 History

 Overview and Principles of Resuscitation

 Initial steps of resuscitation
 Positive – Pressure ventilation
 Chest compressions
 Endotracheal tube intubation and LMA insertion
 Medications
 Special considerations
 Resuscitation of Preterm babies
 Ethics and Care at the end of life
 For the past 40 yrs Fetal anoxia was one of
the most investigated conditions affecting
the newborn.
 Better understanding of the effect of certain
conditions on fetus like placental disease
and hemorrhage.
 It was then realized that obstruction to the
airway immediately following birth should be
the first concern in newborn resuscitation.
 18th Century Scottish Obstetrician Blundell first
used mechanical device for tracheal intubation
in living newborn
 In 1920 Joseph B. DeLee introduced simple
rubber catheter and glass trap to clear upper
airways and stomach.
 In 1953 Apgar Score was given by Varginia
Apgar. She is also the first to catheterise UA in
newborn
 1966 national guidelines for resuscitation of
adults was recommended by National Academy
of Sciences.

 In 2000 the consensus document on advanced

life support of the newborn converted the
previously published advisory statements into a
set of guidelines.

 In 2010 revised guidelines was published.

Professor of Pediatrics and Director of the
Neonatology Department at Saint Louis
University in St. Louis, Missouri.
 Diarrhoea Others
Tetanus 3% 7%
7% Preterm
Congenital 27%
7%

Asphyxia Sepsis &

23% pneumonia
26%

4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900
WHY TO LEARN NEWBORN RESUSCITATION ?

 Birth asphyxia accounts for about 1/4th of the

4 million neonatal deaths that occur each year
worldwide.
 For many newborns resuscitation is not
available
 Outcomes of these newborns can be improved
with timely and effective resuscitation.
 Approximately 90% of newborns make
smooth transition from intrauterine to
extrauterine life requiring little or no
assistance
 10% of newborns need some assistance
 Only 1% require extensive resuscitation
 We must always be prepared to resuscitate,
as even some of those with no risk factors
will require resuscitation.
 ADULT vs. NEONATAL RESUSCITATION

 The sequence of resuscitation in adults is C-A-B

 But in newborns the sequence remains
A-B-C as the etiology of neonatal compromise is
nearly always a breathing difficulty

 AIRWAY(position and clear)

 BREATHING (stimulate to breathe)
 CIRCULATION (assess HR and oxygenation)
Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required Always needed
Dry, stimulate to breathe

Give supplemental oxygen, as required

Assist ventilation with positive Needed less

pressure frequently

Intubate the trachea

Provide chest
compressions Rarely needed

Medications
BEFORE BIRTH

 Oxygen supply by placental

membranes
 No role of lungs. Fluid filled
alveoli and constricted arterioles
due to low Po2 in fetal blood.
 Low Po2 
constricted arterioles
 increased
pulmonary vascular
resistance 
shunting of blood
from Pulmonary
Artery  Ductus
Arteriosus  Aorta.
AFTER BIRTH
 Baby cries  takes first breath  air enters alveoli
 alveolar fluid gets absorbed  increased Po2 
relaxes pulmonary arterioles  decreased PVR
 Umbilical arteries constrict +
clamp cord  closure of
Umbilical Arteries and
Umbilical Vein  increased
SVR
 Decreased PVR + Increased
SVR  functional closure
of Ductus Arteriosus 
increased blood flow into
lungs  oxygenation 
supply to body through
aorta.
WHAT CAN GO WRONG ?
 Compromise of uterine or placental blood flow 
deceleration of FHR (1st clinical sign)
 Weak cry  inadequate ventilation to push the alveolar
fluid
 In utero hypoxia  Meconium passage may block the
airways
 Fetal blood loss (abruption)  Systemic Hypotension
 Fetal Hypoxia/ischemia  poor cardiac contractility &
fetal bradycardia  Systemic Hypotension
 Pulmonary arterioles remain constricted  PPHN
 Low muscle tone
 Respiratory depression
(apnoea / gasping)
 Tachypnea
 Bradycardia
 Hypotension
 Cyanosis
 Rapid Irregular
breathing Gasping

If the baby does not begin breathing immediately after being
stimulated, he or she is likely In secondary apnea and will require
PPV
Changes due to oxygen deprivation
Primary Apnea

