Neonatal resuscitation is an emergency procedure performed at birth to optimise an newborn's airway, breathing, and circulation. The first minute after birth is critical, as failure to resuscitate can result in death or cerebral palsy. Gentle handling is important to avoid injury. Outcomes are unpredictable - some infants revive after extensive efforts while others suffer disabilities despite good care. Effective resuscitation requires anticipation of risks, a skilled team, appropriate equipment and environment, and standardized steps including drying, warming, suctioning, clamping the cord, and documenting the APGAR scores. Additional steps like ventilation or chest compressions are needed if breathing or heart rate are inadequate. Medications may be required

1. NeonatalResuscitation
• Neonatal resuscitation is a an emergency step by step maneuvers that are performed to
optimise newborn’s airway, breathing and circulation.
• First minute of birth is called the golden minute because if you don’t know how to
resuscitate, the neonate might die or end up with cerebral palsy.
• Neonates are very delicate beings, be very gentle while doing any manipulation and
always hold them as one piece & transferring is better to be on trolley (to avoid falling).
• Neonates are very very unpredictable, you could revive one after a long duration of chest
compressions and rescue breathing and end up totally normal while another one with
good antenatal care might end up handicapped.
What are the things you would need:
I. Anticipation: detailed maternal Hx, Ex & Ix to know how risky the baby is.
II. Help: great skilled team.
III. Safe environment: optimum temperature is 25 ± 0.6 °C
IV. Preparation of equipments: before delivery:
1. Infant warmer = overhead radiant warmer
2. Two dry warm towels
3. Sucker (Syringe ball sucker or electrical sucker)
4. Umbilical cord clump
5. Documentation
6. APGAR score sheet
7. Watch to know time for APGAR score
8. IV line equipments (cannula, fluids like normal saline, dextrose water….)
9. Umbilical catheter as peripheral pulses maybe absent
10. Vitamin K
11. Stethoscope
12. Pulse oximeter
13. Thermometer
14. Oxygen supply sources: numbers should be equal to the number of neonates.
15. Oxygen giving equipments (Ambu bag, oropharyngeal airway, endotracheal tube)
16. Intubation set (laryngoscope): double check the battery and light working.
17. Nasogastric (NG) tube
18. Drugs: adrenaline, naloxone, sodium bicarbonate, dobutamine.
19. Aseptic technique of everything above.
APGAR 0 1 2
Appearance Central cyanosis Peripheral/Acral cysnosis Pink
Pulse Absent < 100 > 100
Grimace (to nasal
or oral catheter)
No response Some facial expression
Coughing, sneezing,
pulling head away
Activity Floppy, extended UL & LL Flexed UL, Extended LL Flexed UL & LL
Respiration Apnea Slow, irregular Normal, Crying
• Current guidelines only depend on Pulse, Respiration & Activity.
• Pulse is checked either by palpating umbilical stump pulsation or stethoscope on heart (only listen
for few seconds and judge immediately)

2. Things that should be done for all neonates:
1. Dry the baby: by dry warm towel, start from head → whole body → back → sole of feet.
• It is important to start with head as it has largest surface area (25%).
• Drying will prevent evaporation & risk of cold injury.
• Most sensitive areas are back (over spine) & sole of feet to stimulate respiration (if
APGAR score is abnormal, repeat this twice, if still abnormal → treat as apnea).
2. Cover the baby: especially the head by a cap (🤠 ) or the second dry warm towel.
3. Warm the baby: by putting in the overhead radiant warmer & covering.
4. Simple suction:
• Syringe ball sucker: deflate, put it in mouth, release to let it suck,
pull out from mouth, repeat for both nostrils.
• Electrical sucker: it will automatically suck.
• Avoid excessive suction as it can lead to vagal stimulation & cardiac arrest.
Clump the umbilical cord at about 2.5 cm (1 inch):
• Keep the baby at or below the level of mother.
• Optimum time is 30 s - 1 min.
• Delayed clumping has the benefit of decreasing risk of iron deficiency anemia but
at the cost of polycythemia & neonatal jaundice.
Documentation: 0% of neonates come out of their mothers womb wearing shoes, clothes
or holding a recognizable face, so always document by:
• Stamp the leg of baby on the case-sheet.
• Put a bracelet on hand / leg of neonate having mothers name & phone number on it.
Record the APGAR score at 1, 5 and 10 minutes.
Give IM vitamin K injection 1 mg for term babies, 0.5 mg for preterms (don’t do if G6PDD)
Put the baby on mothers chest & let her breastfeed (oxytocin binds human beings together
and prevents PPH).
The most important thing we are doing is prevention of cold injury:
Four mechanisms of losing heat:
• Radiation
• Evaporation
• Conduction
• Convection
Risks of cold injury:
• Any 1 °C reduction of temperature increases mortality by 28%
• Apnea, Cardiac arrest
• Intracranial hemorrhage
• Hypoglycemia
• Late onset neonatal sepsis

3. Things that are done for some neonates:
Preterms <28 weeks, put the baby inside polyethylene wrap..
If meconium stained liquor, should have suction under naked eye.
If pulse is ⊕ but breathing ⊖ (apnea) (despite the 4 things in prior page):
• Put the baby in neutral position (chin & forehead are same level).
• Bring the right sized Ambu bag with right sized mask.
• Mask should cover mouth & nose but not the whole face.
• Give 5 rescue breathing by holding the mask with C shape hand.
• Make sure it is effective by looking at the chest, if chest is not
expanding with rescue breathing, re-check the position & try again.
• Rescue breathing should not be too strong to cause barotrauma (pneumothorax) but not so
weak that would be ineffective.
• You can avoid barotrauma by an automatic device that gives breathing at the correct rate,
volume & pressure (T-Piece Neopuff)
⊕ response (baby started breathing) → put on oxygen therapy.
⊖ response (persistent apnea) → give another 5 rescue breaths
recheck every 30 seconds and repeat until condition improves or deteriorates.
If breathing ⊖ (apnea), Pulse ⊖ (<60, absent or the above scenario developing bradycardia):
• Put the baby in neutral position (chin & forehead are same level).
• CPR: Chest compression & Ventilation at ratio of 3:1 at a rate of 100-120 chest
compressions, after each 3 compressions give a ventilation via Ambu bag.
• This should be done by 2 persons (holding & thumbs method).
• Recheck every 30 seconds:
• Pulse <60, continue CPR & rechecking (save it, please!)
• If pulse remained <60 despite a lot of efforts, give adrenaline.
• If pulse raised to >60, stop chest compressions and check breathing:
⊕ response (baby started breathing) → put on oxygen therapy.
⊖ response (persistent apnea) → give 5 rescue breaths
recheck every 30 seconds and repeat until condition improves or deteriorates.
Adrenaline: is given if the heart rate fails to rise despite resuscitation efforts:
• The dose to be given: 0.1 mg / kg
• The ampoule contains 1 mg/mL (which is 100 IU)
• Put this ampoule in 9 mL of normal saline or distilled water.
• Now you have 1 mg / 10 mL which equals to 0.1 mg/mL
• Give 1 mL of this solution per kg (which equals to 0.1 mg or 10 IU of adrenaline)
Naloxone (opioid antagonist): is given if mother received opioid analgesia & there is
neonatal respiratory depression despite resuscitation efforts.
Dextrose: is given if there is hypoglycemia.
Dobutamine (inotrope) might be given if there is cardiogenic shock despite resuscitation.
Sodium Bicarbonate is given ONLY if protracted cardiac arrest
Finally if all above methods failed, the neonate is transferred to the NICU (which ideally
should be very close) for intubation & ventilation.