Neonatal Resuscitation

Dr.Kiran.M
 Neonatal resuscitation
• Asphyxia accounts for 20-25% newborn
deaths
• 10% neonates require some assistance at
birth
• 1% neonates need extensive resuscitative
measures
Francoise Chaussier
Professor of Obstetrics

French Academy of Science

–oxygen to neonate in 1780

–mouth-to-mouth resuscitation in infants
–intra-laryngeal tube for use in infants
–means of providing ventilatory support for infants
Dr. Benjamin Pugh (1754)
• Treatise on Midwifery
• “If the child does not breathe immediately upon
• Delivery, which sometimes it will not,
especially when it has taken Air in the womb;
• Wipe its Mouth, and press your Mouth to the Child’s,
at the same time pinching the Nose with your
Thumb and Finger, to prevent the Air escaping;
inflate the lungs; rubbing it before the Fire;
by which Method I have saved many.”
 “Ventilation of the lungs is the single
most important and most effective step
in cardiopulmonary resuscitation of the
compromised newly born baby.”

Neonatal Resuscitation Textbook, 4th

Edition
4 Questions at birth
• Full term
• Amniotic fluid clear/Meconium/infection
• Baby breathing / crying
• Good muscle tone

Yes No Resucitation
Anticipation of Resuscitation Need
 Anticipaton ,
 Adeqate Preparation,
 accurate evaluation, and
 prompt initiation of support.

www.aap.org/NRP
 ASPHYXIA – THE BASIC

1.Primary Apnea:  When asphyxiated, the

infant responds with an increased RR.  If the
episode continues, the infant becomes apnic,
followed by a drop in HR and a slight increase in
BP. The infant will respond to stimulation and
therapy with spontaneous respirations.

RR HR BP
 2. Secondary apnea: after primary apnea,  the
infant responds with a period a gasping
respirations, falling HR, and falling BP .The infant
takes a last breath and then enters the secondary
apnea period.The infant will not respond to
stimulation and death will occur unless
resuscitation begins immediately.
* 
Because after delivery of an infant, it is impossible to differentiate
between primary apnea and secondary apnea, assume the infant
is in secondary apnea and begin resuscitation immediately.
1.Antepartum and intrapartum history
CONT.
Intrapartum Factors
Intrapartum Factors

Maternal substance
abuse
No prenatal care
Maternal narcotics
Previous stillbirth
(within 4 hrs of delivery)
Bleeding - 2nd/3rd
General anaesthesia
trimester
Meconium-stained fluid
Hydramnios
Prolapsed cord
Oligohydramnios
Placental abruption
Multiple gestation
Placenta previa
Post-term gestation
Uterine tetany
Small-for-dates fetus
Fetal malformations
Premature babies : concerns
• surfactant deficient
• Immature brain, poor respiratory drive
• Weak muscles, not able to breathe
• More prone to hypothermia
• More likely to be infected,
• Prone to intraventricular hemorrhage
• Small blood volume, prone to hypovolemia
• Immature tissues, prone to oxygen toxicity
 Equipment
SUCTION EQUIPMENT
BULB SYRINGE
SUCTION CATH NO 5, 6, 8, 10 Fr,
8 Fr FEEDING TUBE, 20 ml SYRINGE,
MECONIUM ASPIRATOR,
BAG-MASK EQUIPMENT
FACE MASK
ORAL AIRWAY
OXYGEN
 Equipment CONT.
INTUBATION EQUIPMENT
LARYNGOSCOPY-BLADE NO 0-1
BATTERY FOR LARYNGOSCOPE
E T Tube NO 2.5 , 3.0 ,3.5 ,4.0 mm
STYLET, SCISSOR, GLOVES
MISCELLANEOUS
RADIANT WARMER
STETHOSCOPE
TAPE
SYRINGE-NEEDLE
ALCOHOL
UMBILICAL Catheter
 Initial Steps for Neonatal Resuscitation in
Delivery Room
ANTICIPATION,ASSESSMENT OF ACTION
1.PREVENT HEAT LOSS
• Place the infant under an overhead radiant
heater to minimize radiant and convective
heat loss.
• Dry the body and head to remove amniotic
fluid and prevent evaporative heat loss.
This will also provide gentle stimulation to
initiate or help maintain breathing.
 Initial Steps for Neonatal Resuscitation in
Delivery Room CONT.
• B-BREATHING ADEQUACY
1.TACTILE STIMULATION
slapping or flicking the soles of the feet
rubbing the back gently
( Do not waste time continuing tactile stimulation if there is no

response after 10 - 15 seconds.)

