The document summarizes changes to the 7th edition of NRP guidelines. Key changes include: delayed cord clamping is recommended for 30-60 seconds for term and preterm infants without need for resuscitation; meconium-stained amniotic fluid no longer requires routine intubation; assessment order changed to gestation, tone, breathing; PPV indications clarified; oxygen administration guidelines updated; chest compressions ratio changed to 90:30. Highest priorities are effective ventilation and establishing an artificial airway if needed before starting compressions.

1. 7th
edition
What is the
new?
DR MAHMOUD EL NAGGAR
NRP instructor
Mecca-HGH
2016

3. The class of recommendation of
NRP guidelines
Class I - definitely recommended
Class II - acceptable and useful
Class II a - Acceptable and useful, very good
evidence provides support
Class II b - Acceptable and useful, fair to good
evidence provides support
Class III - Not acceptable, not useful, may be
harmful

4. RESUSCITATION TEAM
 Every birth should be attended by at least 1
person who can perform the initial steps of
newborn resuscitation and PPV perfectly, and
whose only responsibility is care of the newborn.
 When perinatal risk factors are identified, a
resuscitation team should be assigned and a
team leader identified.
 Meconium-stained amniotic fluid is a perinatal
risk factor that requires presence of one
resuscitation team member with full resuscitation
skills, including endotracheal intubation. In spite
of no routine intubation and tracheal suctioning.

5.  As time permits, the leader should conduct a pre-
resuscitation briefing, identify interventions that may be
required, and assign roles and responsibilities to the
team members.
 During resuscitation, it is vital that the team
demonstrates effective communication and teamwork
skills to help ensure quality and patient safety.
RESUSCITATION TEAM

6. NRP’s 10 Key Behavioral Skills
 Know your environment
 Anticipate and plan
 Assume the leadership role
 Communicate effectively
 Delegate workload optimally
 Allocate attention wisely
 Use all available information
 Use all available resources
 Call for help when needed
 Maintain professional behavior

7. Before delivery of the baby the team
should do:
 A) Antenatal counseling
 B) Ask OB/GY 4 Q?; gestational age?
Clear amniotic fluid?
How many babies?
Any additional risk factors?
 C) Team briefing
 D) Equipment check

8. Delayed cord clamping
 There is a new recommendation that delayed cord
clamping for 30 -60 seconds is reasonable for both term
and preterm infants who do not require resuscitation at
birth. (Class IIa)
 If placental circulation is not intact, such as after a
placental abruption, bleeding placenta previa, bleeding
vasa previa, or cord avulsion, the cord should be
clamped immediately after birth.

9. Delayed cord clamping
 But there is insufficient evidence to recommend an
approach to cord clamping for infants who require
resuscitation at birth, and a suggestion against the routine
use of cord milking for infants born at less than 29 weeks of
gestation, until more is known of benefits and complications.
(Class IIb)

10. Delayed cord clamping
Is associated with:
1- less intraventricular hemorrhage
2- Higher blood pressure and blood volume
3- less need for transfusion after birth
4- less necrotizing enterocolitis.
5- Slightly increased level of bilirubin, associated with
more need for phototherapy.

11. There are 2 levels of post-resuscitation
care
 A) Routine Care for:
1- Vigorous term infants with no risk factors
2- Babies who required but responded to initial steps
 They now can stay with Mother Skin to skin contact
recommended, Clear airway, dry newborn, provide
ongoing evaluation:
Breathing
Activity
Color
 Transfer to postnatal with mother

13. There are 2 levels of post-
resuscitation care
 Post-Resuscitation Care for:
1- Babies with depressed breathing or
activity
2- Those requiring supplemental oxygen &/or
ongoing nursing care
3- Those with high risk factors to be
evaluated in an ICU setting
4- Those who require frequent evaluation
 Transfer to NICU

14. INITIAL ASSESMENT
 The order of the 3 assessment questions has
changed to:
(1) Term gestation?
(2) Good tone?
(3)Breathing or crying?

15. The Golden Minute
 The Golden Minute (60-second) mark for
completing the initial assessment, initial steps,
reevaluating, and beginning ventilation (if
required) is retained to emphasize the importance
of avoiding unnecessary delay in initiation of
ventilation witch is the most important step for
successful resuscitation of the newly born who
has not responded to the initial steps.

16. INITIAL STEPS
 1- Provide warm and maintain normal
temperature during resuscitation
 2- Positioning…..sniffing
 3- Clear the airway only if copious and/or
obstructing the airway. (Class IIb)
 4- Dry thoroughly
 5- Tactile stimulation
 6- Remove wet linen
 7- Repositioning to sniffing position

17. PROVIDE WARM
 Temperature of newly born non asphyxiated
infants should be maintained between 36.5°C
and 37.5°C after birth through admission and
stabilization.(Class I)
 Temperature should be recorded as a predictor
of outcomes and as a quality indicator. (Class I)

