Neonatal Resuscitation Workshop

Version 3.0 Date: 20 April 2022

• NEWBORN: First few hours after birth
• NEONATE: First 28 days of life
Children face the
• INFANT: 1 year/12months highest risk of dying in
their first month of life

https://data.unicef.org/topic/child-survival/neonatal-mortality/
 In 2020
 Globally 2.4 million babies died
in first 1 month of life
 6500 neonatal deaths every day
 1/3 die on first day of birth
 ¾ die in first week of birth

https://childmortality.org/wp-content/uploads/2020/09/UNICEF-2020-Child-Mortality-Report.pdf
 Neonatal mortality rate 40
Infant mortality rate 54
Under –five mortality rate 65

https://data.unicef.org/country/pak/
Pakistan (PAK) - Demographics, Health & Infant Mortality - UNICEF DATA
 Causes of Neonatal Deaths in Pakistan

10%
6%
1% 36%

18% The majority of all neonatal deaths (75%)

occur during the first week of life between
25% to 45% occur within the first 24 hours

22%

Preterm Birth Complications Intrapartum Related Events

Sepsis Congenital Abnormalities
Pneumonia Other Conditions

Source:
https://www.healthynewbornnetwork.org/country/pakista/
 Introduction and Overview

• Annual number of births in Pakistan = 5.8 Mio

• Annual number of children under 5 deaths = 377,000 (65/1000)
• Neonatal Mortality Rate of Pakistan 40 /1000 LB
• Annual number of neonatal deaths in Pakistan = 232,000
• 69% conducted by skilled birth attendants
• 66% conducted in Institutions
• Access to skilled birth attendant in urban = 70%
• Access to skilled birth attendant in rural = 30%
• Neonatal deaths from asphyxia…..25%
• Serious neurological sequelae ….. 25%
Source: PDHS 2017-2018,
UNICEF: https://data.unicef.org/country/pak/
 Before Birth

 Since the oxygen supplied to the fetus comes from the placenta, the
lungs contain no air.
 The alveoli (air sacs) of the fetus are filled instead with fluid that
has been produced by the lungs.
 Diminished blood flow through the lungs of the fetus is a result of
the partial closing of the arterioles in the lungs.

http://hamiltonhealthsciences.ca/workfiles/basehospital/Anatomy%20and%20Physiology%20of%20Neonates
 At Birth

 At birth, the alveoli are filled with “fetal lung fluid.”

 Approximately 1/3 of fetal lung fluid is removed during vaginal delivery
as the chest is squeezed and lung fluid exits through the nose and mouth.
 The remaining fluid passes through the alveoli into the lymphatic tissues
surrounding the lungs.
 How quickly fluid leaves the lungs depends on the effectiveness of the
first few breaths.

http://hamiltonhealthsciences.ca/workfiles/basehospital/Anatomy%20and%20Physiology%20of%20Neonates
After Birth
Alveoli
Fluid in the alveoli is absorbed • EXPAND

• GET FILLED WITH AIR (O2)

Neonatal medicine: Transition from intrauterine to extrauterine life Thor Willy Ruud Hansen, MD, PhD, FAAP.Section on Neonatology,Department of Pediatrics,Rikshospitalet
Normal Transition
• For the respiratory system to function effectively, the infant must
have:
• Adequate pulmonary blood flow
• Adequate amount of surfactant
• Respiratory musculature strong enough to support respiration

http://www.cmnrp.ca/uploads/documents//Newborn_Adaptation_Assessment_2013_FINAL.pdf
Problem

• Problems clearing fluid from the lungs occur in infants whose lungs do
not inflate well with the first few breaths. These are:
• Apnea at Birth: With an infant who has never taken an initial breath, the
lungs remain filled with fluid.
• Weak initial respiratory effort: Shallow, ineffective respirations:
gasping . May occur in premature infants or in infants who are depressed
due to asphyxia, maternal drugs, or anesthesia.

