Based on standardized and global validated Guidelines

3. Neonatal and under-5 Deaths
Source: WHO global health estimates, 2019

4. Foundations of neonatal Resuscitation
• After birth, the baby's lungs must take over respiratory function.
• They must be filled with air to exchange oxygen and C0 2
• Respiratory failure can occur if the baby does not initiate or cannot maintain
effective breathing effort.
• If respiratory failure occurs either before or after birth, the primary problem is a
lack of gas exchange.
• Therefore, the focus of neonatal resuscitation is effective ventilation of the
baby's lungs
Ventilation of the newborn's lungs is the single most important and effective
step in neonatal resuscitation.

5. Anticipating and preparing for Resuscitation
Before a baby is born
Prepare for birth

6. Anticipating and preparing for Resuscitation

7. Anticipating and preparing
for Resuscitation
Don’t forget to prepare also
emergency DRUGS (Epinephrine,
fluid for expansion,… )

8. Anticipating and preparing for Resuscitation
Pre-resuscitation team briefing
• Assess risk factors.
• ldentify team leader.
• Anticipate potential complications and plan a team response.
• Delegate tasks.
• ldentify who will document events as they occur.
• Determine what supplies and equipment will be needed.
• ldentify how to call for additional help

9. Initial steps of newborn care
Antenatal counseling
Team briefing
Equipment check
• Term?
• Tone?
• Breathing or crying? NO
YES
Rapid Evaluation forEvery Newborn
A BIRTH
ANTICIPATION
BEFORE BIRTH
5 Initial steps
+ Routine neonatal care
5 Initial steps
+ Neonatal resuscitation
Immediately after birth
this’ not yet APGAR SCORE

10. Initial steps of newborn care
• Term?
• Tone?
• Breathing or crying? NO
YES
Rapid Evaluation forEvery Newborn
A BIRTH
Continue
Routine neonatal care Neonatal resuscitation
• Provide warmth
• Dry
• Stimulate
• Position the head and neck.
• Clear secretions if needed
5 initial steps
AIRWAY
TEMPERATURE

11. Continue Routine neonatal care
• Provide warmth
• Dry
• Stimulate.
• Position the head and neck.
• Clear secretions if needed
5 initial steps
AIRWAY
TEMPERATURE
After stimulation
Is the baby breathing well?
End of the first 30sec
A
+ Temperature
B
BREATHING
Routine care
+ Start Neonatal resuscitation
YES NO
Golden minute
30sec
30sec

12. The neonate or infant senses heat loss as a stress and responds with increased heat production and peripheral
vasoconstriction, with centralization of circulation, in an effort to maintain the core temperature
Mechanisms of heat loss
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

13. Hypothermia:
occurs when, Heat losses exceed heat production, dropping the infant’s
temperature below the normal range of 36.5° to 37.5°C (97.7° to 99.5°F)
Hyperthermia: increase in the body temperature to above 37.5°C (99.5°F)
Mild hypothermia (cold stress): 36° to 36.4°C (96.8° to 97.5°F)
Moderate hypothermia: 32° to 35.9°C (89.6° to 96.6°F)
Severe hypothermia: Below 32°C (89.6°F)
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

14. Effects of hypothermia
• Peripheral vasoconstriction (Acrocyanosis, pallor, and coldness to touch)
• Respiratory distress / apnea (a strong pulmonary vasoconstrictor inducing hypoxemia and central cyanosis)
• With Hypoxia, shift to anaerobic metabolism and lactic acid production
• Plus Increased oxygen consumption and metabolic demands result in metabolic acidosis
• May even lead to arrhythmias (Bradycardia and death)
• Depletion of caloric reserves and hypoglycemia,…
However : Controlled hypothermia has a neuroprotective effect in term and near-term infants with
moderate to severe hypoxic ischemic encephalopathy
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

15. Prevention of heat loss in the delivery room
• Warm environment, room temperature >25°C: Maintains temperature and reduces insensible water loss
(IWL) by 25%
• Radiant warmer
• Dry the skin with a prewarmed towel and then remove any wet towels immediately
• Hats : Stockinette caps ?, Woolen hats ,…
• The Neonatal Resuscitation Program and the International Liaison Committee on Resuscitation consensus
statement recommends the use of a plastic wrap in addition to standard techniques in the delivery room
for very–low-birth-weight infants
Step 1: PROVIDE WARM
30sec
Initial steps
first 30sec

