PEDIATRICS II

Saint Louis University School of Medicine MMXXII

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

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
Figure 1: Fetal Circulation Anatomy
 ~10%of NB requires some assistance to begin breathing at
birth
 <1%need extensive resuscitative measures to survive
IV. AFTER BABY’S BIRTH
A. LUNGS AND CIRCULATION AFTER DELIVERY
II. WHY DO NEWBORNS REQUIRE DIFFERENT APPROACH TO
 Fetal lung fluid leaves alveoli:
RESUSCITATION?
o At birth, as the newborn takes the first few
A. ADULT CARDIAC ARREST
breaths, several changes occur, whereby the lungs
 Most often a complication of trauma or existing heart
take over the lifelong function of respiration.
disease
o Following birth, the lungs expand as they filled
o A sudden arrhythmia → ineffective heart
with air. The fetal lung fluid gradually leaves the
contraction → decreased cardiac output and most
alveoli.
importantly, brain circulation → loss of
o Hematogenous
consciousness → stops breathing
o Lymphatics
o During the arrest, O 2 and CO2in the blood are
o Aspiration
usually normal
o Vaginal squeeze
o Chest compressions are needed to be started
o Expelled
immediately in order to maintain circulation until
electrical defibrillations or medications restore
 Lung expands with air:
cardiac functions
o It is important that the bay takes the initial
respiration immediately for a more efficient
B. NEWBORNS NEEDING RESUSCITATION
clearing of the alveolar fluid from the baby’s lungs.
 Most newborns requiring resuscitation have a healthy heart
o Otherwise, fluid will be retained and may cause
 Newborns requiring resuscitation have a problem in
unwanted complications such as transient
respiration, in contrast to adults whose main problem is
tachypnea or worse, persistent pulmonary
cardiac→ inadequate gas exchange
hypertension of the newborn.
o Respiratory failure may occur before or during
birth
FROM THE ATTACHED VIDEO CLIP:
o Placenta responsible for in utero respiration
 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.
III. FETAL PHYSIOLOGY
A. IN THE FETUS

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Saint Louis University
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
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School of Medicine MMXXII
 Blood oxygen levels rise:
o And since the lungs now take over the function of
the placenta for gas exchange, the pulmonary
blood now will be increasingly oxygenated.
 Ductus arteriosus now constricts:
o This 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.
Figure 7: Fetal Lung and Circulation Before Birth
Figure 8: Fetal Lung and Circulation After Birth
 Pulmonary arterioles dilate
 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
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 PEDIATRICS II
Saint Louis University School of Medicine
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
 Prolonged lack of adequate perfusion and oxygenation →
damage to brain, damage to other organs, or death
 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.
Figure 10: Good Tone with Cyanosis VS Bad Tone with
Cyanosis
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.
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 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 apneaCANNOT 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.
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 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 labored
breathing (CPAP) or low oxygen saturation
(oxygen)
 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
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 PEDIATRICS II
Saint Louis University School of Medicine
X. PRE-RESUCITATION 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: 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.
 Identify who will document events as they occur
 Determine what supplies and equipment will be needed
 Identify how to call for additional help
TEAM LEADER
 Mastery of the Neonatal Resuscitation Program (NRP) Flow
Diagram
 Effective leadership skills – good communication skill
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 because the
mother is a diagnosed case of HIV for their protection;
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
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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.
For example, the mother is Hepatitis B positive, then this should be
shared to each member of the team especially those that will handle
anything with blood, so that they will have to take necessary
precautions like wearing of gloves and goggles. Or if the mother is
COVID suspect, of has positive COVID swab, then every member of
the team should be alerted to be able to wear the proper protective
equipment.
It would be better if we put our name on our chest area so that
we can call each other by name, and direct our request to a specific
individual. Make an eye contact when talking to your members,
speak clearly, and ask the receiver to report back as soon as the
task is completed. For example, the leader orders: Gilbert, please
administer epinephrine 1:10,000 dilution, 0.5 mL via the umbilical
catheter bolus now. Then after Gilbert does his task, he echoes by
saying epinephrine, 1:10,000 0.5mL given via umbilical catheter.
ACCURATE DOCUMENTATION
 Complete records are important for clinical decision making
and source for quality improvement data for the future
 Events during resuscitation documented as they occur;
supplemented with retrospective narrative summary
 Use single time reference to avoid confusion, especially
when data is to be used for court cases
 Recorder should not be responsible for other roles (assigned
to experienced team member) as she needs to focus and not
be distracted as she documents the resuscitation
 Use well designed forms that follow NRP / NRPH+ flow
diagram for more rapid data entry
POST-RESUSCITATION DEBRIEFING
 Reinforces good teamwork habits and helps team identify
areas of improvement for future resuscitations
 Quick debriefing immediately after the event and a more
comprehensive debriefing may be scheduled afterward
 Debriefings do not have to find major problems to be
effective
o May identify series of small changes that result in
significant improvements in your team’s performance
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 PEDIATRICS II
Saint Louis University School of Medicine MMXXII
Category II or III fetal heart Shoulder dystocia
pattern
Maternal general anesthesia Meconium-stained amniotic fluid
Maternal magnesium therapy Prolapsed umbilical cord
Placental abruption