Stimulation

Secondary Apnea

Effective Positive pressure ventilation

Myocardium is depressed

Chest compressions, medications

 Oral mucus sucker

Suction Catheter

Radiant warmer
TRANSPORT
INCUBATOR
Term / Preterm ?
 Term: smooth transition
 Preterm : stiff, under-developed lungs,
insufficient muscle strength, can’t maintain
temperature
Breathing/Crying ?
 Watch baby’s chest
 Gasping is a series of deep, single or stacked
inspirations that occur presence of
hypoxia/ischemia. Treated as apnea.
Good tone ?
 Term: flexed extremities
 Preterm/sick: flaccid/limp,
extended extremities
 Provide warmth :
Radiant warmer, don’t
cover with towels.
 Position head and
clear airway as
necessary
 Dry and stimulate
the baby to breathe,
reposition
 Suction mouth first, then
nose
 “M” before “N”
 To prevent aspiration of
mouth contents
Vigorous if
1. Good tone
2. Good Cry/
Breathing
3. HR> 100/min
Insert Laryngoscope
Clear Mouth and posterior
pharynx using 12F/14F catheter
Insert ET tube
Attach ET tube to meconium
aspirator and suction source
Apply suction and remove
slowly
Count 1-1000,2-1000,3-1000,
withdraw
Repeat if HR is < 100
Stimulate :
Flicking the soles/
drying & rubbing
the back
 Respirations
 Heart rate: Best is
auscultation, alternatively
pulsations at base of cord is
felt. Count for 6s and “x”10
 Oxygenation by oximeter
If Apneic or HR < 100 bpm:
 Provide positive-pressure
ventilation,spo2 monitoring.
 If breathing, and heart rate is
>100 bpm but baby is cyanotic,
give supplemental oxygen,
spo2 monitoring. If cyanosis
persists, provide positive-
pressure ventilation
 If respiratory distress is
persistent , consider CPAP and
connect oximeter
 Free flow oxygen  Start with room air and
 Oxygen mask increase to maintain
 Flow inflating bag target SpO2
 T- piece resuscitator
Time Target Spo2
 Oxygen tubing held
1min 60-65%
close to baby’s nose
2min 65-70%
 CPAP provided with
3min 70-75%
 Flow inflating bag
4min 75-80%
 T-piece resuscitator
5min 80-85%
10min 85-95%
MASK T-Piece Resuscitator

Flow Inflating Bag

 Ventilation of the lungs is the
single most and most effective
step in newborn resuscitation
Indications:
 Gasping/apnea
 HR < 100/min
 SpO2 remains below target
values despite free flow
supplemental oxygen increased
to 100%.
 Peak inspiratory pressure (PIP) : Pressure
delivered with each breath, such as the
pressure at the end of a squeeze of
resuscitation bag or at the end of breath with
a T – piece resuscitator
 Positive end – expiratory pressure (PEEP) :
The gas pressure which remains in the system
between breaths, such as during relaxation
and before the next squeeze
 Continuous positive airway pressure(CPAP) :
Same as PEEP, but used when the baby is
breathing spontaneously and not receiving PPV.
It is pressure in the system at the end of
spontaneous breath when a mask is held tightly
on baby’s face but the bag is not being
squeezed.
 Rate: The number of assisted breaths given per
minute
DEVICES USED
Self Inflating bag T-Piece Resuscitator

Flow Inflating Bag

 Self inflating bag Flow inflating bag T- Piece resuscitator

Does not require Requires Compressed Gas Requires Compressed

Compressed Gas Source for inflating the bag Gas Source for
source for inflation of inflating the bag
Bag
Functions even Does not work without Does not work
without a proper seal proper seal without proper seal

PIP/Ti How hard & Long the Flow of incoming gas and Can be set exactly
bag in squeezed how hard & long the bag is manually
squeezed
PEEP Only if additional valve Given by adjusting flow Can be set exactly
is attached control valve manually
CPAP/Fre Cannot be delivered Given by adjusting flow Can be set exactly
e flow O2 control valve manually

Safety Pop-Off Valve Pressure gauge Maximum Pressure

Features Pressure gauge relief valve
Pressure gauge
Appropriate
Sizes
 Mask should
Rest on Chin
Cover Mouth
& Nose
 Suction & Position

Light Pressure on
mask to create a
Cup the chin in seal
the mask and Anterior pressure
then cover the on posterior rim
nose of mandible
40 to 60 breaths per minute

Start With 21% ( higher in preterm's) oxygen and

increase according to target Saturation
Initial Pressure at 20mmH2O
 Most Important sign is the rising of HR
 Improvement in Oxygen Saturation
 Equal and adequate breath sounds B/L
 Good Chest rise
 Heart rate
If heart rate <100 bpm
 Oxygenation by
oximeter
 Corrective steps Action

M Mask Adjustment Ensure Good seal of mask

on face
R Reposition airway Sniffing Position

S Suction Mouth and nose If secretions present

O Open mouth Ventilate with baby mouth

slightly open and lift the
jaw forward
P Pressure increase Gradually increase the
pressure every few breaths