16. Occlusive plastic blankets/bags
Extremely low–birth-weight preterm newborn
wrapped in occlusive polyethylene sheet
during resuscitation.
Polyethylene bags (20 cm × 50 cm)
prevent evaporative heat loss in infants <29 weeks’ GA
Environment: Maintains temperature and reduces insensible water loss (IWL) by 25% (24,25)
Access: Allows neonatal resuscitation (secure airway, intubation, and chest compressions), but vascular access is limited
Asepsis: Limited by access
Precautions: Record core temperature every 5 to 10 minutes until infant is stable
Complications: Hyperthermia, skin maceration, risk of infection

17. Radiant warmer bed: For unstable infants
Precautions:
Keep infant 80 to 90 cm from radiant heat
For premature infants, heat shielding must be added. Increase fluid infusions
To avoid burns, do not place oily substances on infant’s skin.
• Unimpeded access to infants receiving intensive care
• Ability to maintain infant position and wide sterile field;
• also allows assistants to participate
• Leave the baby uncovered to allow full visualization and to permit the
radiant heat to reach the baby.
Complications:
Hyperthermia, Dehydration, Burns, …
Unstable

18. Mechanisms of heat loss/gain in infants
during delivery room resuscitation and stabilization:
(A)
Conventional:
drying and placement under
Radiant warmer
(B)
Radiant warmer PLUS Vinyl bag.
(C) Radiant warmer PLUS
Thermal mattress

19. Resource-Limited Settings :
WHO Standard recommends measures to prevent hypothermia.
• Warm delivery rooms
• Immediate drying
• Skin-to-skin contact
• early breast-feeding
• Postponed bathing and weighing, appropriate clothing and bedding,
and warm transportation and resuscitation
• Kangaroo mother care (KMC)

20. Step 2: DRY
30sec
Initial steps
first 30sec
• Gently rub the back, trunk, or extremities
• No Overly vigorous stimulation, can cause injury.
• Never shake a baby
• Gently dry with dry towels or blankets
• If towel or blanket becomes wet, discard and use fresh
For extreme preterm < 32w GA :
should be covered immediately in polyethylene plastic if available and skip
drying by towels or blankets
Step 3: STIMULATE

21. Step 4: POSITION THE HEAD AND NECK TO OPEN AIRWAY
30sec
Initial steps
first 30sec
• Position the baby on the back (supine)
• Head and neck neutral or slightly extended «sniffing the morning air" position

22. Step 5: SUCTION, IF NEEDED
30sec
Initial steps
first 30sec
Suck oropharynx under direct vision
Do not do deep, blind suction (before first breath and drying/stimulating)
When ?
Routine suction for a crying, vigorous baby is not
indicated
Clear secretions from the airway only if :
• if the baby is not breathing
• if the baby is gasping
• if the baby has poor tone
• if secretions are obstructing the airway
• if the baby is having difficulty clearing their
secretions
• or if you anticípate starting PPV.
How?
Suctioning gently with a bulb syringe upper airway
«Mouth before Nose"
How to Remember :
“M" comes before ”N" in the alphabet
Unnecessary suction
can be harmful.
Suction only if secretions
block mouth and nose
and you cannot ventilate
(WHO)

23. Routine care of newborn
• Provide warmth,
• Dry
• Stimulate.
• Position the head and neck.
• Clear secretions if needed
5 initial steps
If GoodTone, Breathing well, Crying
• Delayed of Clamping the cord (at 30th or 60th sec of life)
• Cord care, T-E-O ,…
• Give to the mother
Continue Routine care

24. Routine care of newborn
For most vigorous term and preterm newborns, clamping the umbilical cord
should be delayed for at least 30 to 60 seconds.
30 Sec
30 Sec
Golden
Minute
Delayed Clamping
the umbilical cord
(30 to 60sec)

