Neonatal Resuscitation

Overview

Risk Factors

APGAR Score

• 7-10: Normal

• 4-6: Moderately abnormal (requires intervention)

• 0-3: Severely abnormal (requires immediate resuscitation)

Note: APGAR score should not delay resuscitation. It is used for assessment and documentation, not to guide initial resuscitation decisions.

Preparation

• Radiant warmer (pre-warmed)

• Clock

• Warm towels/blankets

• Suction equipment (bulb syringe, mechanical suction)

• Bag-mask ventilation device

• Oxygen supply

• Laryngoscope with blades (size 0 and 1)

• Endotracheal tubes (sizes 2.5, 3.0, 3.5 mm)

• Medications: adrenaline, sodium bicarbonate, naloxone

• Umbilical catheterization equipment

• Pulse oximeter

• At least one person skilled in resuscitation at every delivery

• Additional personnel for high-risk deliveries

Steps of Resuscitation

1. Term gestation?

2. Good muscle tone?

3. Breathing or crying?

1. Dry and stimulate the baby

2. Position the head in neutral or slightly extended position ("sniffing" position)

3. Suction if needed:
• Mouth first, then nose ("M before N")
• Avoid deep suctioning (can cause vagal bradycardia)
• Only suction if secretions are visible

4. Reassess after 30 seconds

• If baby is vigorous (good tone, breathing, HR >100): Routine care

• If baby is non-vigorous: Suction under direct laryngoscopy may be considered (no longer routinely recommended)

• Apnoea or gasping

• Heart rate <100 bpm despite initial steps

• Use bag-mask ventilation or T-piece resuscitator

• Initial pressures: 20-25 cmH₂O (first few breaths may require up to 30-40 cmH₂O)

• Rate: 40-60 breaths/minute

• 21% oxygen (room air) for term infants initially

• Reassess after 30 seconds

• Chest rise

• Improved heart rate

• Improved colour and tone

• Breath sounds bilateral

• Check mask seal

• Reposition airway

• Suction secretions

• Open mouth

• Increase pressure

• Consider airway obstruction

• Consider endotracheal intubation

• Heart rate <60 bpm after 30 seconds of effective PPV

• Two-thumb technique (preferred): Thumbs on lower third of sternum, hands encircling chest

• Two-finger technique: Two fingers on lower third of sternum

• Depth: One-third of anteroposterior diameter of chest

• Rate: 90 compressions : 30 breaths per minute (3:1 ratio)

• Synchronize compressions and ventilations

• Reassess every 60 seconds

• 30 seconds of effective PPV

• 60 seconds of chest compressions + PPV

• Dose: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution)

• Route:
• Intravenous (via umbilical venous catheter) - preferred
• Endotracheal (higher dose 0.05-0.1 mg/kg may be used, but less effective)

• Repeat: Every 3-5 minutes if needed

• Indication: Suspected hypovolaemia (pallor, weak pulses, poor response to resuscitation)

• Fluid: Normal saline or O-negative blood

• Dose: 10 mL/kg IV over 5-10 minutes

• May repeat if needed

• Not recommended routinely

• Consider only in prolonged arrest with effective ventilation

• Dose: 1-2 mEq/kg (2-4 mL/kg of 4.2% solution) slowly

• Not part of initial resuscitation

• Consider if maternal opioid administration and persistent respiratory depression after effective ventilation

• Dose: 0.1 mg/kg IV, IM, or SC

Oxygen Management

• 1 minute: 60-65%

• 2 minutes: 65-70%

• 3 minutes: 70-75%

• 4 minutes: 75-80%

• 5 minutes: 80-85%

• 10 minutes: 85-95%

• Start with 21% oxygen (room air) for term infants

• Start with 30% oxygen for preterm <35 weeks

• Increase oxygen if SpO₂ below target despite effective ventilation

• Decrease oxygen if SpO₂ above target

• Use blended oxygen with pulse oximetry when available

Endotracheal Intubation

• Ineffective or prolonged bag-mask ventilation

• Tracheal suctioning for meconium (if indicated)

• Need for chest compressions

• Special situations (e.g., congenital diaphragmatic hernia)

• Extremely low birth weight infants for surfactant administration

• <1000 g: 2.5 mm

• 1000-2000 g: 3.0 mm

• 2000 g: 3.5 mm

• Chest rise

• Breath sounds bilateral

• Mist in ETT

• Improved heart rate and SpO₂

• CO₂ detector (gold standard)

• Chest X-ray

Post-Resuscitation Care

• Maintain normothermia (36.5-37.5°C)

• Monitor vital signs continuously

• Maintain normal glucose

• Avoid hypoxia and hyperoxia

• Transfer to NICU if indicated

• Gestation ≥36 weeks

• Evidence of moderate-severe HIE (Hypoxic-Ischaemic Encephalopathy)

• Within 6 hours of birth

• Detailed resuscitation record

• APGAR scores at 1, 5, 10 minutes

• Time to spontaneous respirations

• Response to interventions

• Medications and fluids given

• Team discussion after resuscitation

• Identify areas for improvement

• Support staff emotional wellbeing

When to Stop Resuscitation

• No heart rate detected

Note: Decision should be individualized based on circumstances, gestational age, presence of congenital anomalies, and parental wishes.

Special Situations

• Use polyethylene wrap or bag (without drying) to prevent hypothermia

• Start with 30% oxygen

• Delayed cord clamping (30-60 seconds) if stable

• Consider early CPAP

• Lower inflation pressures

• No longer routinely suction vigorous infants

• For non-vigorous infants, initiate resuscitation as per standard algorithm

• Avoid bag-mask ventilation (causes gastric distension)

• Early intubation

• Nasogastric tube decompression

• Anticipate difficult ventilation

• May need pleural/peritoneal drainage

• Volume resuscitation likely needed

Remember: Effective ventilation is the key to successful neonatal resuscitation. Most babies respond to inflation of their lungs.