resuscitation

1. Care in Labour Room &
Resuscitation
Dr. Ashik Majumder
PGT-II, Pediatrics

2. Care at Birth
 Most newborns make the
cardiorespiratory transition to extrauterine
life without any intervention
 After birth, approximately 4-10% of term
and late preterm will receive PPV, while
only 1-3 per 1,000 will receive chest
compression or emergency medications.

3. Check list for Resuscitation
Preparedness
For Warmth •Preheat Warmer
•Prewarmed towel and blanket
Thermoregulation •Plastic bag or plastic wrap, heated
mattress and cap for small babies
Positioning •Shoulder rolls (2cm thickness)
Clearing airway •10-12F Suction catheter (80-
100mmHg)
•Bulb Syringe
•Meconium Aspirator

4. Ventilation •PPV device
•Masks (size 00,0,1)
•8F feeding tube with large syringe
Oxygenation •Oxygen tubing
•Pulse oxymeter
•Target oxygen saturation table
Intubation •Laryngoscope with blades (size 00,0,1)
•ET tubes (size 2.5,3.0,3.5)
•Stylet (Optional)
Medication •1:10000 epinephrine
•NS
•Supplies for emergency umbilical
catheter and administering medications

5. Standard precautions and
asepsis at birth
 Sterile Gloves, masks and gowns
 The protective eye wear or face shield
 Maintaining 5 cleans:
◦ Clean Hands
◦ Clean surface
◦ Clean cut
◦ Clean thread
◦ Clean cord

6. Preventing Hypothermia
 Temp. of delivery room: 25-28⁰C
 Free from draft of air
 Baby should be received in prewarmed
sterile linen
 Baby should be dried thoroughly
including head and face areas
 Any wet linen should not be allowed to
remain in contact

7. Skin to skin contact (STS)
 Any infant born vaginally and requiring
only routine steps should be placed on
mother’s abdomen or chest immediately
after birth for initial 1 hour.
 This will maintain normal temperature,
promote early breast feeding and decrease
pain and bleeding of the mother
 Mother-baby dyad Should not be left
alone and observed for breathing, color
and temperature

8. Delayed cord clamping
 At least 60 seconds
 Infants who require resuscitation beyond
the initial steps, cord should be clamped
and divided shortly after birth
 The cord should be clamped at 2-3 cm
away from abdomen
 The stump should be away from genitals
to avoid contamination

9. Care of eye
 The baby should be dried and cleaned at birth
 Should be gentle and should only wipe out the
blood and meconium
 Not be vigorous enough to remove vernix
caseosa
Cleaning of baby
• Both eyes should be cleaned with separate
swabs.
• Sterile water or NS can be used

10. Routine stomach wash
 Should not be done
Patency of esophagus should be checked
at birth in following circumstances
• Presence of polyhydraminos
• Antenatally suspected esophageal atresia
or diaphragmatic hernia
• Excessive frothing
• Presence of vertebral or anorectal
anomalies (VACTERL association)

11. Identity Band
 Each infant must have an identity band
containing name of the mother, hospital
registration number, gender and birth weight
of the infant
• Should be recorded at 1 minute and 5 minutes
of birth.
Apgar Score

12. Weight
 The baby should be weighed after stabilization
and the temp. is documented to be normal
Initiation of breastfeeding
• At earliest as possible within one hour of birth

13. Vitamin K administration
 To all babies (0.5 mg for less than 1000 gm
and 1 mg for babies more than 1000 gm)
 IM injection on anterolateral aspect of the
thigh
First examination
• The baby should be thoroughly examined and
findings should be recorded in neonatal record
sheet.

14. Resuscitation

16. Preparing for Resuscitation
 Ask the following 4 pre-birth questions:
◦ What is the expected gestational age?
◦ Is the amniotic fluid clear?
◦ How many babies are expected?
◦ Are there any additional risk factors?
 Every delivery should be attended by at
least 1 skilled person whose only
responsibility is the management of the
newborn

17.  If risk factors are present, at least 2 qualified
people should be present solely to manage
the baby. The number and qualifications of
personnel will vary depending on the
anticipated risk, the number of babies, and
the hospital setting
 Perform a pre-resuscitation team briefing
 All appropriate supplies and equipment
should have been checked and ready for
immediate use

18. A rapid evaluation for every newborn
 Term?
 Tone?
 Breathing or crying?

19. Initial steps of newborn care
◦ Provide warmth
◦ Position the head and neck
◦ Clear secretion if needed
◦ Dry
◦ Stimulate

20. Indications for Positive-Pressure
Ventilation
 Apnea (not
breathing)
 Gasping
 Heart rate less than
100 bpm
 Oxygen saturation
below the target
range despite free-
flow oxygen or
CPAP

21.  Breaths should be given at a rate of 40 to 60
breaths per minute
 Use the rhythm, “Breathe, Two, Three;
Breathe, Two, Three; Breathe, Two, Three.”
 Say “Breathe” as
you squeeze the
bag or occlude the
T-piece cap and
release while you
say “Two, Three”
 Start with a PIP of
20 to 25 cm H2O

22. Indications for Pulse Oximetry
 When resuscitation is anticipated
 To confirm your perception of persistent
central cyanosis
 When supplemental oxygen is
administered
 When positive-pressure ventilation is
required

23. When is supplemental oxygen indicated

24. Oxygen Supplementation
 For the initial resuscitation of
newborns greater than or equal to 35
weeks’ gestation, set the blender to 21%
oxygen
 For the initial resuscitation of
newborns less than 35 weeks’ gestation,
set the blender to 21% to 30% oxygen
 Set the flow meter to 10 L/minute

27. Ventilation corrective steps

28. When should an alternative airway
be considered?
 If PPV with a face mask does not result
in clinical improvement
 If PPV lasts for more than a few minutes
 If chest compressions are necessary
 special circumstances, such as
◦ stabilization of a newborn with a suspected
diaphragmatic hernia
◦ for surfactant administration
◦ for direct tracheal suction if the airway is
obstructed by thick secretions.