http://hamiltonhealthsciences.ca/workfiles/basehospital/Anatomy%20and%20Physiology%20of%20Neonates
Apnea
• It is important to note that, as a result of fetal hypoxia, the infant may go
through primary apnea and into secondary apnea while in-utero.Thus an
infant may be born in either primary or secondary apnea.
• In a clinical setting, primary and secondary apnea are virtually
indistinguishable from one another.
• In both instances the infant is not breathing, and the heart rate may be
below 100 per minute.

http://hamiltonhealthsciences.ca/workfiles/basehospital/Anatomy%20and%20Physiology%20of%20Neonates
Asphyxia
Cardiac Function and Circulation
Pulmonary Vasoconstriction • Early in asphyxia :
A term commonly used to refer
to decreased pulmonary blood arterioles in the bowels,
flow in the asphyxiated infant is kidneys, muscles, and skin
pulmonary vasoconstriction. constrict.
• Late in asphyxia: Reduced
cardiac output leading to
organ damage

http://hamiltonhealthsciences.ca/workfiles/basehospital/Anatomy%20and%20Physiology%20of%20Neonates
NRP Key Behavioral Skills

• Know your environment.

• Use available information.
• Anticipate and plan.
• Clearly identify a team leader.
• Communicate effectively.
• Delegate the workload optimally.
• Allocate attention wisely.
• Use available resources.
• Call for additional help when needed.
• Maintain professional behavior.
 PERCENTAGE

5% 2%
10% Spontaneous breathing
1-3 newborns/1000
Drying & Stimulation births will receive
PPV chest compressions or
Intubation
emergency
medication

83%

NRP 8th Edition

 Ask 4 Questions before every birth:

PREPARATIO 1. Expected gestational age

2. Is the AF clear ?
N 3. Any additional risk factors?
4. Umbilical cord management plan
RISK FACTORS
Pre-Resuscitation Team Briefing
• Assess risk factors.
• Identify team leader.
• Anticipate potential complications and plan a team response.
• Delegate tasks.
• ldentify who will document events as they occur.
• Determine what supplies and equipment will be needed.
• Identify how to call for additional help.
Preparation
 Wash your hands
 Draught free, warm room*
 Clean, dry and warm delivery surface
 Radiant heater
 Two clean, warm towels/clothes
 A folded piece of cloth
 Self inflating bag - newborn size
 Infant masks in two sizes - normal and small newborn
 Suction device
 Clock
Components

The components of the neonatal resuscitation procedure as related

to the ABCs of resuscitation are:

A- Establish an open airway:.

B- Initiate breathing:

C- Maintain circulation:
What to Look For ?

• Evaluate after every 30 seconds:

• Breathing
• Heart rate
• Color
Golden Minute

! The most important and effective action

is to ventilate the baby’s lungs
 Neonatal Resuscitation
Antenatal counseling.
Algorithm
Team briefing and equipment check.

Birth Pre-ductal SpO2 Target

1 min 60%-65%

Term? Tone?
Yes 2 min 65%-70%
Stay with mother for initial steps 3 min 70%-75%
Breathing or routine care and ongoing evaluation. 4 min 75%-80%
crying?
5 min 80%-85%
10 min 85%-95%
No
A Warm, Dry, Position airway, clear
1 secretions if needed, stimulate. Laboured
breathing or
minute
persistent
Apena, No cyanosis
gasping or HR
below 100
bpm?
Yes Yes ETT or Laryngeal mask.
PPV. Position airway, suction if Chest compressions.

