Neonatal resuscitation also known as newborn resuscitation is an emergency procedure focused on supporting the approximately 10% of newborn children who do not readily begin breathing, putting them at risk of irreversible organ injury and death.

1. New born resuscitation
Dr. ashutosh kumar singh

2. Introduction
• the process of birth brings the fetus from a fluid environment to an
air environment.
• This transition is accompanied by physiological and biochemical
changes.

3. Causes of Neonatal Mortality

4. Neonatal resuscitation
• 10% neonates require some assistance at birth.
• 1% neonates need extensive resuscitative measures.
• Asphyxia accounts for 20-23% newborn deaths.

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

6. Pulmonary vessels dilate, causing
increased blood flow to lungs

7. Assessment after Birth
Most infants have Apgar score between 7/10 to 10/10 at one minute
and do not require resuscitation .
Infants with Apgar score 4-6 require some intervention while those
with <3/10 are severely compromised and warrant urgent
resuscitation.

8. Apgar score

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

10. Antepartum Risks
• Maternal diabetes
• Chronic maternal illness
• Pre eclampsia
• Maternal infection
• Poly / Oligohydramnios
• PROM
• IUGR
• Post term gestation
• Multiple gestation
• Anaemia
• Age <16 or > 35

11. Intrapartum Risks
• Instrumental delivery
• Abnormal position
• Premature labour
• Chorioamnionitis
• Prolonged rupture of
membranes
• Prolonged labour > 24 hrs
• Prolonged 2ndstage of
labour
• Fetal bradycardia
• Narcotics administered within 4
hours of delivery
• Meconium stained liquor
• Prolapsed cord
• Abruptio placentae
• Placenta previa

12. Fetal asphyxia
Asphyxia means lack of oxygen and blood flow to the brain. Birth
asphyxia happens when a baby’s brain and other organs do not get
enough oxygen and nutrients before, during or right after birth.

13. Fetal asphyxia
Primary apnoea
 Apnoeic
 Blue
 Heart rate ↑
 Resuscitate easily
Secondary apnoea
 apnoeic
 White, floppy
 Heart rate ↓
 Require active resuscitation

14. Equipment Needed for Resuscitation
• Radiant warmer
• Warm towel and blankets
• Resuscitation bag & mask
 Self inflating bag
• Endotracheal tubes
• Laryngoscope
• Oxygen source and tubing
• Suction source

15. Equipment Needed
Overhead radiant warmer

17. 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

18. Inverted Pyramid of neonatal
resuscitation

19. http://eccguidelines.heart.org/wp-
content/uploads/2015/10/Neonatal-
Resuscitation-Algorithm.pdf

20. Steps in Resuscitation - ABCD
Airway
• Clear airway if required
• Removal of secretions if present
• Suction mouth and nose
Positioning
• Supine or lateral
• Head in neutral or slightly extended position
“M” before “N”

21. Neonatal Position for Opening the Airway –
‘neutral position’
Incorrect:
Neck Hyperextension
Incorrect
NeckUnderExtended
Correct
Neck Slightly extended

22. Head in neutral or ‘sniffing’ position

23. Acceptable methods of stimulation

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

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

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

28. 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

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

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

31. Technique
Position of Hands on Chest
Thumb technique

32. Technique
Position of Hands on Chest
Two finger technique

33. Chest (cardiac)compressions
“Two-thumb”techniqueisusuallypreferred

34. Steps in resuscitation - ABCDE
Drugs
1. Epinephrine
2. Volume Expanders
3. Naloxone

35. 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)
 Dose – 0.1-0.3 ml/kg – via IV/UVC
0.5-1ml /kg - via ET)
 Rate of admn. – as rapidly as possible
 Repeat dose if no response after 3-5 mins .
f/b 1ml NS flush

37. Volume 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
 O-negative blood cross-matched with mother’s blood

38. Dose – 10ml/kg
Route – Umbilical vein /IV
Volume Expander

39. Naloxone - 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
 Route: Intravenous
 Dose: 0.1-0.2 mg/kg

40. 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

41. 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

42. 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
• Pneumothorax
• Diaphragmatic hernia
• Cong. Heart disease

43. What to do if still no improvement?
If HR absent or no progress
• Ethical considerations of when to Discontinue Resuscitation
• An Apgar score of 0 at 10 minutes is a strong predictor of
mortality and morbidity in late preterm and term infants.

44. Discontinuing Resuscitative Efforts
https://pediatrics.aappublications.org/content/136/Supplement_2/S196
infants with an Apgar score of 0 after 10 minutes of resuscitation, if
the heart rate remains undetectable, it may be reasonable to stop
resuscitation.
Variables to be considered may include whether the resuscitation
was considered optimal; availability of advanced neonatal care,
such as therapeutic hypothermia; specific circumstances before
delivery (Eg, known timing of the insult) and also wishes expressed
by the family

45. 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

46. 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.