This document provides an overview of neonatal resuscitation. It discusses the initial steps of assessing the newborn and providing warmth, positioning, clearing the airway if needed. If the newborn is breathing or has a heart rate over 100 bpm, supplemental oxygen may be provided. If apneic or bradycardic, positive pressure ventilation is indicated. Chest compressions are indicated if the heart rate remains under 60 bpm despite adequate ventilation. Endotracheal intubation provides better ventilation support and allows for medication administration if needed during resuscitation.

1. NEONATAL RESUSCITATION
Presented By:
Dr. Deepak Kumar Singh
Junior Resident
DEPT. OF PAEDIATRICS
Moderated By:
Dr. Yogendra Yadav
(Asst. Proff.)

2. Neonatal Resuscitation
• 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

3. Causes of Neonatal Mortality
Preterm
27%
Sepsis &
pneumonia
26%
Asphyxia
23%
Congenital
7%
Tetanus
7%
Diarrhoea
3%
Others
7%
4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891–900

4. Overview and Principles
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.

5. Overview and Principles
• 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.

6. Overview and Principles
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)

7. Newborn Resuscitation Pyramid
Assess baby’s risk for requiring resuscitation
Provide warmth
Position, clear airway if required
Dry, stimulate to breathe
Give supplemental oxygen, as required
Assist ventilation with positive
pressure
Intubate the trachea
Provide chest
compressions
Medications
Always needed
Needed less
frequently
Rarely needed

8. Overview and Principles – Changes in
newborn physiology

9. Overview and Principles – Changes in
newborn physiology
BEFORE BIRTH
 Oxygen supply by placental
membranes
 No role of lungs. Fluid filled
alveoli and constricted arterioles
due to low Po2 in fetal blood.

10. Overview and Principles – Changes in
newborn physiology
 Low Po2 
constricted arterioles
 increased
pulmonary vascular
resistance  shunting
of blood from
Pulmonary Artery 
Ductus Arteriosus 
Aorta.

11. Overview and Principles – Changes in
newborn physiology
AFTER BIRTH
• Baby cries  takes first breath  air enters alveoli 
alveolar fluid gets absorbed  increased Po2 
relaxes pulmonary arterioles  decreased PVR

12. Overview and Principles – Changes in
newborn physiology
• 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.

13. Overview and Principles – Changes in
newborn physiology
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

14. Consequences of interrupted
transition
 Low muscle tone
 Respiratory depression (apnoea
/ gasping)
 Tachypnea
 Bradycardia
 Hypotension
 Cyanosis

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

16. Primary Apnea
Stimulation
Secondary Apnea
Effective Positive pressure ventilation
Myocardium is depressed
Chest compressions, medications
Changes due to oxygen deprivation

17. Equipment required
Suction Catheter
Oral mucus sucker
Radiant warmer
O2 source

18. Blender
Flow meter
Ambu bag & mask with reservior
Ambu Mask

19. Endo-tracheal tube
Laryngoscope blades
Laryngeal Mask airway

20. Spo2 probe
Nasogastric tube
Transport Incubator

21. INITIAL STEPS OF RESUSCITATION

22. Initial steps of resuscitation
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.

23. Initial steps
Good tone ?
• Term: flexed extremities
• Preterm/sick: flaccid/limp,
extended extremities

24. Initial steps
• Provide warmth :
Radiant warmer, don’t
cover with towels.
• Position head and
clear airway as
necessary
• Dry and stimulate the
baby to breathe,
Reposition

25. Position “ SNIFFING DOG ”

26. Clear airway
• Suction mouth first, then
nose
• “M” before “N”
• To prevent aspiration of
mouth contents

27. Clear airway
Vigorous if
1. Good tone
2. Good Cry/
Breathing
3. HR> 100/min

28. Meconium, non-vigorous baby
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

29. Dry ,Reposition, Stimulate
Stimulate : Flicking
the soles 2 times/
drying the whole
body

30. Evaluation
• Respiration
• Heart rate: Best is auscultation, alternatively pulsations
at base of cord is felt. Count for 6s and “x”10
• Oxygenation by Pulse-oxymeter

31. Breathing
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 oxymeter

32. Supplemental oxygen
• Free flow oxygen
– Oxygen mask
– Flow inflating bag
– T- piece resuscitator
– Oxygen tubing held close
to baby’s nose
• CPAP provided with
– Flow inflating bag
– T-piece resuscitator
• Start with room air and
increase to maintain
target SpO2
Time Target Spo2
1min 60-65%
2min 65-70%
3min 70-75%
4min 75-80%
5min 80-85%
10min 85-95%

33. Free-flow oxygen given via oxygen
tubing

34. MASK
Flow Inflating Bag
T-Piece Resuscitator

35. Positive pressure ventilation
• 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%.

36. Positive pressure ventilation
• 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

37. Positive pressure ventilation
• 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

38. Self Inflating bag
Flow Inflating Bag
T-Piece Resuscitator
DEVICES USED

39. Self inflating bag Flow inflating bag T- Piece resuscitator
Does not require
Compressed Gas source
for inflation of Bag
Requires Compressed Gas
Source for inflating the bag
Requires Compressed
Gas Source for inflating
the bag
Functions even without
a proper seal
Does not work without
proper seal
Does not work
without proper seal
PIP/Ti How hard & Long the
bag in squeezed
Flow of incoming gas and
how hard & long the bag is
squeezed
Can be set exactly
manually
PEEP Only if additional valve
is attached
Given by adjusting flow
control valve
Can be set exactly
manually
CPAP/Free
flow O2
Cannot be delivered Given by adjusting flow
control valve
Can be set exactly
manually
Safety
Features
Pop-Off Valve
Pressure gauge
Pressure gauge Maximum Pressure
relief valve
Pressure gauge