B Pulse oximeter,
Consider Cardiac monitor
needed.
Pulse oximeter
Supplemental O2
Coordinate with PPV.
100% O2
UVE
C
Consider CPAP
HR below 100 HR below 60
bpm bpm?
No Post- resuscitation care NO
No Yes Team debriefing Yes
Ensure adequate Ventilation
corrective steps if needed.
ETT or laryngeal mask
Cardiac monitor
IV epinephrine.
If HR persistently below 60 bpm:
D
Consider hypovolemia,
pneumothorax
HR below 60
Yes
bpm
 Steps in Resuscitation

Routine Care
&
Initial Steps
Warm & Dry
Place the baby on a warm towel or
blanket and gently dry any fluid.
Techniques for Stimulation

Do not shake the baby

 Correct Position

Sniffing position
Optional shoulder roll for maintaining correct position
In-Correct Position
Suction if Needed
Routine suction for a crying, vigorous
baby is not indicated.
Clear secretions from the airway only If
• Baby is not breathing
• Baby is gasping
• Baby has poor tone
• Secretions are obstructing the airway
• Baby is having difficulty clearing their
secretions
• Anticipate starting PPV
Positive
Pressure
Ventilation
Steps in Neonatal Resuscitation

Airway
If the baby has labored breathing, or the oxygen saturation
cannot be maintained within the target range despite 100%
oxygen, you may consider a trial of :
 continuous positive airway pressure (CPAP) or
 PPV
CPAP

 CPAP is a method of respiratory support that

uses a continuous low gas pressure to keep a
spontaneously breathing baby's lungs open.
 CPAP should only be considered in the
delivery room if the baby is breathing and the
baby's heart rate is at least 100 bpm.
 Administering CPAP may increase the chance
of developing a pneumothorax ( air leak).
 If desired, a trial of CPAP in the delivery room
can be given by using a flow-inflating bag or a
T-piece resuscitator attached to a mask that is
held tightly to the baby's face
When to Start PPV?

After completing the initial steps, positive-pressure ventilation (PPV) is indicated if the
baby is not breathing, OR if the baby is gasping, OR if the baby's heart rate is less
than 100 beats per minute (bpm).

During PPV, the initial oxygen concentration (Fro2)

 for newborns greater than or equal to 35 weeks' gestation is 21 %.
 for preterm newborns less than 35 weeks' gestation is 21 % to 30%.

 The ventilation rate is 40 to 60 breaths per minute

 initial ventilation pressure is 20 to 25 cm H20 .

The most important indicator of successful PPV is a rising heart rate.

If the heart rate is not increasing within the first 15 seconds of PPV and you do
not observe chest movement, start the ventilation corrective steps.

MR- SOPA ( Corrective Steps)

Equipment Used for PPV
Technique of Using PPV
Masks

 Cushioned/Non-cushioned
 Round/Anatomical shaped
 Size 0 or 1
Steps in Ventilation

1 FORMING THE SEAL : Enclose chin, mouth & nose, ensure snug seal, avoid
pressure over neck and eyes
2 Squeeze the bag with fingertips: Don’t squeeze empty the bag with whole hand
3 Observe chest movements: Noticeable rise and fall of chest, shallow and easy
breathing
4 Rate : 40-60 breaths/minute
5 Pressure : Initial breath :30-40 cm H2O
Later : 15-20 cm H2O
Steps in Ventilation

SQUEEZE TWO THREE SQUEEZE

Steps in Ventilation

• 1: LOOK FOR CHEST RISE

• 2: Heart rate
• 3: Color

If the heart rate is not increasing within the first 15 seconds of PPV and
you do not observe chest movement, start the ventilation corrective steps.
Steps in Neonatal Resuscitation

Airway
Settings for PPV
Use of Pulse Oximetery?
Alternate Airway
 Steps in Neonatal Resuscitation

Alternate Airways
Alternate Airways?
Endotracheal Intubation
Steps

• Prepare equipment
• Correctly position the baby
• Hold laryngoscope in left hand . Open mouth with right hand
• Insert laryngoscope on right side of mouth
• Identify important landmarks thru laryngoscope
• Insert the endotracheal tube
• Secure the endotracheal tube
• Ventilate through the endotracheal tube
• All steps to be completed within 30 seconds
Positioning for Intubation and Insertion

Hold laryngoscope in left hand

 Detect exhaled CO2 within 8-10 positive pressure breaths
 Rapidly rising heart rate
Chest
Compressions
Steps in Neonatal Resuscitation

CHEST
COMPRESSIONS
When to Begin Chest Compressions ?