2.FREE FLOW OXYGEN

3.PPV
A

Breathing

Circulation

Drugs
Evaluation-Decision-Action
cycle
Evaluation
RR, HR, Colour

Action Decision
• NRP 1996 Guidelines:
“During resuscitation and when a baby is cyanotic,
• it is important to deliver as close to 100% oxygen
as possible, without allowing it to mix with room
air.”
• NRP 2000 Guidelines:
“100% oxygen is recommended for assisted
ventilation; however, if supplemental oxygen is
unavailable, positive pressure ventilation should
be initiated with room air.”
Clearing the Airway of Meconium
One obstetrical technique to try to decrease
aspiration has been to suction meconium from
the infant’s airway after delivery of the head but
before delivery of the shoulders (intrapartum
suctioning).
• meconium-stained infants have endotracheal
intubation immediately following birth and that
suction be applied to the endotracheal tube as it
is withdrawn.
• Randomized controlled trials have shown that
this practice offers no benefit if the infant is
vigorous
Supplemental Oxygen

Treatment Recommendations:
– Term infants
• 100% when cyanotic or when PPV required during
resuscitation
• Resuscitation with less than 100% may be just as
successful
• If start with less than 100%, increase to 100% if no
appreciable improvement within 90 seconds
• If oxygen unavailable, use room air to deliver PPV
Treatment Recommendations:
– Preterm infants (<32weeks)

• Use oxygen blender and pulse oximetry

• Begin PPV w/ oxygen concentration somewhere between
21-100%
• Adjust oxygen to achieve oxy hemoglobin concentration
that gradually increases towards 90%
• Decrease oxygen concentration as saturation rises over
95%

• If HR does not respond by increasing rapidly to >100bpm,

correct any ventilation problem and use 100%O2
• There is no convincing evidence that a brief period of
100% oxygen during resuscitation will be detrimental to
preterm infant
Continuous oximetry studies show healthy term
newborns may take >10 minutes to achieve
preductal oxygen saturation >95% and nearly
1hour to achieve this post-ductally

Harris, J Pediatrics, 1986

Reddy, Clin Pediatr (Phila), 1999
Toth, Arch Gynecol Obstet, 2002
– Potential adverse effects of 100%
• Breathing physiology
– Prolong time until initial ventilation
• Cerebral circulation
– Decrease cerebral blood flow
• Tissue damage from oxygen free radicals
– Antioxidant systems develop in 3rd trimester
– Oxidize enzymes
– Inhibit protein and DNA synthesis
– Decrease surfactant production
– Cause lipid peroxidation
– Lung injury sequence secondary to hyperoxia
– Retinopathy of prematurity
– Potential adverse effects of not using 100%
• resulting in lower oxygen concentrations
(especially in preterm)
• Potentiate PPHN
• Contribute to hypoxic brain injury
• Potentially lead to higher mortality rate
• Be more likely to keep ductus arteriosus open
Initial Assisted Breaths:
Treatment recommendations:
– Establishing effective ventilation is primary objective
• Prompt improvement of heart rate is
primary measure
• Chest wall movement and breath sounds secondary
measures
– Term infant
• Initial inflation pressure of 20cm H2O may be effective,
but ≥ 30 to 40 cm H2O may be necessary for some
infants.
– Premature infant
• Initial inflation pressure of 20-25 cm H2O.
(higher if needed)
Charecteristics of resucsitation device
• Appropriately sized masks
• Capability to deliver a variable O2 upto
100%
• Capability to control peak pressure, end
expiratory pressure & inspiratory time,
• Appropriate size bag
• Safety features .
Devices:
• Self Inflating bag : fills spontaneously
after it is squeezed, PIP depends on
pressure excerted ,
( CPAP & PEEP continuos ) dis advtg
• Flow inflating bag : fills only when gas
from compressed source PIP depends on
flow rate, tight seal b\n mask and face
doesn’t have safety pop off valve
• T piece resuscitator: flow controlled &
pressure limited
Self inflating bag
• A T-piece is a valved mechanical device
designed to control flow and limit pressure.
• The pop-off valves of self-inflating bags are flow-
dependent, and pressures generated may
exceed the desired value.
• Target inflation pressures and long
inspiratory times are more consistently
achieved in mechanical models when T-piece
devices are used rather than bags .
• Compliance of lung cant be felt
 Signs of effective PPV
• Rapid rise in heart rate
• Improvement in colour and tone
• Audible breath sounds
• Chest movements
• (Tidal vol of infant = 5 – 8 ml/kg )
• 1/10th size of 250ml self inflating bag
• 1/30th size of 750ml bag

• Loudly Breathe ……two……three…..Breathe…..