18. PROVIDE WARM
 A variety of strategies may be reasonable to prevent
hypothermia in preterm infants less than 32 W:
1- Radiant warmers
2- plastic wrap with a cap
3- thermal mattress
4- warmed humidified gases
5- increased room temperature to 26
6- Portable incubator(Class IIb)
 All resuscitation procedures, including endotracheal
intubation, chest compression, and insertion of
intravenous lines, can be performed with these
temperature-controlling interventions in place.(Class IIb)

19. PROVIDE WARM
 In resource-limited settings simple measures to
prevent hypothermia in the first hours of life :
1-Use of plastic wraps
2- Skin to-skin contact
3- Placing the infant after drying in a
clean food-grade plastic bag up to the neck, May
reduce mortality. (Class IIb)
 Hyperthermia (temperature greater than 38°C)
should be avoided because it introduces potential
associated risks. (Class III: Harm)

20. MECONIUM STAINED AMNIOTIC
FLUID
 If an infant is born through meconium-stained amniotic
fluid and presents non vigorous the infant should be
placed under a radiant warmer and PPV should be
initiated if needed.
 Routine intubation for tracheal suction is no longer
suggested because there is insufficient evidence to
continue this recommendation.
 Appropriate intervention to support ventilation and
oxygenation should be initiated as indicated for each
individual infant.
 This may include intubation and suction if the airway
is obstructed.

21. MECONIUM STAINED AMNIOTIC FLUID
 If the infant born through meconium-stained
amniotic fluid presents with poor muscle tone and
inadequate breathing efforts(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 in this
setting is not suggested, because there is
insufficient evidence to continue recommending
this practice. (Class IIb)

22. Evaluation Process
 Subsequent evaluations and decision making
are based on:
a) Respiratory effort
b) Heart rate
c) Oxygenation based on Pulse Oximetry

23. ASSESMENT OF THE HEART
RATE
 Assessment of heart rate remains critical during the first
minute of resuscitation and the use of a 3-lead ECG
may be reasonable (Class IIb)
 Because providers may not assess heart rate
accurately by auscultation or palpation, and pulse
oximetry may underestimate heart rate.
 Use of the ECG does not replace the need for pulse
oximetry to evaluate the newborn’s oxygenation.

24. Pulse Oximetry
It is recommended that oximetry be used when:
1. Resuscitation
can
be anticipated.
2. Positive
pressure is
administered for
more than a few
breaths.
3. Cyanosis is
persistent.
4.Supplem-
entary O2 is
administer-
ed.

25. After initial steps
Evaluate respirations and heart rate ,Not color
if:
a) HR <100 or if newborn is apneic or
gasping give PPV
b) HR >100 but spontaneous respiration
with respiratory distress may be supported by
continuous positive airway pressure rather than
with routine intubation for administering PPV
either preterm or full term. (Class IIb)

26. Oxygen administration
 Term infants start resuscitation with 21% O2 (Class IIb)
 If blended oxygen is not available, resuscitation
should be initiated with air. (Class IIb)
 Preterm less than 35 W should be initiated with low
oxygen (21% to 30%) and the oxygen titrated to achieve
preductal oxygen saturation approximating the range
achieved in healthy term infants. (Class I)
 Initiating resuscitation of preterm newborns with
high oxygen (65% or greater) is not recommended.
(Class III—No Benefit)

27. OXYGEN ADMINSTRATION
 If a baby is breathing but oxygen saturation (Sp02) is not
within target range, free-flow oxygen administration may
begin at 30%. Adjust the flowmeter to 10 L/min. Using
the blender, adjust oxygen concentration as needed to
achieve the oxygen saturation (Sp02) target.
 Free-flow oxygen cannot be given through the mask of a
self-inflating bag; however, it may be given through the
tail of an open reservoir
 If the newborn has labored breathing or Sp02 cannot be
maintained within target range despite 100% free-flow
oxygen, consider a trial of continuous positive airway
pressure (CPAP).

28. 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%
Pulse oximeter provide reliable reading with in 1 to 2
minutes following birth.

29. PPV Indications
1. Apnea /Gasping
2. Heart rate <100 even with strong respiratory
drive
3. Oxygen saturation cannot be maintained
within target range despite free flow oxygen
or CPAP.

30. PPV
 Adjust the flowmeter to 10 L/min.
 Inflation pressure should be monitored; an initial
inflation pressure of 20-25 cm H2O may be
effective, but ?30 to 40 cm H2O may be required
in some term babies without spontaneous
ventilation.(Class IIb)
 recommendation that, when PPV is administered
to preterm newborns, approximately 5 cm H2O
PEEP is suggested. (Class IIb)

31. PPV
 Start with oxygen concentration 21% for Full
Term and 30% for Preterm and adjust later.
 Assisted ventilation should be delivered at a rate
of 40 to 60 breaths per minute to promptly
achieve or maintain a heart rate >100 per minute.
(Class IIb)
 When PPV begins, consider using an electronic
cardiac monitor for accurate assessment of the heart
rate.

32. PPV
 Rate of PPV 40-60 / minute.
 Song Breathe, two, three…….Breathe, two ,
three……….
 Duration of effective ventilation 30 seconds then
assessment.