A Airway alternative Consider ET or Laryngeal

mask airway
 Place an OG tube, Suction gastric contents
and leave the end open.
If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,
 Indications :
 HR <60/min
despite at least
30 sec of
effective PPV

Strongly consider Endotracheal intubation at this point

as it ensures adequate ventilation and facilitates the
coordination of ventilation and chest compressions
Rationale:
 HR<60/min despite PPV indicates
very low O2 levels and significant acidosis 
depressed myocardium  no blood in lungs
to get oxygenated(supplied by PPV)
 Chest compressions + effective ventilation
(ET/PPV)  oxygenation of blood 
recovery of myocardium to function
spontaneously  HR increases  O2 supply
to brain increases
Principle:
 Rhythmic compressions of
sternum that
 Compress the heart against the
spine
 Increases intrathoracic pressure
 Circulate blood to vital organs
 Chest compressions 
compresses heart & increased
Intrathoracic pressure  blood
pumped into arteries
 Pressure released  blood enters
heart from veins
Positions :
 Chest compressions are of
little value unless the lungs
are effectively ventilated
 2 persons are required
 1 – chest compressions
provider should have access to
the chest with his hands
positioned correctly
 2 – Ventilation provider should
be at head end to maintain
effective mask-face seal or to
stabilize ET tube
Technique:
 Thumb technique: 2
thumbs depress the
sternum, hands encircle the
torso and the fingers
support the spine.
Preferred technique
 2 – Finger technique: Tips
of middle & index/ring
finger of one hand
compresses sternum, other
hand supports the back.
 Thumb technique is
preferred as
 Better control of depth of
compression
 Can provide pressure
consistently
 Superior in generating
peak systolic and coronary
arterial perfusion
pressure.
For small chests with
thumbs overlapped
2- finger technique
 Depth : 1/3rd of the
anter0posterior
diameter of chest.
 Duration of
downward stroke
should be shorter
than the duration
of release
 Do not lift the
fingers off the
chest
Complications:
 Laceration of liver
 Breakage of ribs
Coordination of chest compressions and
ventilation:
 Avoid giving compression and ventilation
simultaneously
 1 breathe after every 3 compressions
 Ratio is 1 : 3 or 30: 90 per minute
 One cycle: 2 sec, 3Compresssions + 1 ventilation
 1 minute : 30 cycles or 120 events (90 compressions +
30 breaths)
When to stop chest compressions?
 Reassess after 45-60 sec, if HR > 60/min stop
chest compressions and increase breaths to
40-60 per minute.
If HR is not improving…
 Insert an umbilical catheter and give IV
epinephrine
 WHEN TO CONSIDER INTUBATION ?

Indications in resuscitation
 Baby is floppy, not crying, and preterm
 HR < 100/min, gasping/apnea
 HR < 100/min inspite of PPV
 HR < 60/min
 No adequate chest rise and no clinical
improvement
 If chest compressions are needed, intubation
provides better coordination and efficacy of PPV
 To administer drugs
 WHEN TO CONSIDER INTUBATION ?
 Special conditions
 Meconium aspiration if baby is depressed in
which it is the first step to be done
 Extreme Prematurity
 Surfactant administration
 Suspected diaphragmatic hernia
 Laryngoscope with extra
blades and bulbs
 Straight blades
 Term – 1
 Preterm – 0
 Extremely preterm - 00
Weight GA(weeks) Tube size(mm)
(internal diameter)
Below 1 kg 28 2.5

1-2 kg 28-34 3.0

2-3 kg 34-38 3.5

>3kg >38 3.5- 4.00

 CRICOID
PRESSURE

SUCTIONING
 Wt Depth of
insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm

 Add 6 to baby’s wt.

