Neonatal asphyxia and

resuscitation
Birth asphyxia
 Indicates baby suffered hypoxic insult
 Indicated by low apgar
 Majority of cases –intrauterine adverse

events/inherent abnornmalities of baby

 Can occur –in utero,during

delivery,immediately after
 Combination –hypoxemia,hypercapnea and

metabolic acidosis
 Hypoxia-adverse events in organs-hypoxic
ischaeic injury
 Babies with delayed crying/poor resp efforts-

sucessfully resuscitated no organ

dysfunction-perinatal depression
causes
 Maternal-maternal diseases, hypotension,
shock, analgesia,anaesthesia,drug intake
 Placental-pl.insuffiency, cord copression &

prolapse,abruption
 Fetal-prematurity, meconium staining,

infections,malformations as CDH
 Intrapartum-prolonged labor,difficult

instrumental delivery, breech delivery,birth

trauma
Apgar score
 Scoring for better understanding and
standardisation of Mx
 Asertains severity of asphyxia
 Scoring at 1’ and 5’ and every 5’ until stable

therafter
 1’-condition at birth
 5’-effectiveness of resuscitation
 Co-relate poorly with long term neuro

outcome
Pre-requisites
 Resuscitation place
 Flat surface- table /trolley
 warm and clean
 Room temp-26C
 Radiant warmer/heater/200 watt bulb
 Heat source turned on before delivery
 2 pre warmed towels-receive baby
equipments
 De Lee Trap
 Mechanical suction
 Suction Catheters-12F,14F
 Feeding tubes 6F,8F;20 ml syringe
 Neonatal self inflating resuscitation bags-500ml
 Face masks-term,preterm sizes
 Oygen with flowmeter n tubing
 T piece resuscitator
 Air oxygen blender
 Pulse oximeter
 Intubation equipments-laryngoscope,endotracheal

tubes
 Drugs and fluids
 Epinephrine
 Normal saline,sterile water
General measures
 Hypothermia should be avoided-cold stress –
increase oxygen consumption-impede
postnatal adaptation
 Baby received in pre warmed towel
 Head and skin dried rapidly
 Wet linen discarded, baby wrapped in another

prewarmed towel
 Place under radiant warmer
 Another strategy- skin to skin
position
 NB –supine with head neutral/slight etension
 Blanket/towel placed under shoulder-

maintain position-airway open

airway
 Airway –secretions removed by gentle suction
 Mouth-nose
 2-3 sec only;pressure not ore than 100 mm

Hg
 Avoid deep suctioning-vagal stimulation-

apnea& bradycardia
 stimulation
 Earlier steps-adequate stimulation;if not cried
 External stimulation-flicking toes and sole

twice, rubbing back

 All these steps completed in 30s;if baby not

started breathing-BMV
Evaluation

 Throughout-reassessed at 30” interval

 Evaluate-respiration,HR,color
 HR-auscultation-6s x 10
Oxygen
 If normal breathing,HR nl,but blue limbs-o2
at 5L/mt
 Via O2 mask/O2 tubing
 After cyanosis disappears-wean off slowly

over minutes
 Current recommendation-air O2 blender with

spO2 monitoring-prevent hyperoxemia

induced injury
 Target spO2-85-95% achieved after 10’ of

birth
BMV
 Ambu bag used for this
 Indications
 Apnoea/gasping respiration
 HR<100bpm
 Persistent central cyanosis despite 100% O2
procedure
 Key to sucessful resusciation-establish
adequate ventilation
 Bag and mask with oxygen reservoir used
 Mask –covering chin upto nose,avoiding

eyes-airtight manner
 Provider aat head end-clear view of chest and

abdomen
 Visible chest expansion-reliable sign of
effective vetilation
 Rate-40-60 breaths/mt;30 when chest

compressions deliverd simultaneously

 Entilation-bring up HR
 Baby evaluate every 30s
 If HR>100-only then BMV stopped
 HR<60-chest compression begun
 Rate-90/mt;ratio 3:1 with ppv
Non expansion of chest
 Causes
 Blocked airway-suction,check position
 Leak-reapply mask with proper seal
 Insufficient inflation-check leak,increase

pressure
MR SOPA
 6 ventilation corrective steps
 M-ask adjust
 R-reposition airway
 S-suction mouth,nose
 O-open mouth
 P-pressure increase
 A-alternate airway
 Despite these measures –chest does not

expand-endotracheal intubation done

Chest compression
 Two thumb tehnique-provider encircles chest
with both hand-compression on lower 3rd of
sternum –avoid xiphisternum
 Lower third- site below line b/w nipples
 Fingers should not be lifted off
 Thumb flexed at DIP joint
 Pressure perpendicular to chest
 Two finger method
 2 fingers on sternum at right angles to chest
 Other hand support back
 Useful when only single resuscitator
 Rate of compression90/mt;rate of vntilation-

30/mt
Endotracheal intubation
Indications
 No response to BMV
 CDH
 Chest compressions simultaneously
 Tracheal administration of drugs-surfactant
Resuscitation algorithm
 Baby good resp effort/crying,HR>100,pink-
no intervention-drying and warming only
 good resp effort/crying,HR>100,blue-free

flow O2;O2 weaned off if cyanosis

disappears,tactile stimulation if not cried so
far
poor resp effort/crying,HR<100:BMV with
100% o2 is best,evaluate every 30s
 Hr remains <60 after 30 s ventilation-chest
compression started continuing BMV
 Evaluate HR after 30s;if HR >60-compression

stopped
 If HR<60 despite CC +BMV-give epinephrine-

dose:0.1-0.3ml/kg 1:10000
 Route:umbilical vein
documentation
 Apgar assigned at 1’ and 5’ after birth then
every 5’ until vitals establish
 Description of interventions done
Resuscitation discontinued?
 No detectable HR for >10 min despite
adequate resuscitstive measures
Neonatal resuscitation changes
recent
 1 assessment: 3 questions
 Term gestation?
 Crying/breathing?
 Good tone?
 Progression to determined by simultaneous

asssessment of 2 vital characteristics

 HR-</>100 bpm;
 Respiration-

apnoea,gasping,laboured,unlaboured
Depend on 2 factors only; color deleted-hence
free flow o2 deleted
2.oximetry-should be used for evaluation of
oxygenation
If PPV begun-assessment consist of
simultaneous evaluation of 3 factors-HR,resp,
oxygenation
 Spontaneously breathing pre term infants
with distress-support with
CPAP/Intubation/Mech.Vent
 4 room air resuscitation
 Term babies-begin resuscitation with room

air than 100% o2

 Supplementary oxygen regulated by

blender,guided by oximetry
 5-adequacy of ventilation by chest wall rise
 6-chest compression ratio remain 3:1 unless

arrest is of known cardiac cause-15:2

 7-Therapeutic hypothermia-term/near term

with evolving HIE

 8-Delayed cord clamping-1 mt
 9-Naloxone not recommended