33. PPV Assessment
 Best indicator that you are bagging correctly is an
rising heart rate
 Increase in HR should be evident for the first 15
seconds of PPV.
 If heart rate not rising you asses chest movement and
bilateral breath sounds with ventilation.
 If not-then following the corrective actions
MR SOPA

34. MR. SOPA
(ventilation corrective steps)
1. M- Adjust Mask in the face
2. R- Reposition the head to open airway
Re-attempt to ventilate…if not effective then
1. S- Suction mouth then nose
2. O- Open mouth and lift jaw forward
Re-attempt to ventilate…if not effective then
1. P- Gradually increase Pressure every few breaths
until visible chest rise is noted
Maximum PIP 30 for PT and 40cmH2O for FT
If still not effective then…
1. A- Artificial Airway (ETT or LMA)

35. LARYNGEAL MASK
 A laryngeal mask may be considered as an
alternative to tracheal intubation if face-mask
ventilation is unsuccessful. (Class IIb)
 a laryngeal mask is recommended during
resuscitation of newborns 34 weeks or more of
gestation when tracheal intubation is unsuccessful
or not feasible. (Class I)

36. TRACHEAL SUCTION
 If you are attempting PPV but the baby is not improving
and the chest is not moving despite performing each of
the ventilation corrective steps (MR. SOPA), including
intubation, the trachea may be obstructed by thick
secretions…………………… Suction the trachea using a
suction catheter inserted through the endotracheal tube
or directly suction the trachea with a meconium
aspirator

37. Highest Priority in Neonatal
Resuscitation
 Establishing effective ventilation
 It may take longer than 30sec to establish effective
ventilations
 Corrective actions required
 MR SOPA
 Do not start chest compressions without 1st ensuring
effective ventilations defined by bilateral breath sounds
& chest movement

38. SUSTAINED INFILATION
 There is insufficient data regarding short and
long-term safety and the most appropriate
duration and pressure of inflation to support
routine application of sustained inflation of
greater than 5 seconds’ duration to the
transitioning newborn. (Class IIb)

39. Chest Compressions
 HR <60bpm despite effective ventilation
 Coordinate with ventilations for at least 60sec before
assess of heart rate
 2 hands wrapped around chest with 2 thumb technique is
preferred method of chest compressions(Class IIb)
 Be careful to concentrate pressure on the heart not over
entire chest
 Note your thumb position

40. Chest Compressions
 Compress 1/3 diameter of chest(Class IIb)
 90 compressions to 30 ventilations/minute (120 events )
(Class IIa)
 (3:1) One & two & three & breathe & One & two & three &
breathe &…
 rescuers may consider using higher ratios (e.g., 15:2)
if the arrest is believed to be of cardiac origin. (Class
IIb)

41.  Increase FiO2 to 100% once you begin compressions
(Class IIa)
 Adjust FiO2 to pulse oxmetry readings
 To reduce the risks of complications associated
with hyperoxia the supplementary oxygen
concentration should be weaned as soon as the
heart rate recovers. (Class I)
 Pulse oxetry may not work while newborn is receiving
chest compressions
 Intubation is strongly recommended when
compressions begin

42. UVC
 Consider placement of UVC once
compressions are initiated or if extended
resuscitation is anticipated
 Continue chest compressions by moving
around to head of bed using thumb technique
to allow room for insertion of UVC
 Intraosseous needle is a reasonable
alternative.

43. Epinephrine
 Epinephrine is indicated when heart rate remains
<60 after 30 seconds of effective ventilations and
another 60sec of coordinated compressions and
ventilations

44.  ETT route
Unreliable absorption
Less effective
But readily available so give while establishing
UVC (Class IIb)
 UVC route
Preferred method (Class IIb)
Requires skills to place line
May give dose soon as line is placed even
after just giving via ETT (Class IIb)

45.  Give rapidly
 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
 Re-check heart rate after 1minute of
compressions and ventilations, Maybe longer
if give ETT
 Repeat dose every 3 – 5 minutes
 Epinephrine can be given again immediately
after UVC placement if given initially through
ETT do not wait 3 minutes.

46. VOLUME EXPANSION
 Volume expansion should be considered
when blood loss is known or suspected (pale
skin, poor perfusion, weak pulse) and the
infant’s heart rate has not responded
adequately to other resuscitative
measures.(Class IIb)
 An isotonic crystalloid solution or blood O-ve
may be useful for volume expansion in the
delivery room. (Class IIb)

47. Therapeutic Hypothermia for HIE
 Cooling used for >/= 36wks & meet special criteria for
this modality
 Usually initiated before 6 hours after birth
 In resource-limited settings, use of therapeutic
hypothermia may be considered under clearly defined
protocols similar to those used in clinical trials and in
facilities with the capabilities for multidisciplinary care
and follow-up.

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

49. NALOXONE
 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.

50. When to stop resuscitation?
 In general, no new data have been published to
justify a change in the 2010 recommendations about
withholding or withdrawing 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.

51. It is suggested that
neonatal resuscitation
task training occur
more frequently than
the current 2-years
interval.

52. THANK YOU