(Squeeze) (release………) (Squeeze)
No improvement

• Inadequate seal …..Re apply

• Blocked airway…….reposition head
…… check for secretions
,suctions
• Not enough pressure :
consider of E T intubation
Endotracheal Tube Placement
 When tracheal suctioning for meconium
is required
 If bag-mask ventilation is ineffective or
prolonged
 When chest compressions are performed
 When endotracheal administration of
medications is desired
 For special resuscitation circumstances,
such as congenital diaphragmatic hernia
or extremely low birth weight (1000 g)
Tube size Weight Gestational Age
(ID mm) (gm) (weeks)
2.5 <1000 <28
3.0 1000-2000 28-34
3.5 2000-3000 34-38
3.5-4.0 >3000 >38
 PPV
• 1.Indication for PPV
APNEA OR GASPING
HR < 100 bpm
CENTRAL CYANOSIS
• 2.BAG-Self inflating vs. flow dependent bag
• 3. Rate 40-60 bpm
• 4. Pressure used
a.  Initial breath after delivery = 30-40 cm H2O
      b.  Normal delivery = 15-20 cm H2O
       c.  Diseased Lungs =20-40 cm H2O
 PPV
• 5. Technique/Trouble shooting problems

of Bag mask ventilation

a. Check for a good seal
    b. Check for a patent airway
     c. Are you using enough pressure ?
• 6.Checking for chest movement
check mask position
head position-hyperflexion or hyperextention
secretion obstruction
slighly open infant mouth
checking for pressure
 Chest compression ****
• 1. Indications: 
If after 15-30 seconds of effectivepositive
pressure ventilation with 100% FI O2 the heart

rate is
a. below 60 bpm
b.between 60-80 bpm and not increasing
• 2. Technique:
a. 1 fingers breadth below nipple line, using
2 fingers
       b. 1/2 to 3/4 compression depth
       c. accompanied by ventilations, ratio is 3:1
**** Always two people are required
1 and 2 and 3 and
Breathe

Depth of 1\3rd A P
chest diameter
 Common Post-Resuscitation Airway
Complications

• Displaced ET Tube
• Obstructed ET Tube
• Pneumothorax
• Equipment Failure
– Inadequate Ventilatory Support
– Gastric Distension
Epinephrine
– IV route is preferred
• Dose 0.01-0.03mg/kg (0.1-0.3ml/kg of
1:10,000)
– ETT route if necessary
• Dose 0.03-0.1mg/kg (0.3-1.0ml/kg of
1:10,000)
• Smaller doses will likely be ineffective
• Safety and efficacy have not been evaluated
Naloxone
– Studies shows, may interfere with critical
functions of endogenous opioids and
exacerbate long-term neuro histologic injury of
cerebral white matter in asphyxiated animals
– NOT recommended as part of initial
resuscitation
– Indications for use (all must be present):
• Continued respiratory depression after PPV has
restored HR, tone, color
• History of maternal narcotic w/in past 4 hours
Guidelines To stop Resucsitation
– Resuscitation not indicated
(early death and unacceptably high morbidity)
• Extreme prematurity (<23wks or BW <400g)
• Anencephaly
• Confirmed trisomy 13 or 18
– Resuscitation nearly always indicated with
high rate of survival and acceptable morbidity
≥25wks, unless otherwise compromised
• Most congenital malformations
– Uncertain prognosis (borderline survival and
high rate of morbidity), parents views should
be supported
• If no signs of life (no heart beat and no
respiratory effort) after 10 minutes
continuous and adequate resuscitative
efforts, acceptable to discontinue.
 What to do after resuscitation ?
• Routine care: 90% N Term Delivery
• Observational Care : Admission to
transitional area of newborn nursery &
Cardiorespiratory Monitoring (mother &
baby bonding)
• Post-Resuscitation Care : PPV if
required then transfer to Intensive Care
Nursery
 Before birth

•Pulm arterioles constricted •Umbilical arteries feeding low

pressure placenta circulation

•High pressure in pulmonary •Low pressure in systemic

circuit circuit

•Very little pulmonary blood

flow
 After birth
Alveoli
1. •Fluid in the alveoli is absorbed
• EXPAND

• GET FILLED WITH AIR (O2)

 After birth

•Pulm arterioles dilate •Umbilical arteries and veins

are clamped

•Low pressure in pulmonary •High pressure in systemic

circuit circuit

•Dramatic increase in
pulmonary blood flow
Apgar score