 Watching the tube passing between cords
 Watching for chest movements
 Listening for breath sounds ( Axilla and stomach)
 Colourimeter/Capnography ( Can also be used for PPV
with mask or LMA
 Improvement in HR and Spo2
 Vapour Condensing inside tube
LMA
Mechanism of action :
 Increases systemic vascular resistance
 Increases coronary artery perfusion pressure
 Improves blood flow to myocardium and
restores depleted ATP
Indications :
 If HR remains < 60/min even after 30 sec of
effective ventilation preferably after intubation
and atleast another 45-60 sec of coordinated
chest compressions and effective ventilation
Administration :
 Intravenous (recommended)
 Endotracheal
Preparation and dosage:
 Adrenaline vial 1ml = 1mg (1:1000 solution)
 Dilute with NS to make 1:10,000 solution (1ml =
100 mcg)
 IV : 0.1-0.3 ml/kg = 10-30 mcg/kg
 ET : 0.5 – 1 ml/kg = 50-100 mcg/kg
 Give rapidly – as quickly as possible
 Can repeat every 3-5 minutes
Indications:
 Bradycardia not improving with adrenaline
 Placenta previa/ Abruption
Volume Expanders:
 Normal saline (recommended)
 Ringer lactate
 Dosage: 10 ml/kg
 Route : Umbilical vein
 Rate: over 5-10 min , rapid infusion may
cause IVH in <30 weeks babies
 Additional resources , additional personnel,
additional thermoregulation strategy
▪ Portable warming pad
▪ Polyethylene Plastic wrap (< 29wk)
▪ Prewarmed transport incubator
 Use of Oxymeter, blender to target Spo2
85%- 95%
 Use Lower PIP 20-25 cm of H2O during PPV
 Consider giving CPAP
 Consider Surfactant
 Avoid hyperthermia, consider therapeutic
hypothermia within 6 hrs for >36wks and E/O
Acute perinatal HIE
 Monitor for Apnea, bradycardia, BP, SPo2
&Urine output.
 Monitor B. Sugars, electrolytes , Hematocrit ,
Platelets, ABG
 Maintain adequate oxygenation & support
ventilation as needed
 Delay feeds, Start IV fluids, consider
parenteral nutrition
 Consider inotropes , fluid bolus
 Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)
 Choanal atresia – oral Airway
 Pierre Robin : place prone , 12F Et through
nose with tip in post pharynx
 Laryngeal web, cystic hygroma, Cong. Goiter-
ET/tracheostomy
 Pneumothorax : Percutaneous needle
aspiration
 Pleural effusion : Percutaneous needle
aspiration
 Congenital Diaphragmatic hernia
 Meeting and discussing with parents and
documenting the conversation.
 Where GA ( < 23wks ), B.wt ( < 400g) and / or
Cong. Anomalies are associated with certainly
early death and unacceptably high morbidity
among rare survivors resuscitation is not
indicated
 After 10 minutes of continuous and adequate
resuscitative efforts, discontinuation of
resuscitation may be justified if there are no
signs of life (no heart beat and no respiratory
effort).
Resuscitation Recommendatio Recommendations Comments/LOE
step ns (2005) (2010)

Assessment Four questions Three questions However, tracheal

• Amniotic fluid- • Gestation-term or not? suction of nonvigorous
clear or not? • Tone- Good? babies with
• Breathing /Crying? (MSAF)
still to be continued

Assessment Look for 3 signs Look for 2 signs

(after • Hear rate • Heart rate
initial steps ) • Color • Respiration( Labored,
• Respiration unlabored, apnea,
gasping)

HR Palpation of Auscultation of heart at

umbilical cord the LOE4
pulsation precordium is the most
accurate
Resuscitation Recommendatio Recommendations (2010) Comments/LOE
step ns (2005)

Oxygenation Pulse oximetry pulse oximetry

recommended for both term and preterm
for only
preterm <
32weeks with
need for PPV

Target Not defined Target SpO2 ranges provided as

saturation a part of algorithm
(pre-ductal)
Initial oxygen Term babies(≥ 37 weeks)
concentration for • Start with 100% O2 during
resuscitation in PPV
case • In case non availability of
of PPV O2- start room air
resuscitation
Preterm babies(<32weeks)
Start with oxygen
concentration
between 21-100%
Term babies (≥ 37 weeks) LOE-2
• Start with room air (21%)
•use higher
concentration by graded
increase up to 100% to
attain target saturations
Preterm(<32weeks)
• Initiate resuscitation using
O2 concentration between
30-90%

Initial breath No specific PIP PIP- for initial breaths 20-25 cm H2O
strategy recommendation for preterm and 30-40 cm H2O for
Positive • No specific some term babies
pressure recommendation for PEEP • PEEP for preterm infants, if provided
ventilation • Guiding of PPV looking at with T-piece or flow inflating bags
(PPV) chest rise and improvement (LOE 5)
in heart rate
CPAP in delivery Suggested for preterm Spontaneously breathing
room babies preterm infants with respiratory
( < 32 weeks) with distress may be supported with
respiratory CPAP
distress

Therapeutic No sufficient evidence recommended for infants ≥

Hypothermia 36weeks with moderate to
severe HIE
 Doing the simple things better is probably the
most cost-effective policy.

 Resuscitation can come as complete surprise

So be prepared for resuscitation.
 It may take several hours to learn but it
should be implemented over seconds.

 Practice makes one perfect.

 Neonatal resuscitation Textbook 6th ed.
 4 million neonatal deaths: When? Where?
Why? Lancet 2005; 365: 891–900
 Park’s Textbook of Preventive and Social
Medicine , K. park 21st Edition .