25. • Term?
• Tone?
• Breathing or crying?
NO
Rapid Evaluation for Every Newborn
30 Sec
Airway & Temperature
Golden
Minute
• Provide warmth,
• Dry
• Stimulate.
• Position the head and neck.
• Clear secretions if needed
Neonatal resuscitation at birth
30 Sec
Breathing (Second 30sec)
Apnea or Gasping
HR < 100 Bpm
Labored breathing
or persistent cyanosis
Positive Pressure Ventillation
Pulse Oximeter + cardiac monitor
Position airway + Suction if needed
Pulse oximeter
Oxygen if needed + Consider CPAP
Breathing
Second 30sec

26. After completing the initial steps,
positive-pressure ventilation (PPV)
is indicated if the baby is not
breathing, OR if the baby is gasping,
OR if the baby's heart rate is less
than 100 beats per minute (bpm)

27. Check the self-inflating bag and mask and the suction device
Golden minute Second 30sec

28. Breathing
Second 30sec
30sec

29. A B C
Correct size face mask in the
correct position covers:
The nose
The mouth
The tip of the chin
BUT NOT THE EYES
Face mask that is too SMALL
Does not cover the nose
Does not cover the mouth
effectively
Face mask that is too LARGE
Covers the eyes
Extends over the tip of the chin
Correct mask size and position

30. Breathing
Second 30sec
30sec

31. For ≥ 35Weeks of GA: Resuscitation is initiated with room air (21% oxygen)
For < 35Weeks GA, resuscitation is initiated with 21 to 30% oxygen
Oxygen concentration for PPV
Needs PPV+ connect to O2
Breathing
Second 30sec
30sec

32. Positive Pressure Ventilation (PPV)
• Squeeze the bag smoothly between your thumb and 2 fingers, to produce a gentle movement of the chest
• Squeeze the bag harder if you need to deliver more air with each breath
• Effective PPV must inflates the lungs, this is evidenced by chest movement
Check the chest expansion
Breathing
Second 30sec
30sec

33. Positive Pressure Ventilation (PPV)
Give 40 to 60 breaths / min (count aloud)
Newly born term infant: 30 – 40 cm H2O
Preterm: 20 – 25 cmH2O
Which Pressure?
Which RATE?
Breathing
Second 30sec
30sec

34. Positive Pressure Ventilation (PPV)
Breathing
Second 30sec
30sec
Give 40 to 60 breaths / min (count aloud)
Start PPV for 15sec
Assess HR
Do Ventillation correctives steps (MR. SOPA)
Resume PPV for 15sec
If HR <100bpm

35. The most important indicator of successful PPV is a rising heart rate
Rise of HR indicate good myocardial oxygenation
Sign of positive response to PPV
Breathing
Second 30sec
30sec
Check heart rate
Positive Pressure Ventilation (PPV)

36. PPV For how long?
15 Sec
15 Sec
Second 30seconds Start PPV
Give 10 to 15 initial breaths (taking 15sec)
Re-assess
If HR is not increasing
Ventilation corrective steps (MR. SOPA)
And Resume PPV
Mask adjustment.
Reposition the head and neck.
Suction the mouth and nose.
Open the mouth.
Pressure increase.
Alternative airway.
Re-assess
Resume PPV for 15sec

37. Target Pre-ductal Oxygen saturation
Measured on
the Right arm
Preductal SpO2
Postductal
SpO2

38. First APGAR SCORE

39. First APGAR SCORE
Reported at 1 minute and 5 minutes after birth for all infants and,
Infants with a score less than7: at 5-minute intervals thereafter until 20
minutes.
Interpretation at 5 minutes:
7 -10: reassuring or normal
4 – 6: moderately abnormal
0 - 3: Low (term infant and late-preterm infant)

40. 30 sec 30 sec
Birth
Initial Step
A B C
30 sec
PPV (HR< 100bpm)
[Oxygen] <>¨35 GA
Chest compression
Reassess PPV
Reevaluate by
assessing
Resp status
HR < or > 100bpm
HR < 60 bpm
HR % 60 - 100
Third 30sec of life
C
PUT ALTERNATIVE AIRWAY, IF AVAILABLE
Ie. Place Laryngeal Mask
Continous PPV with Laryngeal Mask for 30sec
i.e Endotracheal intubation, if no improvement
INCREASE OXYGEN UP To 100%
Always remember
Ventilation of the newborn's lungs is the
single most important and effective
step in neonatal resuscitation.

