Special

Considerations

Lecture 6
MODULE 5: Newborn Resuscitation
 At the end of this activity, the participants will
understand the following:

• Special problems that complicate resuscitation

Objectives
• Additional risks associated with prematurity

• Special precautions in resuscitation of preterms

 The appropriate action for a baby who fails
to respond to resuscitation will depend on
the presentation
Failure to
respond to 1. Failure to ventilate
advanced
resuscitation 2. Persistent cyanosis or bradycardia

3. Failure to initiate spontaneous breathing

 Mechanical blockage of airway

●Meconium or mucus plug

#1
Failure to ●Choanal atresia
Ventilate
●Airway malformation (e.g. Robin
syndrome)

●Other rare conditions

 ● Nasal airway is
obstructed by bone or
tissue

● Baby may have

Choanal difficulty breathing
Atresia unless they are
crying and breathing
through their mouth.

● Test by passing a
thin suction catheter
into the posterior
pharynx through the
nares
 ● If the baby has bilateral choanal atresia and
respiratory distress, you can keep the mouth and
airway open by inserting one of the following into
the baby’s mouth

Choanal ● Feeding nipple or pacifier modified by

Atresia cutting off the end (McGovern nipple)

● Oral endotracheal tube positioned with

the tip just beyond the tongue in the
posterior pharynx,

● A plastic oral (Guedel) airway

Choanal
Atresia
 ● Combination of facial anomalies that
occur because the lower jaw does not
develop normally
● Lower jaw is small and set back
Robin ● Baby’s tongue is positioned further back
in the pharynx obstructs the airway
Sequence ● Commonly have cleft palate
 Airway obstruction from Robin syndrome can be
helped by inserting a nasopharyngeal tube and
placing the baby prone

Robin
Syndrome
 ● If baby has labored breathing,
place on prone position

● If prone positioning is not

successful, insert a small
endotracheal tube (2.5 mm)
through the nose with the tip
Robin placed deep in the posterior
pharynx, past the base of the
Sequence tongue, and above the vocal
cords

● If the baby has severe difficulty

breathing and requires
resuscitation, face-mask
ventilation and endotracheal
intubation may be very difficult.

● Laryngeal mask may provide a

lifesaving rescue airway
 Impaired function

● Pneumothorax

● Congenital pleural effusion

#1
Failure to ● Congenital pneumonia
Ventilate
● Congenital diaphragmatic hernia

● Pulmonary hypoplasia

● Extreme prematurity
 ● Air collects in the pleural space
Pneumothorax surrounding the lung

● May occur spontaneously,

● Risk is increased by PPV,

babies with meconium
aspiration, and babies with
other lung abnormalities

● Small pneumothorax:
asymptomatic/ mild distress
Tension ● Pneumothorax becomes
Pneumothorax large interfering with blood
flow within the chest causing
severe respiratory distress,
oxygen desaturation, and
bradycardia

● Transillumination:
● light on the side with a
pneumothorax will appear
to spread further and
glow brighter than the
opposite side
 ● A small pneumothorax usually will
resolve spontaneously and often does
not require treatment.

Pneumothorax ● If a pneumothorax causes significant

respiratory distress, bradycardia, or
hypotension, it should be relieved
urgently by placing a catheter into
the pleural space and evacuating
the air
Pleural
Effusion ●Fluid that collects in the
pleural space

●A large pleural effusion can

prevent the lung from
expanding

●May be caused by edema,

infection, or leakage from
the baby’s lymphatic system
 ●Small pleural effusion may not
require treatment

Pleural ●If respiratory distress is

Effusion significant and does not resolve
with intubation and PPV, you
may need to insert a catheter
into the pleural space to drain
the fluid
 ● Take a brief “time-out” and confirm the
side that you plan to aspirate.

● PNEUMOTHORAX: 4th ICS anterior

How do you axillary line or the 2nd ICS
evacuate a mid-clavicular line
pneumothorax or
pleural effusion?
 ● PLEURAL EFFUSION: 5th or 6th ICS along the
posterior axillary line

How do you
evacuate a
pneumothorax or
pleural effusion?

● Prepare the insertion site with topical antiseptic

and sterile towels.
● Insert an 18- or 20-gauge percutaneous
catheter-over-needle device perpendicular to the
chest wall and just over the top of the rib
How do you
evacuate a
pneumothorax or
pleural effusion?

● PNEUMOTHORAX: direct catheter upward

● PLEURAL EFFUSION: direct catheter downward
 HOW DO YOU EVACUATE A PNEUMOTHORAX OR PLEURAL EFFUSION?