WHAT QUESTIONS TO ASK BEFORE EVERY BIRTH

 What is the expected gestational age?
o Preterm: then you will need equipment particularly for
thermoregulation, assisting the breathing of the baby,
surfactant, umbilical venous catheter insertion and the
like.
o Postmature: then you will expect the baby to be
possibly meconium-stained if not aspirated meconium
already and that the baby might be born limp and will
require assistance in the initiation of breathing.
 Is the amniotic fluid clear?
o A clear amniotic fluid would make the resuscitating
team at ease. But a meconium-stained fluid will
keep them on their toes as they will now need to
assess if the baby, upon birth, is active or limp.
 How many babies are expected?
o Knowing the answer to this will make the team prepare
or additional team if we are expecting multiple
pregnancy, as compared to when this is a singleton
pregnancy.
 Are there any additional risk factors?
o Does the mother have SLE? Was the baby antenatally
diagnosed to have congenital anomalies that will hinder
the normal transition process, does the baby need an
immediate surgical intervention upon birth, so that we
need the surgery team on stand by at the time the
baby is delivered?
Figure 11: Debriefing form.
Where questions are asked about what was the best part of the
RESUSCITATION TEAM
resuscitation event, what was the most challenging part, what areas
 Every birth should be attended by at least 1 qualified
still need to be worked upon for improvement. (There are different
individual, skilled in the initial steps of newborn care and
available templates of debriefing form online, and your institution may
PPV, whose only responsibility is the management of the
have its own debriefing form being used)
newborn baby.
o This individual should be skilled in performing the initial
steps of newborn care and positive pressure ventilation.
XI. NEONATAL RESUSCITATION
 If risk factors are present, at least 2 qualified people
PERINATAL FACTORS INCREASING THE LIKELIHOOD OF
should be at the delivery room, plus another members of the
NEONATAL RESUSCITATION
team on standby nearby. Again, these two qualified people
should be only managing the newly born baby.
It is ideal to know if there are any risk factors surrounding the
 Qualified team should have at least one with full
birth of the baby so that the pediatric team would be ready, be able to
resuscitation skills, including endotracheal intubation,
organize a resuscitation team way before the birth of the baby,
chest compressions, emergency vascular access and
delegate task to each members of the team, check for the supplies and
medication administration, should be identified and
equipment and their functionality. But often times, in the real world,
immediately available for every resuscitation and should not
there are instances when the mother arrives at the emergency room
be on an on-call basis.
about to give birth, giving the pediatric team insufficient time to fully
organize a resuscitation team, much less delegate a task or have a
briefing. PRE-RESUSCITATION TEAM BRIEFING
 Review the risk factors and management plans developed
ANTENATAL RISK FACTORS during antenatal counselling (during the briefing before
Gestational age <36 0/7 weeks Oligohydramnios entering the delivery room)
Gestational age >41 0/7 weeks Fetal hydrops o For example, you have a baby who had an
Preeclampsia or eclampsia Fetal macrosomia antenatal diagnosis of gastroschisis, and who is
Maternal hypertension Intrauterine growth restriction about to be delivered via NSD, aside from
Multiple gestation Significant fetal malformation or organizing the pediatric resuscitation team, you
anomalies ought also to have consulted a pediatric surgeon
Fetal anemia
prior to the delivery. The parents should have
Polyhydramnios No prenatal care
consulted this surgeon, who in turn will explain to
INTRAPARTUM RISK FACTORS
the parents what will be anticipated, whether they
Emergency cesarean delivery Intrapartum bleeding
will do direct closure of the defect immediately at
Forceps or vacuum-assisted Chorioamnionitis birth, or will they do a staged reduction of the
delivery intestines and perform the primary closure later.
Breech or other abnormal Narcotics administered to  Identify team leader (based on the characteristics discussed
presentation mother within 4 hours of before), discuss the possible scenarios that your team may
delivery encounter, assign roles and responsibilities