Chest compressions are indicated when the heart rate remains less than 60 beats per
minute (bpm) despite at least 30 seconds of positive-pressure ventilation (PPV) that
inflates the lungs (chest movement).

In most cases, you should have given at least 30 Sec of ventilation through a properly
inserted endotracheal tube or laryngeal mask

Note: If the chest is not moving with PPV, the lungs have not been inflated than chest compressions are
not yet indicated. Continue to focus on achieving effective ventilation.
Where Do You Stand During Chest Compressions ?

Once the endotracheal tube or laryngeal mask is

secure, move to the head of the bed to give chest
compressions.

• It provides space for safe insertion of an

umbilical venous catheter
• It provides mechanical advantages that result in
less compressor fatigue.

 Compressor standing at the head of the Bed

Techniques of Compressions ?

Thumb Technique Two Finger Method

• Duration of Downward stroke should be shorter than duration of release

• Do not lift the fingers of the chest
Position of Chest Compressions ?

Place your thumbs on the sternum, in the center,

just below an imaginary line connecting the baby's
nipples.

• Encircle the torso with both hands.

• Support the back with your fingers.
• Your fingers do not need to touch each other.
 •Position
• Neck slightly extended with firm support for the back
• Lower 1/3rd of sternum between nipple line & sternum

•Pressure Required – depth

• 1/3rd of the AP diameter of chest

•Rate
Steps of Chest • 3 Chest Compressions then 1 ventilation (3:1)

Compressions • 90 Chest Compressions to 30 ventilation in one minute

Evaluation of Chest Compressions

After 60 seconds of chest compressions and ventilation, briefly stop compressions and
check the heart rate. A cardiac monitor is the preferred method for assessing heart rate
during chest compressions. You may also assess the baby's heart rate by listening with
a stethoscope. If necessary, you may briefly stop ventilation to auscultate the heart rate.

If the heart rate is 60 bpm or greater, discontinue compressions and resume PPV at 40 to
60 breaths per minute

If the baby's heart rate remains less than 60 bpm despite 60 seconds of effective
ventilation and high-quality, coordinated chest compressions, epinephrine administration
is indicated, and emergency vascular access is needed.
What Oxygen Concentration should be used with
PPV During Compressions ?

• When chest compressions are started, increase the FiO2 to 100%.

• Once the heart rate is greater than 60 bpm and a reliable pulse oximeter signal
is achieved, adjust the FiO2 to meet the target oxygen saturation guidelines
Medications
Steps in Neonatal Resuscitation

Medications
When is Epinephrine Indicated ?
Epinephrine is indicated if the baby's heart rate remains less than 60 beats per minute
(bpm) after:

At least 30 seconds of positive-pressure ventilation (PPV) that inflates the lungs as

evidenced by chest movement
and

Another 60 seconds of chest compressions coordinated with PPV using 100% oxygen.

In most cases, ventilation should have been provided through a properly inserted
endotracheal tube or laryngeal mask.

Epinephrine is not indicated before you have established ventilation that effectively
inflates the lungs, as evidenced by chest movement.
How to Administer ?

 IV preferred. Endotracheal route only if IV access not available

 Umbilical vein catheterization
Dose:

• Intravenous or Intraosseous = 0.02 mg/kg ( equal to 0.2 mL/kg)

• May repeat every 3 to 5 minutes
• Range = 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3 mL/kg)
• Rate: Rapidly-as quickly as possible
• Flush: Follow intravenous or intraosseous lose with a 3-mL saline flush
• Endotracheal = 0.1 mg/kg (equal to 1 mL/kg)
Volume Expanders

Normal Saline: The recommended dose is 10 mL/kg, which may need to be

repeated. When resuscitating premature infants, care should be taken to avoid
giving volume expanders rapidly
Only indicated if baby is not responding to all above steps of resuscitation and
has history of acute blood loss or shows signs of shock.
Post Resuscitation Care

