dr ekhlas obs

1. Neonatal Resuscitation
DR. EKHLAS ALI

3. Neonatal resuscitation
10% neonates require some assistance
at birth.
1% neonates need extensive
resuscitative measures.
Asphyxia accounts for 20-25%
newborn deaths.

4. How does a baby receive oxygen
before birth?
Oxygen diffuses across placenta from
mother’s blood to baby’s blood.
Lungs receive very little blood.
Alveoli are fluid filled rather than air.

5. After birth
•Fluid in the alveoli is
absorbed
Alveoli
• Expand
• Get filled with air (O2)
1.

6. After birth
Umbilical arteries and veins are
clamped
Sudden increase in systemic blood
pressure
2.

7. Pulmonary vessels dilate, causing
increased blood flow to lungs
3.

8. Apgar score
Calculated at 1 & 5 min after birth

9. Consequences of interrupted transition
 The compromised baby may exhibit 1 or
more of the following clinical findings:
1. Low muscle tone
2. Respiratory depression (apnea / gasping)
3. Bradycardia
4. Cyanosis

10. Antepartum Risks
Maternal diabetes
Chronic maternal illness
 Cardiovascular
 Thyroid
 Neurological
 Pulmonary
 renal
Pre eclampsia
Maternal infection
Polyhydramnios
Oligohydramnios
Premature rupture of
membranes
IUGR/preterm
Fetal malformation
Maternal substance abuse
No antenatal care
Post term gestation
Multiple gestation
Anaemia
Age <16 or > 35

11. Intrapartum Risks
Emergency CS
Instrumental delivery
Abnormal position
Premature labour
Precipitous labour
Chorioamnionitis
Prolonged rupture of
membranes
Prolonged labour > 24 hrs
Prolonged 2nd
stage of
labour
Fetal bradycardia
Non-reassuring fetal heart
rate pattern
General anaesthesia
Narcotics administered
within 4 hours of delivery
Meconium stained liquor
Prolapsed cord
Abruptio placentae
Placenta previa

12. Fetal asphyxia
Primary apnoea
 Apnoeic
 Blue
 Heart rate 
 Resuscitate easily
Secondary
 apnoeic
 White, floppy
 Heart rate 
 Require active resuscitation

14. Equipment Needed for Resuscitation
Radiant warmer
Warm towel and blankets
Resuscitation bag and
mask
 Self inflating bag
 Anaesthetic bag
Endotracheal tubes
Laryngoscope
Stethoscope
Oxygen source and
tubing
Suction source and
tubing
Drugs and fluids
Syringes, needles,
cannulae, IV lines
+/-Umbilical lines

15. Equipment Needed
Overhead radiant warmer

16. Normal Delivery Procedures
Place under warmer and
towel dry
Use bulb syringe to clear
mouth, then nose
Tactile stimulation if not
breathing yet
Auscultate heart and
lungs & assess color
Free flow O2 as needed

17. Steps in Resuscitation
Warmth and stimulation and assessment for
the 1st
30 seconds
 Use warm cloth
 Replace when wet
 Rapidly assess
 Tone
 Colour
 Respiratory effort

18. Steps in Resuscitation - ABCDE
Airway
 Clear airway if required
 Removal of secretions if present
 Suction mouth and nose
DO NOT SUCTION IF AIRWAY IS CLEAR
 Positioning
 Supine or lateral
 Head in neutral or slightly extended position

19. Neonatal Position for
Opening the Airway –
‘neutral position’
Incorrect: Neck
Hyperextension
Incorrect: Neck
Under Extended
Correct: Neck
Slightly
Extended

20. Head flexed by large occiput

21. Head in neutral or ‘sniffing’
position

22. Acceptable methods of stimulation

23. Steps in Resuscitation - ABCDE
Breathing
Assessment of respiratory effort and colour
Indications for oxygen administration
 Cyanosis
 Respiratory distress
 Give free flowing oxygen 5L/min

24. Breathing: Indications for
positive pressure ventilation
Apnoea
Gasping respiration
HR < 100 bpm
Persistent central
cyanosis despite 100%
O2
40-60 breaths/min
No response

26. Watch for slight rise of
chest
Rate is 40-60

27. Indications of endo-tracheal
Intubation
 Prolonged positive-pressure ventilation (PPV) required
 Bag & mask ineffective: Inadequate chest expansion
 If chest compressions required: Intubation may facilitate
coordination and efficiency of ventilation
 Tracheal suction required

28. Steps in Resuscitation - ABCDE
Circulation
Assessment of heart rate and response
to previous measures
 Umbilical arteries
 Apex beat
 Auscultation

29. Chest
Compressions
HR < 60 bpm despite
adequate vent with
100% O2 for 30
seconds
 2 techniques
 2 thumb (preferred)
 2 finger
 3:1 ratio
 1/3 of AP diameter

30. Technique
Position of Hands on Chest
Thumb technique
( preferred )

31. Technique
Position of Hands on Chest
Two finger technique

32. Chest (cardiac) compressions
“Two-thumb” technique is usually preferred

33. Steps in resuscitation - ABCDE
Drugs
Adrenaline
Volume Expanders
Naloxone

34. Epinephrine
 Indications
HR <60 /min after PPV & CC for 30 secs
 Route of administration
 Intravenous
 Endotracheal route (when I.V line is not secured )
 Recommended
Conc. – 1:10,000 (0.1mg/ml)
Route – UVC/ IV
Dose – 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T)
Rate of admn. – as rapidly as possible
Repeat dose if no response after 60 seconds
 Now, intravenous route is first preferred route

35. Volume ExpanderVolume Expander
 Indications:
Poor response to other resuscitative measures
Evidence of blood loss or suspected ( pale skin,
poor perfusion, weak pulse)
 Crystalloid
 Normal Saline
 Ringer Lactate or
 O-negative blood cross-matched with mother’s blood
Dose – 10ml/kg
Route – Umbilical vein
Preparation – large syringe
Rate of administration – 5-10 min

36. Naloxone Narcotic antagonistNaloxone Narcotic antagonist
 Indications :
A history of maternal narcotic administration within the
past 4 hours
Severe respiratory depression is present after PPV has
restored a normal HR & color
 Recommended
 Concentration: 1.0 mg/ml
 Route: Intravenous
 Dose: 0.1 mg/kg

37. Meconium present and baby vigorous
Vigorous Baby- Strong respiratory efforts,
Good muscle tone,
Heart rate > 100 bpm
suction catheter or bulb syringe for suction of mouth or nose
ET suction not required

38. Meconium present and baby not
vigorous
Insert laryngoscope
Clear mouth and posterior pharynx
Insert endotracheal tube into the trachea
Attach the ET to suction source
Apply suction as ET is slowly withdrawn
Repeat as necessary until no meconium or heart
rate indicates further resuscitation

39. What to do if still no improvement?What to do if still no improvement?
 If no improvement seen despite all efforts
Ensure adequate ventilation, chest compressions, drug
delivery
 If still HR < 60/min, consider
 Airway malformation
 Lung problems
 Pneumothorax
 Diaphragmatic hernia
 Cong. Heart disease
If HR absent or no progress
 Ethical considerations of when to D/C Resuscitation

40. Discontinuing Resuscitative Effort
Stop resuscitation, if HR remains undetectable for
10 - 15 min
Also take into consideration factors such as
presumed etiology of the arrest, gestation of the
baby, presence or absence of complications

41. Guidelines for Neonatal
Resuscitation