complete guidelines for neonatal resuscitation 2022

1. Neonatal Resuscitation
Presented By
Dr. Ammar Ahmed
House Officer
Peads Medicine Unit 1 / Services Hospital Lahore

2. Introduction
• Neonatal Asphyxia accounts for 20.9% of neonatal deaths.
• Of 136 million babies born annually, around 10 million require assistance
to breathe. Each year 814,000 neonatal deaths result from intrapartum-
related events in term babies (previously “birth asphyxia”) and 1.03
million from complications of prematurity.
• Approximate 10% will require some assistance at birth to begin
breathing.
• Less then 1% will require extensive Resuscitation.
• On Average newborn infant gasps at 6sec or majority at 20sec
• Majority of newborns are breathing independently on average at 30-
90sec

3. Neonatal Resuscitation?
Neonatal resuscitation is defined as the set of interventions at the
time of birth to support the establishment of breathing and
circulation/ assistance of neonate in making physiological transition
from intra uterine life to extra uterine life.
The goals of neonatal resuscitation are to prevent the morbidity and
mortality associated with hypoxic-ischemic tissue (brain, heart,
kidney) injury and also to re-establish adequate spontaneous
respiration and cardiac output.

4. ASPHYXIA - THE BASIC
1.Primary Apnea:
When asphyxiated, the infant responds with a increased RR. If the
episode continues, the infant becomes apnic, followed by a drop in HR and
a slight increase in BP.The infant will respond to stimulation and therapy
with spontaneous respirations.
2. Secondary apnea
After primary apnea, the infant responds with a period a gasping
respirations, falling HR, and falling BP.The infant takes a last breath and
then enters the secondary apnea period.The infant will not respond to
stimulation and death will occur unless resuscitation begins immediatel

5. Why We Need To Resuscitate

6. 4 Pre Birth Questions
❶ What is the expected gestational age?
❷ Is the amniotic fluid clear?
❸ How many babies are expected?
❹ Are there any additional risk factors?

7. 4 After Birth Questions
1. Was the infant born after a full-term gestation?
2. Is the amniotic fluid clear of meconium and evidence of
infection?
3. Is the infant breathing or crying?
4. Does the infant have good muscle tone?

9. Preparation For Resuscitation
For prompt and effective resuscitation, two major factors must be given
proper attention:
Anticipation (the need for resuscitation): Especially if there are
antepartum and intrapartum risk factors for birth asphyxia.
Adequate preparation equipment and personnel)
Preparation:
Identify helper
Prepare the area for delivery
Wash hands
Prepare an area for ventilation and check equipment

10. Equipment Required
• Resuscitation table
• Sterile linen
• Suction apparatus
• Laryngoscope with straight blade no. 0 and no.1
• Ambu bag and face masks (newborn and premature sizes)
• Oral air ways (newborn and premature sizes)
• Oxygen with flow meter and tubing
• Endotracheal tubes (sizes 2.5, 3.0, 3.5 and 4mm)
• Stylet, scissors, Gloves
• Two pieces of cloth (one to dry the baby, ,one to cover the baby after drying)
• A cap to cover the baby’s head
• A clock or stopwatch

11. Initial Management For All Deliveries
Provide Warmth
Position and Clear Airway
Dry
Stimulate
Give Oxygen if necessary

12. ABCs of Resuscitation
Open the Airway: Position the infant slightly extended to help
keep the airway open and clear. Suction the infant month, nose
and sometimes trachea in case of meconium stained liquor
Initiate Breathing:
Use tactile stimulation( flicking the soles of the feet and gently
rubbing the back once or twice) to stimulate respiration
Employ positive pressure ventilation when necessary using bag and
mask.
Maintain Circulation: Stimulate and maintain the circulation
of blood with chest compressions and medications.

13. Positioning Head and neck to open airway
The baby should be positioned on her back (supine), with the head and neck
neutral or slightly extended in the “sniffing the morning air” position. This
position opens the airway and allows unrestricted air entry. Avoid
hyperextension or flexion of the neck because these positions may interfere
with air entry.
To help maintain the correct position, place a small, rolled towel under the
baby’s shoulders. A shoulder roll is particularly useful if the baby has a large
occiput (back of head) from molding, edema, or prematurity.

15. Breathing
Start PPV if the baby is not
breathing (apnea) OR if the
baby has gasping respirations.
Start PPV if the baby appears
to be breathing, but the heart
rate is below 100 bpm.
Use Ambu Bag for PPV( rate
(40-60)
For free-flow oxygen delivery,
adjust the flowmeter to 10
L/min and blander at 21%
oxygen

16. Ambu Bag

17. Indications for Intubation
• Meconium and baby is not
vigorous
• PPV by bag-mask does not result
in good chest rise
• PPV needed beyond a few
minutes
• Chest compressions necessary
• Route to administer epinephrine
• Special indications: Prematurity,
CDH?

18. Intubation Technique
A. Lip reference mark :( Weight in Kg + 6) cm
B. NTL Method: Distance between babies nasal septum to ear tragus (NTL) + 1cm
Place the ETT so that the marking on the tube corresponding to the estimated insertion depth is
adjacent to the baby's lips

21. Indication For Chest Compression
Chest compressions are indicated when the heart rate remains
less than 60 bpm after at least 30 seconds of PPV that inflates the
lungs, as evidenced by chest movement with ventilation.
In most cases, you should have given at least 30 seconds of
ventilation through a properly inserted endotracheal tube or
laryngeal mask.
Do not begin chest compressions unless you have
achieved chest movement with your ventilation
attempts

23. What is the compression rate?
The compression rate is 90 compressions per minute. To achieve this
rate, you will give 3 rapid compressions and 1 ventilation during
each 2-second cycle.
 When chest compressions are started,
increase the oxygen concentration to 100%.

24. Medicine
 Epinephrine 1: 10,000 : Indicated when heart rate is not improving in spite adequate effective
ventilation and chest compressions.
Dose: 0.1- 0.3ml/kg I/V or intra tracheal, dose can be repeated in 3-5 min.
 Volume expanders: (Normal saline, Ringer lactate or 5% albumin). These are indicated where there is
evidence or suspicion of hypovolemia e.g. pallor persisting after oxygenation, weak pulses with good
heart rate, poor response to resuscitation.
Dose is 10 ml/kg I/V in 5-10 min.
 Sodium bicarbonate 4.2%: It is indicated in prolonged cardiac arrest that does not respond to other
therapy. It should be used only after ventilation is established.
Dose is 1-2 mEq/kg I/V slow diluted over 2 min.
 Naloxone hydrochloride: It is indicated when there is H/O maternal narcotic administration within past
4 hours. Dose is 0.1 mg/kg through endotracheal tube, I/V, I/M or S/C.
Volume expanders i.e. Normal saline, Albumin ,5%, Ringers lactate
 Dextrose water 10%

27. References
1. Basics of Pediatrics by pervez Akbar Khan
2. Textbook of neonatal resuscitation 8th edition
3. American Heart Association
4. The American Board of Pediatrics

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