the first few minutes of life is the most important and vital period to understand and also identify the survivability of a newborn. Resuscitation is one of the emergency management technique when the neonate is unable to initiate respiration on their own.

1. NEONATAL
RESUSCITATION
Mrs. Tina Ann John
Assoc. Professor
Child Health Nursing

2. INTRODUCTION
– The successful transition from intrauterine to extrauterine life is
dependent upon significant physiologic changes that occur at
birth.
– Although most newborns successfully make this transition at
delivery without requiring any special assistance, a small but
significant number will require additional support, including
resuscitation in the delivery room.
– 10% of all babies require resuscitation; 1% need extensive
resuscitative measures.
– Globally, about one quarter of all neonatal deaths are caused by
birth asphyxia.
– By appropriate resuscitation: Outcome of thousands of
newborns may improve.

3. TABCD of
Resuscitation
–Temperature
–Airway (position and clear)
–Breathing (stimulate to breathe)
–Circulation (assess heart rate and
color)
–Drugs (Medications)

4. NEED FOR
RESUSCITATION

7. What normally happens
after birth?
– Three major changes occur
– THE FLUID IN THE ALVEOLI IS ABSORBED.
– THE UMBILICIAL ARTERIES AND VEIN CONSTRICT AND ARE
CLAMPED
– Removes the low resistance placental circulation
– Increases the systemic vascular resistance.
– BLOOD VESSELS IN THE LUNG TISSUE RELAX
– Decrease resistance to blood flow

11. WHAT CAN GO WRONG
DURING TRANSITION?
– BREATHS NOT FORCEFUL TO REMOVE ALVEOLAR FLUID
OR FOREIGN MATERIAL BLOCKS AIR ENTRY OXYGEN NOT
AVAILABLE.
– EXCESSIVE BLOOD LOSS/ POOR CARDIAC CONTRACTILITY
SYSTEMIC HYPOTENSION.
– HYPOXIA CONSTRICTION OF PULMONARY ARTERIOLES,
TISSUE OXYGEN DEPRIVATION (PPHN).

12. RESPONSE OF THE BABY TO AN
INTERRUPTION IN NORMAL
TRANSITION
– POOR MUSCLE TONE DUE TO INSUFFICIENT OXYGEN SUPPLY TO BRAIN,
MUSCLES AND OTHER ORGANS.
– DEPRESSION IN RESPIRATORY DRIVE FROM INSUFFICIENT OXYGEN SUPPLY
TO THE BRAIN.
– BRADYCARDIA
– Insufficient delivery of oxygen to heart, muscle and brain.
– LOW BLOOD PRESSURE
– POOR MYOCARDIAL CONTRACTILITY OR BLOOD LOSS
– TACHYPNEA FROM FAILURE TO ABSORB LUNG FLUID
– CYANOSIS FROM INSUFFICIENT OXYGEN IN BLOOD

13. INDICATIONS FOR
RESUSCITATION

14. MATERNAL CONDITIONS:
– Diabetes Mellitus
– Pre-eclampsia,
hypertension, chronic renal
disease
– Anaemia
– Blood type
incompatibilities
– Antepartum haemorrhage
– Drug or alcohol ingestion
– Previous neonatal death
– PROM with evidence of
amnionitis
– Systemic Lupus
– Maternal cardiac disease

15. LABOUR & DELIVERY
CONDITIONS:
– Forceps or vacuum extraction
– •Breech or abnormal presentation
– •Cesarean section
– •Cephalo-pelvic disproportion
– •Cord prolapse/compression
– •Maternal hypotension or hemorrhage

16. FETAL CONDITIONS
– Premature/postmature
birth
– Meconium in amniotic fluid
– Abnormal heart rate
pattern
– Macrosomia
– Oligo- or polyhydramnios
– Fetal cardiac dysrhythmia
– Fetal growth retardation
– Fetal malformations
– Hydrops fetalis
– Low biophysical profile
– Sepsis
– Multiple births, especially:
– Discordant twins
– Twin-twin transfusion
syndrome with stuck twin
– Mono-amniotic twins

17. GOALS OF RESUSCITATION
– TO ASSIST ADAPTATION TO EXTRA-UTERINE LIFE.
– TO HELP IN INFLATING LUNGS, ESTABLISHING
OXYGENATION AND VENTILATION.
– TO ESTABLISH ADEQUATE PULMONARY BLOOD FLOW.
– TO SUPPORT CARDIOVASCULAR FUNCTION.