• A baby who required resuscitation must have close monitoring and frequent
assessment of respiratory effort, oxygenation, blood pressure, blood glucose,
electrolytes, urine output, neurologic status, and temperature during the immediate
neonatal period.
• Transfer to NICU/NURSERY
• Parental counselling
• Be careful to avoid overheating the baby during or after resuscitation.
• Notes
When to Stop Resuscitation

We suggest that, in infants with an Apgar score of 0 after 20 minutes of

resuscitation, if the heart rate remains undetectable, it may be reasonable
to stop assisted ventilation;*
 No heart rate after 20 minutes of complete and adequate resuscitation
 No evidence of other causes of compromise
THANK YOU
Special
Considerations
 Resuscitation and Stabilization of Preterm Babies?
 If the baby is less than approximately 32 weeks' gestation, a polyethylene
plastic bag or wrap and a thermal mattress should be prepared.

 Consider using CPAP immediately after birth if the baby is breathing

spontaneously with a heart rate of at least 100 beats per minute (bpm) but
has labored respirations or low oxygen saturation.

 To decrease the risk of neurologic injury, handle the baby gently, avoid
positioning the baby's legs higher than the head, avoid high PPV or CPAP
pressures, use a pulse oximeter and blood gases to adjust ventilation and
oxygen concentration, and avoid rapid intravenous fluid infusions.
Pneumothorax

Results from:
◦Positive pressure ventilation
◦Lung malformation
If the chest is not expanding adequately despite proper positioning of airways , Ambu-
bagging, giving adequate pressure, placing Guedel airways and there is no improvement
in heart rate, then this condition must be considered.
Removing obstruction of lung airways by external chest drainage of air through
placement of needle or chest drain in pleural space.
Pleural Effusion

In neonate it may results from:

 Hydrops fetalis
 Chylothorax

 Manage by chest drain insertion.

Congenital Diaphragmatic Hernia (CDH)

If Chest is not expanding adequately despite proper positioning of airways, ambu-baging,

giving adequate pressure, placing Guedel airways and there is no improvement in heart rate.
Think about CDH and confirm on examination.

Resuscitation with a bag and mask contraindicated.

Should have immediate endotracheal intubation and place a large orogastric catheter.
Choanal Atresia
Babies are nasal breathers.
Should be considered where after proper airway opening and clearing maneuvers,
good expansion of the chest cannot be obtained by ambu- baging.

How to Intervene ?
 Inserting a plastic oral airway will allow air to pass through mouth.
Meconium Mucus Blockage

Babies Attempts to aspirate meconium from nose & mouth of the unborn baby ,
while the head is still on the perineum is not recommended.
If at birth, a meconium-stained baby has:
• Normal respiratory effort
• Normal muscle tone
• Heart rate grater than 100beats/min
How to Intervene ?
 Use a bulb/Penguin sucker or large bore suction catheter to clear secretions
from oropharynx and nose if visible.
 Do not Intubate or do blind oropharyngeal suction.
Meconium Mucus Blockage

If at birth, a meconium-stained baby has:

• Depressed respiratory effort
• Poor muscle tone
• Heart rate less than 100 Beats / Min

How to Intervene ?
 Use a bulb/Penguin sucker or large bore suction catheter to clear
secretions from oropharynx and nose if visible.
 Do not Intubate or do blind oropharyngeal suction.
Pharyngeal Airway Malformation (Robin Syndrome)

Developmental malformation of palate and oropharynx.

Small mandible results in critical narrowing of pharyngeal airway.
Tongue, posteriorly placed, falls back into pharynx and obstructs it just
above larynx.
Maintain airway by positioning or use of plastic oral airway.
Maternal Drugs

Naloxone is no longer recommended as part of initial resuscitation in a delivery

room.
Giving a narcotic antagonist is not the correct first therapy for a baby who is not
breathing.

The first corrective action is positive pressure ventilation.