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Saint Louis University School of Medicine MMXXII
o Who will perform initial assessment beyond positive pressure ventilation, the nurse in charge
o Who will stimulate the baby should already lay out the equipment for better access
o Who will start PPV if needed during cannulation of the umbilical vessels.
o Who will document events: it would be best to  For extremely preterm infants, aside from preferably
have a prepared documentation form or template using a blade double 0, be ready as well with a food-grade
for easier input of the data during the actual plastic bag, (or the resealable bag) which will be used to
resuscitation event. wrap the preterm upon birth for thermoregulation.
Remember that extremely preterm infants have weaker
muscle tone which causes now extension of all extremities,
RESUSCITATION SUPPLIES AND EQUIPMENT
increasing the body surface area, hence bigger area loss. We
 Supplies and equipment should be prepared and checked
counter that disadvantage by trying to prevent all heat loss.
if functional. And when in the delivery room, it is already
An alternative will be to wrap the baby with plastic wrap.
laid out in such a way that when it is needed, it is already
If thermal mattress is also available, then it would be useful
within reach and without the necessity to look for it first
to use it while resuscitating a small preterm for heat
when asked by the team leader.
 In areas where transport incubator may not be
 Most important thing to check will be the bag-mask
available in transporting the baby to the nursery for more
apparatus, be sure that it really works, and you are using
intensive care, a close relative, preferably the father may
the appropriate volume. The 200-mL bag is for the
be asked to carry the baby, kangaroo-mother-care or
newborn, whereas the 700 mL is for older infants and
skin-to-skin-contact style in order to minimize
pediatric patients. Please don’t interchange.
evaporative heat loss during transport.
 For the laryngoscope, make sure that the bulb has a
strong light, batteries should be changed regularly.
 The blade appropriate to use for newborns would be UMBILIVAL VESSEL MISCELLANEOUS
straight compared to older children and adults where the CATHETERIZATION
curved blade is preferred. This is due to the peculiarity of Sterile gloves Gloves and appropriate personal
the anatomy of their larynx, especially of the epiglottis. An protection
extremely premature infant , or those who are less than Anti-septic prep solution Radiant warmer or other heat
28 weeks gestational age, would require a blade double sources
0. Bigger preterm infants will require blade 0, whereas Umbilical tape Temperature sensor with sensor
term infants would require blade 1. cover for radiant warmer (for
use during prolonged
SUCTION EQUIPMENT POSITIVE PRESSURE resuscitation)
VENTILATION EQUIPMENT Small clamp (hemostat) Firm, padded resuscitation
Bulb syringe Device for delivering PPV surface
Mechanical suction and tubing Face masks, newborn & preterm Forceps (optional) Timer or clock with second hand
sizes warmed linens
Suction, catheters, 5F or 6F, Oxygen source Scalpel Beanie
10F, 12F or 14F Umbilical catheters 3.5F, 5F Stethoscope
8F feeding tube or large syringe Compressed air source Three-way stop cock Tape ¾ or ½ inch
Meconium aspirator Oxygen blender to mix O2 & CA Syringes 3-ml, 5ml ECG monitor and ECG leads
with flowmeter & tubing Needle or puncture device for Intraosseous needle (optional)
Pulse oximeter with sensor & needleless system
cover NSS for flushes
Target O2 saturation table Clear adhesive dressing to
INTUMATION EQUIPMENT MEDICATIONS temporarily secure umbilical
Laryngoscope with straight Epinephrine 1:10,000 (Since the venous catheter to abdomen
blades, No 0 & No 1 commercially available (optional)
epinephrine is 1:1000 FOR VERY PREMATURE INFANTS
concentration, it would be best Size 00-laryngoscope blades (optional)
to have a pre-mixed 1:10,000) Food grade plastic blade (1-gallon size) or plastic wrap
Extra bulbs & batteries for NSS for volume expansion Thermal mattress
laryngoscope Transport incubator to maintain baby’s temperature during move to
Stylet (optional) D10W (optional) the nursery
Measuring tape NSS for flushes
Endotracheal tube insertion Syringes 1-ml, 3-ml, 5-ml to 60-
depth table ml FOCUS ON TEAMWORK
Scissors
Waterproof tape or tube- BEHAVIOR EXAMPLE
securing device • Anticipate and plan • Identify the risk factors so
Scissors that this will preempt you
Waterproof tape or tube- how to plan the resuscitation
securing device • Know which providers will be
Alcohol pads called to attend the birth
CO2 detector or capnograph based on the perinatal risk
Laryngeal mask and 5-ml factors
syringe • Perform a standardized
5F or 6F OGT if insertion port equipment check before
present on LM every birth
• Assign roles and
 Be on the ready as well with the equipment for umbilical responsibilities (You can post
vessel catheterization. As the resuscitation progresses at the inner side of the

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• Use all available information
• Use available resources
• Know your environment
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School of Medicine MMXXII
nursery door the composition • Clearly identify the leader • If risk factors are present,
of the resuscitation team and identify a leader before the
their designated roles and birth and perform a pre-
responsibilities) resuscitation team briefing (&
mock resuscitation during
your free time so as to
master the correct sequence
of things) to ensure that
• A good history investigation everyone is prepared, and
prior to birth will be very responsibilities are defined.
useful in anticipating every
move inside the delivery NRP KEY BEHAVIORAL SKILLS
room  Know your environment
• Ask the obstetric provider the  Use available information
4 pre-birth questions to  Anticipate and plan
identify risk factors and align  Clearly identify a team leader
your preparation based on  Communicate effectively
the risk factors provided.  Delegate workload optimally
• Prepare additional supplies  Allocate attention wisely
and equipment as necessary,  Use available resources
based on these risk factors  Call for additional help when needed
• If the baby has gastroschisis,  Maintain professional behavior
then you might need already
the presence of pediatric
surgeon at the delivery room
as well
• Orienting yourself with the
nursery and its set-up prior to
starting to work in it
• Know how the resuscitation
team is called and how
additional personnel and
resources can be summoned.
• Know how to access
additional equipment and
supplies for a complex
resuscitation
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 PEDIATRICS II
Saint Louis University School of Medicine MMXXII
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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