18. SEQUENTIAL STEPS IN
RESUSCITATION:
– •Maintain body temperature (dry infant and put under radiant
warmer).
– •Clear airway and initiate ventilation.
– •Cardiac compressions, if needed.
– •Attach ECG leads, pulse oximeter and CO2 monitor and insert OG
tube.
– •Catheterize umbilical artery/vein and measure blood pressures.
– •Give resuscitation drugs as needed.
– •Assign Apgar scores at 1 and 5 min and q5 min until score is ≥7.

19. KEY PRINCIPLES OF
RESUSCITATION:
– ANTICIPATE
 AT EVERY DELIVERY- ATLEAST 1 PERSON WHOSE PRIMARY RESPONSIBILITY IS
THE NEWBORN.
EITHER THAT PERSON OR SOMEONE READILY AVAILABLE- SKILLS TO
PERFORM A COMPLETE RESUSCITATION.
IF NEED FOR RESUSCITATION IS ANTICIPATED- ADDITIONAL SKILLED
PERSONNEL AND NECESSARY EQUIPMENT.

20. PREREQUISITES
FOR
RESUSCITATION

21. PREREQUISITES:
– PHYSICAL SETUP FOR RESUSCITATION
– FLAT SURFACE TO MAINTAIN POSITION OF NEONATE DURING
PROCEDURE
– WARM AND CLEAN ENVIRONMENT
– STERILE EQUIPMENTS WITH DISPOSABLE MATERIALS
– ROOM TEMPERATURE OF 26 c
– FUNCTIONAL RADIANT WARMER WITH OVERHEAD LIGHT
– PRE-WARMED TOWELS

22. EQUIPMENTS
– DEE LEE TRAP
– MECHANICAL SUCTION
– SUCTION CATHETER (12 F AND 14 F)
– FEEDING TUBES (6F AND 8F)
– NEONATAL SELF INFLATING RESUSCITATION BAGS (500 ML)
– FACE MASKS (TERM AND PRETERM)
– OXYGEN WITH FLOW METER AND TUBING

23. – INTUBATION EQUIPMENTS:
– LARYNGOSCOPE WITH STRAIGHT BLADES (No.1 for term, No. 0
for preterm)
– Extra bulbs and batteries
– Endo tracheal tubes (2.5, 3.0, 3.5)
– RESUSCITATION DRUGS AND FLUIDS:
– INJ. EPINEPHRINE
– INJ. NALOXONE
– NORMAL SALINE
– STERILE WATER

24. PHASES OF
RESUSCITATION

25. INITIAL STEPS
AT BIRTH
AT 30 SEC
AT 60 SEC
TERM GESTATION?
BREATHING OR
CRYING?
GOOD TONE
YES ROUTINE CARE:
PROVIDE WARMTH
CLEAR AIRWAY
DRY
ONGOING EVALUATION
WARM , CLEAR AIRWAY IF
NECESSARY, DRY, STIMULATE

26. WARMTH
– AVOID HYPOTHERMIA
– DELIVERY TO BE DONE IN A WARM AND
DRAFT FREE AREA
– BABY TO BE RECEIVED IN A PRE-WARMED
TOWEL
– RAPIDLY DRY HEAD AND SKIN OF BABY
AFTER BIRTH
– DISCARD WET TOWEL AND USE ANOTHER
PRE-WARMED TOWEL TO WRAP THE
NEONATE.
– PLACE IN RADIANT WARMER OR WITH
MOTHER SKIN TO SKIN.

27. POSITIONING
– SUPINE WITH HEAD IN NEUTRAL OR SLIGHTLY EXTENDED POSITION
WITH ROLLED TOWEL UNDER THE SHOULDER BLADES OF THE NEONATE.