41. Alternative airway
Laryngeal mask

42. Insertion of an endotracheal tube (intubation) is strongly recommended if the baby's heart rate remains
less than 100 bpm and is not increasing after positive-pressure ventilation (PPV) with a face mask or
laryngeal mask.
ETT
AHA 2020 Guidelines

43. • Chest compressions always accompained by IPPV
• Using oxygen concentration:
Should be increased up to 100%
Chest compression- ventilations rate is 3:1 (90 by 30 per minute)
30 sec 30 sec
Birth
Initial Step
A B
C
30 sec
PPV (HR< 100bpm)
[Oxygen] <>¨35 GA
Chest compression
Reassess PPV
Reevaluate by
assessing
Resp status
HR < or > 100bpm
HR < 60 bpm
HR % 60 - 100
Third 30sec of life
If Alternative Airway not
available, pass to coordinated
PPV + Chest compressions

44. 1 rescuer
2 fingers in the center of the
chest, below the nipple line
2 or more rescuers
2 thumb–encircling hands in the
center of the chest, below the
nipple line
Chest compressions
30sec
Third
30sec

45. How deeply?
Depth : 1/3 of A-P Chest Diameter
Coordinated Compressions and Ventilations
Chest compressions
Second
minute
3 compressions + 1 ventilation every 2 seconds

46. What is the compression rate?
90 compressions per minute
3 compressions + 1 ventilation every 2 seconds
Coordinated Compressions and Ventilations
The rhythm by counting out loud:
"One-and-Two-and-Three-and-Breathe-and; One-and-Two-and-Three-and-Breathe-and; …11
• Compress the chest with each counted number ("One, Two, Three").
• Release the chest between each number ("-and-").
• Pause compressions and give a positive-pressure breath when the compressor calls out "breathe-and. 11
30sec
Third
30sec
If necessary increase the Oxygen supplementation to 100% (if alternative airway is in place)

47. DRUGS
30 sec 30 sec
Birth
Initial Step
A B C
30 sec
PPV (HR< 100bpm)
[Oxygen] <>¨35 GA
Chest compression
Reassess PPV
Reevaluate by
assessing
Resp status
HR < or > 100bpm
HR < 60 bpm
HR % 60 - 100
EI
Drugs
HR < 60bpm
Color
RR
Drugs are indicated HR remains < 60bpm after :
• At least 30 seconds of PPV that inflates the lungs as evidenced by chest movement
• and Another 60 seconds of chest compressions coordinated with PPV using 100%oxygen
DRUGS are not indicated before you have established ventilation that effectively inflates the lungs.
THE QUALITY OF VENTILATION MATTERS (Do things Properly) NEED PRACTICE FOR IMPROVING SKILLS

48. The superficial venous system
in the neonate.
Get a Vascular access < 90sec
For emergency drugs and fluid administrations
The Vascular access should be ready
in less than 90sec after birth:
Why 90sec?
Drugs should be started if HR remain
<6obpm after :
Initial steps (30sec)
+ PPV (30sec)
+ PPV/Compression (30sec)
Start to look for the IV access before 90sec

49. Correct application of a tourniquet for quick release

50. Rapid option
Get a Vascular access < 90sec
For emergency drugs and fluid administrations
Umbilical vein
Correct (A and B)
and incorrect (C) umbilical venous catheter insertion

51. 1 2
3
lnsertion using
an intraosseous drill
4 5
Intraosseous emergency route

52. Epinephrine
10 ml syringe
9ml of Normal
Saline (0.9%)
Results:
1mg/10 ml
= 0.1mg/1ml
= 0.01mg/0.1ml
Ampule
1 mg /1 mL
+ IV (prefered) or IO
Dose = 0.02 mg/kg
(equal to 0.2 mL/kg)
Range = 0.01 to 0.03 mg/kg
(equal to 0.1 to 0.3 mL/kg)
May repeat every 3 to 5 minutes
flush 3-mL saline, Can Follow
Alternative: ETT:
0.05mg-0.1mg/Kg (0.3 – 1ml/Kg)
(1:10000)
(1:1000)
Indication
Epinephrine is indicated if HR remains < 60bpm after :
• At least 30sec of PPV that inflates the lungs as evidenced by chest movement
• and Another 60sec of chest compressions coordinated with PPV using 100%oxygen

