Neonatal resuscitation guidelines were updated with the following key changes: - Delayed cord clamping for at least 30 seconds is recommended for both term and preterm infants who do not require resuscitation. - For infants requiring resuscitation, there is insufficient evidence on optimal cord clamping approach. - Use of 3-lead ECG is recommended over pulse oximetry for accurate heart rate measurement during resuscitation. - For preterm infants under 35 weeks, resuscitation should use low oxygen (21-30%) and titrate to target saturation rather than high oxygen.

1. Neonatal Resuscitation
Guidelines
Dr . Mohammad AlmaghayrehDr . Mohammad Almaghayreh
Princess Rahmah Teaching HospitalPrincess Rahmah Teaching Hospital
What's new????

2. • IntroductionIntroduction
• Preparation/AnticipatioPreparation/Anticipatio
nn
• Initial assessmentInitial assessment
• Whom to resuscitateWhom to resuscitate
• Steps of resuscitationSteps of resuscitation
• New additionsNew additions
• ConclusionConclusion

3. IntroductionIntroduction
•Approximately 10% of newborn's require some
assistance.
• Less than 1% require extensive resuscitation
measures
Because of the large total number of births, a significant
number will require some degree of resuscitation

4. AnticipateAnticipate the riskthe risk
• Assessment of perinatal risk factors
• Assemble the appropriate personnel
• Organize access to supplies and check equipment
• Effective teamwork and communication

5. Anticipation of Resuscitation Need
Risk FactorsRisk Factors

6. Anticipation of Resuscitation Need

7. Before delivery of the baby the team should do:
• A) Antenatal counseling
• B) Ask OBSTITRECIAN 4Q?
1)gestational age?
2)Clear amniotic fluid?
3)How many babies?
4)Any additional risk factors?
• C) Team briefing
• D) Equipment check

8. Equipment
A complete set of resuscitation equipment
and drugs should always be readily
available in the areas of hospitals where
newborns are born or receive neonatal care1
2.2.1 Equipment checks
• Facilities should maintain a clear record
documenting the checking procedure for
each set of resuscitation equipment and
drugs1
• Each set of resuscitation equipment and
drugs should be checked Before any
resuscitation1

9. Initial Assessment?Initial Assessment?
Questions to answer with yes/no
•Assess the answers to
the following 3
questions:
1) Term gestation?
2) Good tone?
3) Breathing or crying

10. Yes!
Term gestation
 Crying or breathing
Good muscle tone
• Baby does not need
resuscitation
• Should not be separated from
the mother.
• Dry, place skin-to-skin with the
mother
• Cover with dry linen to
maintain temperature
• Observe breathing, activity,
and color

11. Term gestation?
Crying or
breathing?
Good muscle tone?
If the answer to any of these assessment
questions is “NO”
A. Initial steps of stabilization
B. Ventilate and oxygenate (HR/Breathing)
C. Initiate chest compressions (HR < 60)
D. Administer epinephrine and/or volume
Whom to resuscitate?Whom to resuscitate?

12. To proceed or not to Proceed?
• Respirations : apnea,
gasping, or labored or
unlabored breathing)
• Heart rate : whether > or
< 100
ointermittently auscultating
the precordial pulse
opalpation of the umbilical
pulse

13. Approximately 60 seconds (“the Golden Minute”) are allotted for
completing
initial steps, revaluating and beginning ventilation if required
• Most neonatal arrests are
asphyxia in nature.
• First ventilation (if needed)
should be administered
within 60 seconds of initial
assessment.
• “Initial Assessment” can be
done on Mom
• Permitting delayed cord
clamping if stable

14. O2 saturation
• Once positive pressure ventilation
or supplementary oxygen
administration is begun,
assessment should consist of
simultaneous evaluation of 3 vital
characteristics:
1. heart rate
2. respirations
3. state of oxygenation (pulse
oximeter)
The device takes 1 to 2 minutes to apply, and it may not function
during states of very poor cardiac output or perfusion

15. UMBILICAL CORD CLAMPING
• 25‐60% of the circulating
volume of the feto placental
unit resides in the placenta
• 20‐40 mL/kg = normal
transfusion from placenta
to neonate

17. Delayed cord clamping means waiting at least 30
second to stop of umbilical cord pulsation after the
delivery of an infant
Definition of Delayed Cord Clamping

18. New EntriesNew Entries
Umbilical cord management
DCCDCC : less IVH, higher BP, blood volume, less need for
transfusion after birth ,more iron store, and less NEC
No evidence of decreased mortality or
decreased incidence of severe IVH
slightly increased level of bilirubin associated with more
need for phototherapy

