborn care and positive pressure ventilation. Laryngoscope with straight Epinephrine 1:10,000 (Since the
• If risk factors are present, at least 2 qualified people blades, No 0 & No 1 commercially available
should be at the delivery room, plus another members of the epinephrine is 1:1000
team on standby nearby. Again, these two qualified people concentration, it would be best
should be only managing the newly born baby. to have a pre-mixed 1:10,000)
• Qualified team should have at least one with full Extra bulbs & batteries for NSS for volume expansion
resuscitation skills, including endotracheal intubation, laryngoscope
chest compressions, emergency vascular access and
Stylet (optional) D10W (optional)
medication administration, should be identified and
Measuring tape NSS for flushes
immediately available for every resuscitation and should not
Endotracheal tube insertion Syringes 1-ml, 3-ml, 5-ml to 60-
be on an on-call basis.
depth table ml
Scissors
PRE-RESUSCITATION TEAM BRIEFING Waterproof tape or tube-
• During the briefing before entering the delivery room, Review securing device
the risk factors and management plans developed during Scissors
antenatal counselling Waterproof tape or tube-
o For example, you have a baby who had an securing device
antenatal diagnosis of gastroschisis, and who is Alcohol pads
about to be delivered via NSD, aside from
CO2 detector or capnograph
organizing the pediatric resuscitation team, you
Laryngeal mask and 5-ml syringe
ought also to have consulted a pediatric surgeon
5F or 6F OGT if insertion port
prior to the delivery. The parents should have
present on LM

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• Use all available • A good history investigation prior to birth will
• Be on the ready as well with the equipment for umbilical vessel information be very useful in anticipating every move
catheterization. As the resuscitation progresses beyond positive • Use available inside the delivery room
pressure ventilation, the nurse in charge should already lay out the resources • Ask the obstetric provider the 4 pre-birth
equipment for better access during cannulation of the umbilical questions to identify risk factors and align
vessels. your preparation based on the risk factors
• For extremely preterm infants, aside from preferably using a provided.
blade double 0, be ready as well with a food-grade plastic bag, • Prepare additional supplies and equipment
(or the resealable bag) which will be used to wrap the preterm upon as necessary, based on these risk factors
birth for thermoregulation. Remember that extremely preterm • If the baby has gastroschisis, then you might
infants have weaker muscle tone which causes now extension of all need already the presence of pediatric
extremities, increasing the body surface area, hence bigger area of surgeon at the delivery room as well
heat loss. We counter that disadvantage by trying to prevent all heat • Know your • Orienting yourself with the nursery and its
loss. An alternative will be to wrap the baby with plastic wrap. If environment set-up prior to starting to work in it
thermal mattress is also available, then it would be useful to use it • Know how the resuscitation team is called
while resuscitating a small preterm for heat and how additional personnel and resources
• In areas where transport incubator may not be available in can be summoned.
transporting the baby to the nursery for more intensive care, a close • Know how to access additional equipment
relative, preferably the father may be asked to carry the baby, and supplies for a complex resuscitation
kangaroo-mother-care or skin-to-skin-contact style in order
to minimize evaporative heat loss during transport.
• Clearly • If risk factors are present, identify a leader
UMBILIVAL VESSEL MISCELLANEOUS identify the before the birth and perform a pre-
CATHETERIZATION leader resuscitation team briefing (& mock
Sterile gloves Gloves and appropriate personal resuscitation during your free time so as to
protection master the correct sequence of things) to
Anti-septic prep solution Radiant warmer or other heat ensure that everyone is prepared, and
sources responsibilities are defined.
Umbilical tape Temperature sensor with sensor
cover for radiant warmer (for use
during prolonged resuscitation)
Small clamp (hemostat) Firm, padded resuscitation NRP KEY BEHAVIORAL SKILLS
surface • Know your environment
Forceps (optional) Timer or clock with second hand • Use available information
warmed linens • Anticipate and plan
Scalpel Beanie • Clearly identify a team leader
Umbilical catheters 3.5F, 5F Stethoscope • Communicate effectively
Three-way stop cock Tape ¾ or ½ inch • Delegate workload optimally
Syringes 3-ml, 5ml ECG monitor and ECG leads • Allocate attention wisely
Needle or puncture device for Intraosseous needle (optional) • Use available resources
needleless system • Call for additional help when needed
NSS for flushes • Maintain professional behavior
Clear adhesive dressing to
temporarily secure umbilical
venous catheter to abdomen
(optional)
FOR VERY PREMATURE INFANTS
Size 00-laryngoscope blades (optional)
Food grade plastic blade (1-gallon size) or plastic wrap
Thermal mattress
Transport incubator to maintain baby’s temperature during move to
the nursery

FOCUS ON TEAMWORK

BEHAVIOR EXAMPLE
• Anticipate • Identify the risk factors so that this will
and plan preempt you how to plan the resuscitation
• Know which providers will be called to attend
the birth based on the perinatal risk factors
• Perform a standardized equipment check
before every birth
• Assign roles and responsibilities (You can
post at the inner side of the nursery door the
composition of the resuscitation team and
their designated roles and responsibilities)

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APPENDIX

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• This is the local version of the resuscitation flow diagram that

was created for the Philippines. This simplifies the
complicated flow diagram of the AAP and AHA.
• Both algorithms emphasizes that the baby should already
have established breathing during the first 60 seconds of life.
If not yet, then we go down the resuscitation pathway as
outlined.

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