28. CLEAR THE AIRWAY
– GENTLE SUCTION SOS
– FIRST MOUTH THEN NOSE TO PREVENT ASPIRATION OF THE
MUCUS AND MECONIUM.
– EACH SUCTION IS ONLY FOR 2-3 SEC.
– SUCTION PRESSURE IS TO BE MAINTAINED AT < 100 mmHg
– AVOID DEEP SUCTIONING

30. STIMULATION
– FLICKING THE SOLE AND TOES TWICE
– RUBBING OF BACK
COMPLETE ALL THIS IN 30 SECS IF
NOT RESPONSIVE GO FOR BMV

31. EVALUATION
– REASSESS EVERY 30 SEC.
– CONSIDER INTUBATION, IF NEEDED
– EVALUATE HR,RR, COLOUR
– HR BY AUSCULTATION
– COUNT FOR 6 SEC THEN 10 SEC.

32. HR BELOW 100,
GASPING? APNEA
YES
LABOURED
BREATHING?
PERSISTENT CYANOSIS
ROUTINE CARE
30
Sec
60
Sec
PPV, SPO2 MONITORING
HR BELOW 100?
CLEAR AIRWAY, SPO2
MONITORING CONSIDER
CPAP
YES
POST-RESUSCITATION
CARE
YES
TAKE VENTILATION
CORRECTIVE STEPS
HR BELOW 60
TAKE VENTILATION
CORRECTIVE STEPS
Intubate if chest does not
rise
CONSIDER
HYPOVOLEMIA
PNEUMOTHORAXYES
NO NO
NO

33. PROVIDE OXYGEN
– IF NORMAL BREATHING, HEART RATE BUT BLUE
LIMBS
– FREE FLOW OXYGEN AT 5L/MIN
– BY AN OXYGEN MASK/TUBING
– MONITOR SPO STATUS.

35. BAG AND MASK
VENTILATION
– INDICATIONS:
– APNEA OR GASPING
– HR <100 BEATS/MIN
– PERSISTENT CENTRAL CYANOSIS DESPITE 100% OXYGEN

36. PROCEDURE
– APPLY THE MASK OVER THE CHIN
AND NOSE
– RESUSCITATOR SHOULD STAND AT
THE HEAD END
– RATE 40-60/MIN
– IF CHEST COMPRESSIONS IS DONE
THEN 30/MIN
– EVALAUTE EVERY 30 SEC UNTIL
HR>100 BPM
– IF HR IS<60 BPM START CHEST
COMPRESSIONS.
– IF STOMACH IS DISTENDED,
DEFLATE IT.

37. –CAUSES OF NON-INFLATION OF CHEST:
– BLOCKED AIRWAYS
– LEAK IN MOUTH SEAL
– INSUFFICIENT INFLATION OF BAG

38. YES
CONSIDER INTUBATION
CHEST COMPRESSIONS
COORDINATE WITH PPV
HR BELOW 60?
IV EPINEPHRINE
TARGET PREDUCTAL SPO2
1 MIN 60-65%
2 MIN 65-705
3 MIN 70-75%
4 MIN 75-80%
5 MINS 80-85%
10 MINS 85-90%
0.01=0.03 mg/kg
1:1000 (0.1 mg/ml)

39. CHEST
COMPRESSIONS

40. TECHNIQUES
– 2 METHODS ARE FOLLOWED IN NEONATAL RESUSCITATION:
– 2 THUMB METHOD
– TWO FINGER METHOD

41. METHODS CONTINUED

42. – RATE : 90/ MIN
– COMPRESSION : VENTILATION = 3:1
– EVALUATE HR AFTER 3O SEC
– DISCONTINUE IF HR <60 BPM

43. INDICATIONS FOR
ENDOTRACHEAL INTUBATION
– MECONIUM STAINED BABY
– MAS
– NO RESPONSE TO BMV
– CONGENITAL DIAPHRAGMATIC HERNIA
– WHEN CHEST COMPRESSION IS DONE SIMULTANEOUSLY
– FOR ADMINISTRATION OF DRUGS

44. WHEN TO DISCONTINUE
– NORMAL HR FOR >10 MINS.
– WHEN TO RESTRICT OR WITHHELD?
– GA < 23 WEEKS
– BIRTH WEIGHT < 400 GMS
– TRISOMY 13 OR 18
– MECONIUM STAINED LIQUOR
– CONGENITAL DIAPHRAGMATIC HERNIA

46. DOCUMENTATION
– ASSESS AND RECORD THE APGAR SCORE.
– DESCRIPTION OF EVENTS AND TREATMENT PROTOCOLS WITH
TIME TO BE RECORDED.

47. ANY DOUBTS?