19. New EntriesNew Entries
Consensus:
1)DELAYED CORD CLAMPING > 30 seconds is reasonable for
both T/PT infants who do not require resuscitation at birth
2)No routine use of cord milking for infants < 29 weeks of
gestation outside of a research setting
3)• No delay in cord clamping if placental circulation
disrupted (placental abruption, bleeding placenta previa,
bleeding vasa previa, or cord avulsion)
4)Insufficient evidence to recommend an approach to cord
clamping for newborns who require resuscitation at birth
( Non-vigorous)

20. DELAYED CORD CLAMPING
•The risk of death/admission decreased by 20% for
every 10‐second delay in CORD CLAMPING after
SPONTANEOUS RESPIRATION; this risk declined at
the same rate in both BW groups.
Neonatal Outcome Following Cord Clamping After Onset of Spontaneous Respiration
(PEDIATRIC 2014)

21. Physiology of thermal regulation in neonates
Convection Evaporation
Radiation
Conduction
Photograph: "HumanNewborn" by Ernest F - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -
http://commons.wikimedia.org/wiki/File:HumanNewborn.JPG#/media/File:HumanNewborn.JPG
Temperature
09/07/16 21

22. Temperature categories
(World Health Organization)

23. New EntriesNew Entries
Temperature regulation
•Admission temperature strong predictor of mortality at all
gestational ages.
Hypothermia increases risk of:
1)Intraventricular haemorrhage
2)Respiratory Distress
3)Hypoglycaemia
4)late-onset sepsis
predictor of outcomes as well as a quality indicator

24. Strategies to Provide Warmth
 For all newborns
– Environmental Temperature at least 25°C
(77°F)
– Warm Blankets for Drying
– Hats (wool or plastic)
 For newborns requiring resuscitation
– Radiant Warmer
– Warm, humidified gases
 For premature
– Polyethylene Occlusive wrapping
– Heated (Na Acetate) Mattresses

25. New EntriesNew Entries
Consensus
1)Maintain temperature between 36.5-
37.5°C
2)Plastic wrap, radiant warmer, thermal
mattress, warm humidified gases and
increased room temperature
3)Hyperthermia (>38.0°C) should be
avoided
4)Rapid or slow cooling both acceptable

26. New EntriesNew Entries
Maintaining normothermia
in resource-limited settings
1)Clean food-grade plastic bag
up to the level of the neck and
swaddle them after drying
2)Kangaroo mother care

27. New EntriesNew Entries
Maternal hyperthermia in labour is associated with increased
mortality, neonatal seizures and encephalopathy
"Intrapartum fever and chorioamnionitis as risks for encephalopathy in term newborns: A case-control study." Developmental Medicine and Child
Neurology 50(1): 19-24. Blume, H. K., C. I. Li, et al. (2008).

28. A comment about Meconium

29. New EntriesNew Entries
• Deterioration of pulmonary compliance, oxygenation and cerebral
blood flow velocity accompany tracheal suction
Non vigorous baby: Routine intubation for tracheal suction not suggested
Meconium-stained amniotic fluid is a perinatal risk factor that requires the
presence of one resuscitation team member with full resuscitation skills,
including endotracheal intubation
Meconium Stained Amniotic Fluid
Initial steps (warm, dry & stim) may be performed first

30. New EntriesNew Entries
Assessment of Heart Rate
•Increasing heart rate is most sensitive
indicator of a successful response to each
intervention
•Underestimation of the newborn’s heart rate
by auscultation, palpation and pulse oximetry
•3-lead ECG displayed a reliable heart rate
faster than pulse oximetry

31. New EntriesNew Entries
Consensus
During resuscitation of T/PT newborn's, use 3-lead ECG
for the rapid and accurate measurement of the newborn’s heart rate.
 Initial HR assessed by auscultation
– PPV begins, consider ECG monitor
– When/if chest compressions begin, ECG is preferred method of
determining HR.

33. New EntriesNew Entries
Administration of oxygen in Preterm
•Resuscitation of PT newborn's (<35) with high oxygen (65%) showed no
improvement in survival to hospital discharge
Resuscitate preterm < 35 weeks with low oxygen (21-30%)
and titrate to achieve preductal oxygen saturation target.
• Adjust the oxygen concentration as needed to achieve the oxygen saturation target by
pulse oximetry
• If the newborn has labored breathing or oxygen saturation cannot be maintained with
the target range despite 100% free flow oxygen, consider a trial of CPAP