53. Volume expansion
• Normal saline bolus: 10ml/Kg
over 5 – 10 minutes
Can be repeated
• Other solutions: Ringer´s
lactate or Rh.negative blood
If severe blood
loss and/or anemia is
suspected or documented
• Administration of a volume expander is indicated
if the baby is not responding to the steps of
resuscitation and there are signs of shock or a
history of acute blood loss.
• Volume expanders should not be given routinely
during resuscitation in the absence of shock or a
history of acute blood loss.

54. Pass NG tube or Orogastric tube
if Prolonged PPV or need of continuous CPAP
If you continue face-mask PPV or continuous positive airway pressure (CPAP)
for more than several minutes, an orogastric tube should be inserted to act as
a vent for gas in the stomach.

55. What do you do if the baby is not improving after giving
intravenous epinephrine and volume expander?
1. Is the chest moving with each breath?
2. Is the airway secured with an endotracheal tube oral laryngeal mask?
3. Are 3 compressions coordinated with 1 ventilation being delivered every 2 seconds?
4. Is the depth of compressions one-third of the AP diameter of the chest?
5. Is 100% oxygen being administered through the PPV device?
6. Was the correct dose of epinephrine given intravenously?
7. Is the umbilical venous catheter or intraosseous needle in place or has it been dislodged?
8. Is a pneumothorax present?

56. When to stop resuscitation ?
Positive response
• HR > 100*
• Spontanuous respirations*
• Fair muscle tone
• Appropriate target SpO2 (if not, can requires to continous O2 supplementation,
CPAP, … )
Negative response
HR < 30 or Undetectable
No signal pulse oxymeter
+No spontanous respiration
+No muscules tone, pallor
After well done Resuscitative efforts (properly) for 10min or 20min (If Therapeutic
Hypothermia)
NEXT STEP
Post resuscitation care

57. When to stop resuscitation ?
In high resources Setting, at the THERAPEUTIC HYPOTHERMIA ERA
• Previous editions of the AHA Textbook of Neonatal Resuscitation suggested that it may be reasonable
to stop resuscitative efforts if the heart rate was undetectable after 10 minutes of resuscitation.
• The 2020 edition AHA Textbook of Neonatal Resuscitation suggests that the time interval to consider
stopping resuscitative efforts should be around 20 minutes:
Improvements in neonatal intensive care and the availability of neuroprotective interventions, such as
therapeutic hypothermia, may be improving the long-term outcome for these newborns. BY Extending the
time frame to consider discontinuing Resuscitative efforts

58. Post resuscitation interventions
• Maintain temperature: Avoid overheating the baby during or after resuscitation
In case of severe birth asphyxia related HIE, hypothermia can be beneficial (selection of candidates
for therapeutic hypothermia)
• Continuous monitoring of vital signs (Tº,HR, RR, BP, sPO2,…), respiratory status, urine output,
neurologic status, ABGs,
• Investigations / eventual complications of perinatal distress/asphyxia: RBS, RFTs, Serum
Electrolytes, LFTs, serum PH, Arterial Blood Gas (ABGs), baseline CBC, …
• Assess the need to maintain continuous supplemental oxygen, PPV, or continuous positive
airway pressure (CPAP), or other advanced / specialized interventions, …

60. • Pneumothorax or pleural effusion
• Airway obstruction: thick secretions, MAS, Choanal Atresia, Pierre-Robin
Sequence
• Complications from maternal opiate or anesthetic exposure
• NTD: Myelomeningocele
• Abdominal wall defect
Neonatal Resusciatation in Special Considerations
Discussed Separately in another session

61. References

62. #Merci
#Asante
#Thank you
Shamavu.kakuru@studwc.kiu.ac.ug