40. Mask
Appropriate Sizes
• Mask should
Rest on Chin
Cover Mouth
& Nose

41. Suction & Position
Cup the chin in
the mask and
then cover the
nose
Light Pressure on
mask to create a
seal
Anterior pressure
on posterior rim
of mandible

42. Frequency of ventilation:
40 to 60 breaths per minute
Start With 21% ( higher in preterm's) oxygen and
increase according to target Saturation
Initial Pressure at 20mmH2O

43. Ensure Effective PPV
• Most Important sign is the rising of HR
• Improvement in Oxygen Saturation
• Equal and adequate breath sounds B/L
• Good Chest rise

44. Evaluation
• Heart rate
• Oxygenation by oximeter
If heart rate <100 bpm

45. Ventilation corrective steps
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

46. PPV continued more than several
minutes
• Place an OG tube, Suction gastric contents and
leave the end open.

47. Evaluation
If heart rate <60 bpm
despite adequate
ventilation for 30
seconds,

48. Chest compressions
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

49. 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

50. Chest compressions
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

51. Chest compressions
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

52. Chest compressions
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.

53. Chest compressions
• 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.

54. Chest compressions
For small chests with
thumbs overlapped

55. Chest compressions

56. Chest compressions
2- finger technique

57. Chest compressions

58. Chest compressions
• Depth : 1/3rd of the
antero-posterior
diameter of chest.
• Duration of
downward stroke
should be shorter
than the duration of
release
• Do not lift the
fingers off the chest

59. Chest compressions
Complications:
• Laceration of liver
• Breakage of ribs

60. Chest compressions
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)

61. Chest compressions
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

62. Endotracheal Intubation

63. Endotracheal Intubation
 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

64. Endotracheal Intubation
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

65. Endotracheal Intubation- Equipment
and supplies
• Laryngoscope with extra
blades and bulbs
• Straight blades
• Term – 1
• Preterm – 0
• Extremely preterm - 00

66. ET tube sizes
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

67. ET tube – Uniform diameter, uncuffed

68. ET tube – Vocal cord guide

69. Procedure… Position

70. Position

71. Position

72. Position

73. CRICOID PRESSURE
SUCTIONING

74. Endotracheal Intubation:
Anatomic Landmarks

75. Procedure

77. Fixing ET tube
• Add 6 to baby’s wt.
Wt Depth of
insertion
< 750g 6cm
1kg 7cm
2kg 8cm
3kg 9cm
4kg 10cm

78. Confirm position
• 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

79. Laryngeal Mask Airway
LMA

80. Medications - Adrenaline
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

81. Medications - Adrenaline
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

82. Medications – volume expanders
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

83. Resuscitation of preterms
• 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

84. Post Resuscitation Care
• 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

85. Post Resuscitation Care
• Delay feeds, Start IV fluids, consider
parenteral nutrition
• Consider inotropes , fluid bolus
• Ensure adequate ventilation before giving
sodium bicarbonate(only in severe metabolic
acidosis)

86. Special considerations
• 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

87. Ethical issues
• 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).

88. CHANGES IN 2010

89. Resuscitation
step
Recommendatio
ns (2005)
Recommendations
(2010)
Comments/LOE
Assessment Four questions
• Amniotic fluid-
clear or not?
Three questions
• Gestation-term or not?
• Tone- Good?
• Breathing /Crying?
However, tracheal
suction of nonvigorous
babies with
(MSAF)
still to be continued
Assessment
(after
initial steps )
Look for 3 signs
• Hear rate
• Color
• Respiration
Look for 2 signs
• Heart rate
• Respiration( Labored,
unlabored, apnea,
gasping)
HR Palpation of
umbilical cord
pulsation
Auscultation of heart at
the
precordium is the most
accurate
LOE4

90. Resuscitation
step
Recommendatio
ns (2005)
Recommendations (2010) Comments/LOE
Oxygenation Pulse oximetry
recommended
for only
preterm <
32weeks with
need for PPV
pulse oximetry
for both term and preterm
Target saturation
(pre-ductal)
Not defined Target SpO2 ranges provided as
a part of algorithm

91. Initial oxygen
concentration for
resuscitation in
case
of PPV
Term babies(≥ 37 weeks)
• Start with 100% O2 during
PPV
• In case non availability of
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
strategy
Positive
pressure
ventilation
(PPV)
No specific PIP
recommendation
• No specific
recommendation for PEEP
• Guiding of PPV looking at
chest rise and improvement
in heart rate
PIP- for initial breaths 20-25 cm H2O for
preterm and 30-40 cm H2O for some
term babies
• PEEP for preterm infants, if provided
with T-piece or flow inflating bags
(LOE 5)

92. CPAP in delivery
room
Suggested for preterm
babies
( < 32 weeks) with
respiratory
distress
Spontaneously breathing
preterm infants with respiratory
distress may be supported with
CPAP
Therapeutic
Hypothermia
No sufficient evidence recommended for infants ≥
36weeks with moderate to
severe HIE

93. Summary
• 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.

94. References
• 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 .