34. Focus Intently on Achieving Effective Ventilation

35. New EntriesNew Entries
Positive Pressure Ventilation/PEEP
•PEEP :supplementary oxygen required to achieve target oxygen saturation may be slightly
less when using PEEP.
5 cm H2O PEEP when PPV is administered to preterm new-
born's
PPV delivered effectively with a flow-inflating bag, self-inflating bag or T-piece
resuscitator

36. New EntriesNew Entries
• Use of respiratory mechanics monitors have been reported
to prevent excessive pressures and tidal volumes
• Exhaled CO2 monitors may help assess that actual gas
exchange is occurring during face-mask PPV attempts.
Effectiveness, particularly in changing important outcomes,
has not been established

37. New EntriesNew Entries
• CPAP decreases rate of intubation, duration of MV with potential benefit of
reduction of death and/or BPD without significant increase in air leak or severe
IVH.
spontaneously breathing PT infants with respiratory distress may be
supported with CPAP initially rather than routine intubation for
administering PPV

38. Chest Compressions
1) Intubation is strongly recommended prior
to beginning chest compressions
2) • If intubation is not successful or not feasible,
a laryngeal mask may be used
3) • Chest compressions = two-thumb
technique
4) • Once the endotracheal tube or laryngeal
mask is secured, the compressor administers
chest compressions from the head of the
newborn
5) • Chest compressions continue for 60 seconds
prior to checking a heart rate
09/07/16 38

39. New EntriesNew Entries
LMA recommended during resuscitation > 34 weeks when tracheal
intubation is unsuccessful or is not feasible

40. LMA(Laryngeal mask airway)
• Fits over laryngeal inlet
The laryngeal mask airway can be used in resuscitation of
the newborn
if facemask ventilation is unsuccessful
if tracheal intubation is unsuccessful or not feasible.
• –The LMA may be considered as an alternative to a
facemask for positive pressure ventilation among
newborns weighing more than 2000 g or delivered≥34
weeks gestation
09/07/16

41. Endotracheal Intubation

42. Endotracheal Intubation
• Depth of the endotracheal tube,
determined by using the
• “Initial Endotracheal Tube Insertion
Depth” table, or by measuring the nasal-
tragus length (NTL)
• No more weight + 6
NTL = distance from
the base of the nasal septum to the tip of
the tragus on either
side
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45. New EntriesNew Entries
100% Oxygen whenever chest compressions are provided
Supplementary oxygen concentration should be weaned as soon
as the HR recovers
Chest compression

46. New EntriesNew Entries
TH may be considered and offered under clearly defined
protocols similar to those used in published clinical
trials and in facilities with the capabilities for
multidisciplinary care and longitudinal follow-up
Induced Therapeutic Hypothermia (Induced Therapeutic Hypothermia (Resource Limited settingResource Limited setting))

47. Post resuscitation care

48. Post resuscitation care

49. Bundles of interventions
improving the outcome of preterm infants
• Maintain normal temperature
– Without drying, cover in food-grade plastic wrap or bag
and use a hat and thermal mattress or other adjunct
• Use a 3-lead cardiac monitor (chest or limb leads) for
rapid and reliable continuous HR
• Initiate ventilation with low supplemental oxygen (21-
30%)
• If PPV, use a device with PEEP
• Consider CPAP immediately after birth as an alternative
to routine intubation and surfactant administration.
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50. Withholding Resuscitation
New EntriesNew Entries
< 25 weeks, consider accuracy of gestational age assignment,
presence/absence of chorioamnionitis and the level of care
Useful data for antenatal counselling provides outcome figures for infants alive at the onset of labor, not only for
those born alive or admitted to a neonatal intensive care unit

51. What has not changed
Veni, Venti, Vici
• Ventilation of the lungs is the single most important and most
effective step in cardiopulmonary resuscitation of the compromised
newborn.”
Slapping, shaking, spanking, or holding the newborn upside down are
potentially dangerous and should not be used. During all handling,
care should be taken to ensure that the infant’s head and neck are
supported in a neutral position, especially if muscle tone is low If the
infant does not breathe, assisted ventilation should be started
[
Class A,expert consensus
opinion].
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52. Comments about Narcan and the Newly Born
There is insufficient evidence to
evaluate safety and efficacy of
administering naloxone to a
newborn with respiratory
depression due to maternal opiate
exposure. Animal studies and case
reports cite complications from
naloxone, including pulmonary
edema, cardiac arrest, and seizures.

53. SODIUM BICARBONATE
• Sodium bicarbonate should not be routinely
given to babies with metabolic acidosis.
• There is currently no evidence to support this
routine practice.

55. “New and revised treatment recommendations do
not imply that clinical care that involves the use
of previously published guidelines is either
unsafe or ineffective

56. Any Questions???Any Questions???
THANK YOU