29. Endotracheal tube size
The steps of intubation should be completed
within approximately 30 seconds

31. How deeply should the tube be
inserted within the trachea?
 1 to 2 centimeters below the vocal cords
 Two methods may be used for estimating
the insertion depth
◦ The estimated insertion depth (cm) is NTL+1
cm

32. Initial endotracheal tube insertion depth (“tip to
lip”) for orotracheal intubation

33. Sudden deterioration after intubation

34. When should you consider using a
laryngeal mask?
 When you “can’t ventilate and can’t intubate”
 Newborns with congenital anomalies involving
the mouth, lip, tongue, palate or neck, where
achieving a good seal with a face mask is
difficult and visualizing the larynx with a
laryngoscope is difficult or unfeasible
 Newborns with a small mandible or large
tongue, where face-mask ventilation and
intubation are unsuccessful. Common examples
include the Robin sequence and Trisomy 21
 When PPV provided with a face mask is
ineffective and attempts at intubation are not
feasible or are unsuccessful

35. Chest Compressions

36. Indications for Chest Compressions
 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

37.  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
 Use enough downward pressure to depress
the sternum approximately one-third of the
anterior-posterior (AP) diameter of the chest
 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
 “One-and-Two-and-Three and-Breathe-and”

38.  When chest compressions are started,
increase the oxygen concentration to
100%
 Wait 60 seconds after starting coordinated
chest compressions and ventilation before
pausing briefly to reassess the heart rate
 Stop chest compressions when the heart
rate is 60 bpm or higher
 Once compressions are stopped, return to
giving PPV at the faster rate of 40 to 60
breaths per minute

39. Medications
 Epinephrine is indicated if
the baby’s heart rate
remains below 60 bpm
after
 At least 30 seconds of
PPV that inflates the
lungs (moves the
chest),and
 Another 60 seconds of
chest compressions
coordinated with PPV
using 100% oxygen

40. Dose
 Intravenous or intraosseous: 0.1 to 0.3
mL/kg (equal to 0.01 to 0.03 mg/kg)
 Endotracheal: 0.5 to 1 mL/kg (equal to
0.05 to 0.1 mg/kg)
 Only the 1:10,000 preparation (0.1
mg/mL) should be used for neonatal
resuscitation

41. Administration
 Rapidly—as quickly as possible
 Intravenous or Intraosseous: Flush with
0.5 to 1 mL normal saline
 Endotracheal: PPV breaths to distribute
into lungs
 Repeat every 3 to 5 minutes if heart rate
remains less than 60 bpm.

42. Volume Expander
 Normal saline (0.9% NaCl)
 O-negative packed red blood cells
 Route: Intravenous or Intraosseous
 Dose: 10 mL/kg
 Administration: Over 5 to 10 minutes

43. Post-natal Care
 The physiologic transition to extrauterine
life continues for several hours after birth
 Medical complications after resuscitation
may involve multiple organ systems
 These complications can be anticipated &
promptly addressed by appropriate
monitoring

44. Routine Care
 Nearly 90% of newborns are vigorous term
babies with no risk factors and babies with
prenatal or intrapartum risk factors, who
responded well to the initial steps of
newborn care, may only need close
observation for
◦ Breathing
◦ Thermoregulation
◦ Feeding and
◦ Activity
 Frequency of baby’s monitoring depends on
condition of the baby

45. Post-resuscitation Care
 Babies who required supplemental oxygen
or PPV after delivery will need closer
assessment
 They often require ongoing respiratory
support
◦ Supplemental oxygen
◦ Nasal CPAP
◦ Mechanical ventilation

46. Different conditions following
resuscitation
Organ System Clinical Signs and Laboratory Findings
Neurologic Apnea, seizures, irritability, poor tone,
altered neurologic examination, poor
feeding coordination
Respiratory Tachypnea, grunting, retractions, nasal
flaring, low oxygen saturation,
pneumothorax
Cardiovascular Hypotension, tachycardia, metabolic
acidosis
Renal Decreased urine output, edema,
electrolyte abnormalities

47. Organ System Clinical Signs and Laboratory Findings
Gastrointestinal Feeding intolerance, vomiting, abdominal
distention, abnormal liver function tests,
gastrointestinal bleeding
Endocrine
Metabolic
Metabolic acidosis, hypoglycemia (low
glucose), hypocalcemia (low calcium),
hyponatremia (low sodium),
hyperkalemia (high potassium)
Hematologic Anemia, thrombocytopenia, delayed
clotting, pallor, bruising, petechiae
Constitutional Hypothermia

48. Withholding Resuscitation
 Preterm infants at less than 25 weeks of
gestation
 It is reasonable to consider variables such
as perceived accuracy of gestational age
assignment, the presence or absence of
chorioamnionitis, and the level of care
available for location of delivery

49. Discontinuing Resuscitative Efforts
 In infants with an Apgar score of 0 after 10
minutes of resuscitation, if the heart rate remains
undetectable, it may be reasonable to stop assisted
ventilation; however, the decision to continue or
discontinue resuscitative efforts must be
individualized
 Variables to be considered may include whether
the resuscitation was considered optimal;
availability of advanced neonatal care, such as
therapeutic hypothermia; specific circumstances
before delivery (eg, known timing of the insult);
and wishes expressed by the family

50. References
 Cloherty and Stark’s Manual of Neonatal
care, 8th edition
 Care of the Newborn by Meharban Singh,
Revised 8th edition
 Textbook of Neonatal Resuscitation, 7th
edition