This document summarizes the key points of neonatal resuscitation as presented by Dr. Himanshu Dave. It discusses the history and principles of neonatal resuscitation, the initial steps and assessments of resuscitation, positive pressure ventilation and intubation techniques, chest compressions and medications, special considerations for scenarios like meconium staining and hypothermia treatment, and guidelines for when resuscitation efforts should be stopped. The document provides detailed clinical guidelines and recommendations for neonatal resuscitation based on the latest evidence and standards from organizations like the International Liaison Committee on Resuscitation.

1. NEONATAL RESUSCITATION
Presented by: Dr.Himanshu Dave
Secondary DNB (1st year)
DEPARTMENT OF PEDIATRICS
NRCH

2. Topics to be highlighted
• History
• Principles of Resuscitation
• Initial steps of resuscitation
• Positive – Pressure ventilation
• Endotracheal tube intubation and LMA insertion
• Chest compressions
• Medications
• Special considerations
• When to stop resuscitation

3. HISTORY
• Dr.William Keenan – Father of NRP
• Every five years, the International Liaison
Committee on Resuscitation (ILCOR)
comprising representation from 13 countries
worldwide reviews the available resuscitation
science.

4. • It provides recommendations based on the
available evidence at that time.
• The ILCOR guidelines were published in
October 2015 and the AAP launched its 7th
edition of NRP in May 2016.

5. PRINCIPLES OF RESUSCITATION
• Birth asphyxia accounts for about 1/4th of
the neonatal deaths that occur each year
worldwide.
• 90% of newborns make smooth transition
from intrauterine to extra uterine life
requiring little or no assistance.
• 10% of newborns need some assistance.
• Only 1% require extensive resuscitation.

6. WHAT CAN GO WRONG ?
Compromise of uterine or placental blood flow
Deceleration of FHS
Weak cry
Inadequate ventilation to push the alveolar fluid

7. In utero hypoxia
Meconium passage
May block the airways

8. Pulmonary arterioles remain constricted
PPHN
(Persistent Pulmonary Hypertension of New
Born)

9. CONSEQUENCES
• Low muscle tone , apnoea or tachypnea ,
bradycardia or hypotension and cyanosis.
• Outcomes of these newborns can be
improved with timely and effective
resuscitation.

11. INITIAL PREPARATIONS
• There is increased focus throughout the 7th
edition NRP on team preparation and role
assignment.
• Team briefing
• Role assignment
• Equipment check.

12. Initial preparations cont…
• Every birth should be attended by at least 1
person whose only responsibility is care of
the newborn.
• Meconium stained amniotic fluid- ensure a
member with advanced airway and
resuscitation skills is in attendance.

13. Equipment required

14. INITIAL ASSESSMENT
• Ask 4 questions to the obstetrician:
1) Gestational age?
2) MSAF?
3) Single or multiple gestation?
4) Risk factors in mother?

15. INITIAL STEPS
• Initial assessment after birth :Tone ? and
breathing/crying?
• Warmth and position airway
• Suction if necessary
• Dry and stimulate
• Repositioning

16. Initial Steps cont…
• In stable infants, delayed cord clamping should be
performed for at least 30 seconds
• Temperature should be maintained between 36.5 and
37.5 Celsius
• Focus on thermoregulation throughout resuscitation

17. ROUTINE CARE
• Vigorous term babies with no risk factors &
who required but responded to initial steps:
– Skin to skin contact and can stay with mother
– Clear airway
– Dry newborn
– Provide ongoing evaluation: Breathing , Activity
and Colour .

18. Role of supplemental oxygen in NRP
• Starting resuscitation gas for term infant should be 21%
• In infants <35 weeks, starting gas should be 21-30% and
should be increased as per requirement.
• Continue to achieve target saturations using preductal
saturation monitor.

19. TARGETED PREDUCTAL SPO2 AFTER
BIRTH
• 1 min 60%-65%
• 2 min 65%-70%
• 3min 70%-75%
• 4min 75%-80%
• 5min 80%-85%
• 10min 85%-95%

20. The Golden Minute
• The Golden Minute (60-second) mark is for
completing the initial assessment, initial steps,
re-evaluating, and beginning ventilation if
required .
• Evaluations and decision making are based on:
a) Respiratory effort
b) Heart rate

21. Evaluation
• For assessment of heart rate, the use of a 3-
lead ECG is recommended.
• Pulse oximetry to evaluate the newborn’s
oxygenation

22. Positive Pressure Ventilation (PPV)
• Indications for PPV :
- Heart rate less than 100 bpm or
- Ineffective respirations.
• Initial PIP (Peak Inspiratory Pressure) is
suggested in the range of 20-25 cm H20.
• When PPV is administered to preterm infants,
PEEP(Positive End Expiratory Pressure) should
be used. Recommended starting PEEP is 5 cm
H20.