◼ Once the pleural space is

entered, the needle is
removed and a large syringe
(20-60 mL) connected to a
3-way stopcock is attached to
the catheter
◼ x-ray should be obtained to
document the presence or
absence of residual
pneumothorax or effusion.
 In an emergency, a pneumothorax can be
detected by transillumination and treated
by inserting a needle in the chest

Pneumothora
x

Link to high-resolution video:

 ● The diaphragm does not form correctly, the
intestines, stomach, and liver can enter the chest
and prevent the lungs from developing normally
● Most common type of CDH occurs on the baby’s left
Congenital side
Diaphragmatic ● Baby may present with an unusually flat-appearing
Hernia (scaphoid) abdomen, respiratory distress, and
hypoxemia
 ● If a diaphragmatic hernia is suspected,
avoid positive-pressure ventilation by mask

● Immediately intubate the trachea and

insert a double-lumen orogastric tube

Congenital
Diaphragmati
c Hernia
 ◼ If a diaphragmatic hernia is suspected, avoid
positive-pressure ventilation by mask.
◼ Promptly intubate the trachea.
◼ Place a large orogastric catheter (10F) to
prevent gaseous distention. A double-lumen
Resuscitation of sump tube is most effective.
baby with CDH
 ● Any condition that occupies space in the chest or
causes a prolonged, severe decrease in amniotic
fluid (oligohydramnios) may cause the lungs to be
incompletely developed
Pulmonary
Hypoplasia ● Baby’s chest may appear small and bell-shaped

● High inflating pressures are required to inflate the

baby’s lungs and this increases the risk of
developing pneumothoraces.

● Severe pulmonary hypoplasia is incompatible with

survival.
 • Persistent cyanosis and bradycardia
are rarely caused by congenital heart
disease.

#2 • More commonly caused by inadequate

ventilation.
Persistent
cyanosis or • Ensure chest is moving with ventilation

bradycardia • Listen for equal bilateral breath sounds

• Confirm 100% oxygen is being given

• Consider congenital heart block

or cyanotic heart disease (rare)
#3 Consider

Failure to ● Brain injury (hypoxic ischemic encephalopathy)

initiate
● Severe acidosis, congenital neuromuscular
spontaneou disorder
s breathing
● Sedation secondary to maternal drugs
 ● Narcotics given to the laboring mother to relieve
pain may cross the placenta and decrease the
newborn’s activity and respiratory drive.
What do you do if a
baby does not
breathe or has ● Manage the baby’s airway and provide
decreased activity respiratory support with PPV
and the mother
received a narcotic ● If the baby has prolonged apnea, insertion of an
during labor? endotracheal tube or laryngeal mask may be
required

● Although the narcotic antagonist naloxone has

been used in this setting, there is insufficient
evidence to evaluate the safety and efficacy of
this practice.
 ● Other causes of neonatal depression should be
considered.
What do you do if a ●`
baby does not
breathe or has ● If PPV results in a normal heart rate and oxygen
decreased activity saturation, but the baby does not breathe
and the mother did spontaneously, the baby may have depressed
not receive a respiratory drive or muscle activity due to
narcotic during hypoxia, severe acidosis, a structural brain
labor? abnormality, or a neuromuscular disorder

● Medications : magnesium sulfate and general

anesthetics, can depress respirations in the
newborn. There are no medications that reverse the
effects of these drugs
Resuscitation of
Babies born
Preterm
 Additional Risks

• Rapid heat loss

• Vulnerability to hyperoxic injury

Special
• Immature lungs and diminished respiratory
Consideration drive
s for Preterms
• Vulnerability to infection

• Immature brains that are prone to bleeding

• Small blood volume, increasing the implications

of blood loss

• Hypoglycemia
 • Increase delivery room temperature 25-28oC

• Preheat radiant warmer

• Place a hat on baby’s head

• For babies < 32 weeks gestation

Keeping • Use thermal mattress under on the blanket on
Premature the radiant warmer
• Consider polyethylene bag
Babies Warm
Link to high-resolution video:
 ● Follow same criteria for initiating
positive-pressure ventilation with term babies
● If the baby is breathing spontaneously but has
Assisting labored respirations or cyanosis, consider
Ventilation in using CPAP rather than intubating.
Premature ● If PPV is required, use the lowest inflation
pressure necessary to achieve and maintain a
Newborns heart rate greater than 100 bpm.
● If PPV is required, it is preferable to use a
device that can provide PEEP
● Consider administering surfactant if the baby
requires intubation for respiratory distress or is
extremely preterm.
 ● Research indicates that administering excessive
oxygen after perfusion has been restored can
result in additional injury
● Current recommendation: initiate resuscitation of
preterm newborns (less than 35 weeks’
gestational age) with 21% to 30% oxygen and
use a pulse oximeter and oxygen blender to
Adjusting maintain oxygen saturation within the same target
Oxygen range described for full-term newborns.
 ● Handle the baby gently.

● Do not position the baby’s legs higher than the

head (Trendelenburg position).

● Avoid delivering excessive pressure during PPV

Decreasing or CPAP.
Brain Injury
● Use physical examination, pulse oximetry and
blood gases to monitor and adjust ventilation
and oxygen concentration.

● Avoid rapid intravenous fluid boluses and

hypertonic solutions.
Special • Monitor the baby’s temperature.
Precautions
• Monitor blood glucose.
after the
Initial • Monitor the baby for apnea and
bradycardia.
Stabilization
Period
 ● It is recommended that infants born > 36 weeks
AOG with evolving moderate-to severe
hypoxic-ischemic encephalopathy should be
Therapeutic offered therapeutic hypothermia under clearly
defined protocols similar to those used in
Hypothermia published clinical trials and in facilities with the
capabilities for multidisciplinary care and
longitudinal follow-up
Special
Considerations

Lecture 6
MODULE 5: Newborn Resuscitation