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Lesson 1:

OVERVIEW AND
PRINCIPLES OF
RESUSCITATION

Neonatal Resuscitation Program Slide Presentation Kit

The American Academy of Pediatrics is not responsible for any changes or modifications to this program
made by the Neonatal Resuscitation Training Team of Latter-day Saint Charities.
This program, as modified, may not be distributed in the United States.
.
Overview and Principles of
Resuscitation
Lesson content:
• Physiologic changes at birth
• Resuscitation flow diagram
• Resuscitation risk factors
• Equipment and personnel needed

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Which Babies Require
Resuscitation?
• Most newly born babies are vigorous
• Only about 10% of newborns require some
assistance
• Only 1% need major resuscitative measures
(intubation, chest compressions, and/or
medications) to survive

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Fetal Physiology
In the fetus
• Alveoli filled with lung fluid
• In utero, fetus dependent on placenta for
gas exchange

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Fetal Physiology
In the fetus
• Pulmonary arterioles
constricted
• Pulmonary blood flow
diminished
• Blood flow diverted
across ductus
arteriosus Click on the image to play video

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Lungs and Circulation
After Delivery
• Lungs expand
with air
• Fetal lung fluid
leaves alveoli

Click on the image to play video

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Lungs and Circulation
• Pulmonary
arterioles dilate
• Pulmonary blood
flow increases

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Lungs and Circulation
• Blood oxygen
levels rise
• Ductus arteriosus
constricts
• Blood flows through
lungs to pick up
oxygen
Click on the image to play video

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Normal Transition
The following major changes take
place within seconds after birth:
• Fluid in alveoli absorbed
• Umbilical arteries and vein constrict thus
increasing blood pressure
• Blood vessels in lung relax

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What Can Go Wrong During
Transition
• Lack of ventilation of the newborn’s lungs
results in sustained constriction of the
pulmonary arterioles, preventing systemic
arterial blood from being oxygenated
• Prolonged lack of adequate perfusion and
oxygenation to the baby’s organs can lead to
brain damage, damage to other organs, or
death

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Signs of a Compromised
Newborn
• Poor muscle tone Good tone
with
• Depressed cyanosis
respiratory drive
• Bradycardia
• Low blood pressure
• Tachypnea Bad tone
• Cyanosis with
cyanosis

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In Utero or Perinatal
Compromise
Primary Apnea
• When a fetus/newborn first becomes deprived
of oxygen, an initial period of attempted rapid
breathing is followed by primary apnea and
dropping heart rate that will improve with tactile
stimulation

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Secondary Apnea
• If oxygen deprivation
continues, secondary
apnea ensues,
accompanied by a
continued fall in heart rate QuickTime™ and a
Sorenson Video 3 decompressor
and blood pressure are needed to see this picture.

• Secondary apnea cannot


be reversed with
stimulation; assisted
ventilation must be
provided Click on the image to play video


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Resuscitation of a Baby in
Secondary Apnea
Initiation of effective positive-pressure
ventilation during secondary apnea
usually results in
• Rapid improvement in heart rate

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Provider Response
All newborns require
initial assessment to
determine whether
resuscitation is
required

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Initial Steps (Block A)
• Provide warmth
• Position head and
clear airway as
necessary*
• Dry and stimulate the
baby to breathe

*Consider intubation of the trachea at this point (for depressed


newborn with meconium-stained fluid)
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Evaluation
After these initial steps, further actions are
based on evaluation of

• Respirations
• Heart rate
• Color
You have approximately 30 seconds to
achieve a response from one step before
deciding to go on to the next
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Breathing (Block B)
If Apneic or HR < 100 bpm:
• Provide positive-pressure
ventilation*
• If breathing, and heart rate
is >100 bpm but baby is
cyanotic, give
supplemental oxygen. If
cyanosis persists, provide
positive-pressure
ventilation
*Endotracheal intubation may be considered at several steps
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Circulation (Block C)
If heart rate <60 bpm despite adequate
ventilation for 30 seconds,
• Provide chest compressions as you continue
assisted ventilation* 
• Then evaluate again. If heart rate <60 bpm,
proceed to Block D

*Consider intubation of the trachea at this point


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Drug (Block D)
If heart rate <60 bpm despite adequate
ventilation and chest compressions,
• Administer epinephrine as you continue assisted
ventilation and chest compressions* 

*Consider intubation of the trachea at this point


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Important Points in the Neonatal
Resuscitation Flow Diagram
• The most important and effective action in
neonatal resuscitation is to ventilate the baby’s
lungs 
• Effective positive-pressure ventilation in secondary
apnea usually results in rapid improvement of heart
rate 
• If heart rate does not increase, ventilation may be
inadequate and/or chest compressions and
epinephrine may be necessary

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Important Points in the Neonatal
Resuscitation Flow Diagram
• Heart rate <60 bpm → Additional steps needed
• Heart rate >60 bpm → Chest compressions can be
stopped
• Heart rate >100 bpm and breathing → Positive-
pressure ventilation can be stopped
• Asterisk (*): endotracheal intubation may be
considered at several steps
• Time line: if no improvement after 30 seconds,
proceed to next step
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Preparation for Resuscitation:
Personnel and Equipment
• Every delivery should be attended by a person
who is capable of initiating resuscitation.
• When resuscitation is anticipated, ask for
additional help
• Prepare necessary equipment
– Turn on radiant warmer or heat source
– Check resuscitation equipment

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Preparation for
Resuscitation: Risk Factors
• The majority, but not all, of neonatal
resuscitations can be anticipated by
identifying the presence of antepartum
and intrapartum risk factors associated
with the need for neonatal resuscitation

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Why Are Premature
Newborns at Higher Risk?
• Possible surfactant deficiency
• Decreased drive to breathe
• Rapid heat loss, poor temperature control
• Possible infection
• Susceptible to brain hemorrhage
• Susceptible to hypovolemia secondary to blood loss
• Weak muscles make spontaneous breathing difficult
• Immature tissues may be damaged by excessive
oxygen

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Three Levels of Post-
resuscitation Care

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End of Lesson 1
Preparation for Resuscitation:
Personnel and Equipment
• Every delivery 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 immediately available should
have the skills required to perform a complete
resuscitation
• When resuscitation is anticipated, additional personnel
should be present in the delivery room before the
delivery occurs
• Prepare necessary equipment
– Turn on radiant warmer
– Check resuscitation equipment

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NRT Key Point!
Keep it simple:
• Teach to the level of understanding
• Goal: Get oxygen to baby’s brain
• Common problem is getting air into the
lungs
• If you get air into the lungs, the rest takes
care of itself
• Use exam to review each lesson

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Teaching Tip!
Qualities of a good instructor:
• Role model experienced in newborn care
• Organized and communicates well
• Encourages learners and has a sense
of humor
• Views stressful situation as a positive challenge
• Firm belief in ability to apply knowledge and
save lives

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Risk Factors Associated with the
Need for Resuscitation
Antepartum factors: Intrapartum factors:
• Ruptured membranes • Excessive bleeding
over 18 hours • Breech presentation
• Pre-eclampsia and • Meconium
Eclampsia • Abnormal fetal heart tones
• Maternal infection – • Prolapsed or nuchal cord
Malaria, HIV, etc. • Rapid, hard labor
• Premature labor • Foul smelling fluid
• Multiple births • Prolonged labor
• Others • Shoulder dystocia
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