23. PPV cont….
• Rate of PPV is 40-60 / minute. (Breathe ,2,3..)
• Rising of HR
• Improvement in Oxygen Saturation PPV
• Equal and adequate breath sounds Effective
• B/L Good Chest rise If

24. PPV cont…
• After PPV started, reassess in 15 seconds.
• If no response; MR SOPA corrective measures
should be incorporated.

27. Indication of CPAP
• If HR is >100 but has laboured breathing or
Sp02 cannot be maintained within target
range despite 100% free-flow oxygen:
- consider a trial of
Continuous Positive Airway Pressure (CPAP)

28. ADVANCED AIRWAY
Intubation is recommended prior to chest
compressions.
If intubation is not feasible, the laryngeal
mask airway should be used as an alternate
advanced airway.
Recommendations for depth of insertion are
gestation-based or based on formula using
nasal-tragus length (NTL) measurement.

29. NTL + 1

31. CHEST COMPRESSIONS
• The indication for chest compressions:
- Heart rate less than 60 bpm in spite of 30
seconds of effective PPV.
• 100% oxygen to be given when administering
chest compressions.

32. Chest compressions cont…
• The 2-thumb technique
is recommended (Two
finger technique is now
obsolete).

33. Chest compression cont…
• Compress 1/3rd diameter of chest.
• Do not lift the fingers off the chest.
• 90 compressions to 30 ventilations/minute
(3:1- One & two & three & breathe & One &
two & three & breathe…)

34. Chest Compression Cont…
• Chest compressions should be continued for
60 seconds before reassessment of heart rate.
• Electronic cardiac monitor preferred for
assessment of heart rate.

35. Technique of chest compressions with
PPV

36. MEDICATIONS
1.EPINEPHRINE
• Indicated if : HR remains <60 bpm after at least
30 sec of effective PPV and another 60 seconds of
chest compressions using 100% oxygen .
• One dose may be given through ETT.
• If no response, give intravenous dose via
emergency UVC or IO access.

37. MEDICATIONS cont…
• Concentration - 1:10,000 (0.1mg/ml) .
• ETT dose - 0.5 – 1 ml/kg .
• UVC / IV dose 0.1- 0.3 ml/kg ,follow with a 1ml
flush NS .
• Can repeat every 3-5 minutes.

38. MEDICATIONS cont…
2.OTHERS
• For hypovolemic shock: Normal saline and
blood are the solutions of choice and the
recommended volume is 10 ml/kg.
• Ringer’s lactate is no longer recommended.

39. • The routine use of NaHCO3 to correct
metabolic acidosis is not recommended.
• The use of naloxone to manage respiratory
depression in infants born to mothers with
narcotic exposure in labour is not
recommended.

40. SPECIAL SCENARIOS
• DELAYED CORD CLAMPING : Recommendation
that delayed cord clamping for 30 -60 seconds is
reasonable for both term and preterm infants
who do not require resuscitation at birth.
If placental circulation is not intact (placental
abruption or bleeding due to any cause): The cord
should be clamped immediately after birth.

41. SPECIAL SCENARIOS
• MECONIUM STAINED LIQUOR : If the infant born
through meconium-stained amniotic fluid is non
vigorous, the initial steps of resuscitation should
be completed under the radiant warmer.
PPV should be initiated if the infant is not
breathing or the heart rate is less than 100/min
after the initial steps are completed.
Routine intubation for tracheal suction is not
suggested.

42. SPECIAL SCENARIOS
• Pneumothorax : Percutaneous needle
aspiration
• Pleural effusion : Percutaneous needle
aspiration
• Congenital Diaphragmatic hernia : Intubation
• Therapeutic hypothermia for HIE : For >/=
36wks with severe birth asphyxia, initiated
within 6 hours after birth, in facilities with
multidisciplinary care.

43. WHEN TO STOP RESUSCITATION ?
* An APGAR score of 0 at 10 minutes is a strong
predictor of mortality and morbidity in late
preterm and term infants, but decisions to
continue or discontinue resuscitation efforts
must be individualized.
* Where GA ( < 23wks ), B.wt ( < 400g) and /
or Congenital anomalies are associated with
early death and high morbidity, resuscitation
is not indicated.

44. THANK YOU