Lesson (5): Neonatal Resuscitation

Lesson (5): Neonatal Resuscitation

Learning Objectives:
After successful completion of this lesson the students must be able to:
1) Define neonatal resuscitation
2) Identify conditions that may require neonatal resuscitation at delivery.
3) Recognize equipment needed for neonatal resuscitation
4) Demonstrate the ABCDs of resuscitation
5) Apply neonatal resuscitation for different neonate's conditions.
Definition

Neonatal resuscitation is assessment and interventions utilized after birth to

assist a baby with breathing and helping maintain a heartbeat.

Conditions that may require availability of skilled resuscitation at

delivery:
1. Intraportum Problems
• Fetal distress as; (Bradycardia, meconium-stained amniotic fluid, cord prolapse)
• Prolonged, unusual, or difficult labor
• Emergency operative or assisted delivery
• Breech presentation with vaginal delivery
• Narcotic administration to mother within 4 hours of delivery

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 1

 Lesson (5): Neonatal Resuscitation

2. Medical/Obstetric/Fetal Problems
• Medical problems as: diabetes mellitus, substance abuse, pregnancy-induced

hypertension
• Obstetric problems as: third trimester bleeding, abnormal amniotic fluid volume,

prolonged rupture of membranes

• Fetal problems as: multiple gestations, low-birth-weight infant, prematurity, fetal

congenital anomalies.

Neonatal resuscitation supplies and equipment:

I. Suction equipment:
• Bulb syringe.

• Mechanical suction.

• Suction catheters 5 (or 6), 8, 10 Fr.

• Feeding tube 8 Fr

• Meconium aspirator.

Bulb syringe Meconuim aspirator

II. Bag-and-mask equipment:

• Infant resuscitation bag with a pressure-release valve or pressure gauge. The

bag must be capable of delivering 90-100% oxygen.

• Face masks in neonate and preterm sizes. Cushioned rim masks are preferred.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 2

 Lesson (5): Neonatal Resuscitation

Cushioned rim masks Infant resuscitation bag

• Oral airways and oxygen with flow meter and tubing.

III. Intubation Equipment:

Laryngoscope Endotracheal tube

• Laryngoscope with straight blades. No.0 (premature) and No. 1 (full-term).

• Extra bulbs and batteries for laryngoscope.

• Endotracheal tubes. Sizes 2.5, 3, 3.5, 4 mm.

• Scissors.

IV. Medications
• Epinephrine

• Volume expander -one or more of these:

- Albumin 5% solution.
- Normal saline.
- Ringer's lactate.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 3

 Lesson (5): Neonatal Resuscitation

Neonatal Resuscitation:

The ABCD's of Resuscitation:

Neonatal Flow Algorithm

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 4

 Lesson (5): Neonatal Resuscitation

Neonatal Assessment and Resuscitation

Assessment, warmth, and airway
1. Rapidly assess the infant for the following:
a. Full-term gestation?
b. Breathing or crying?
c. Amniotic fluid clear?
d. Good muscle tone?
2. If a full-term infant is breathing or crying, and has good muscle tone,
resuscitation may not be needed.
3. If the answer is no to any of the above questions, resuscitate the infant with the
following steps. After 30 seconds at each step (ABCs), reassess respirations,
heart rate, and color and progress to the next step if indicated. Markers of
success are a heart rate above 100 bpm, pink skin/mucous membranes, and
effective spontaneous ventilations.
a. Place the infant's head into the sniffing position.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 5

 Lesson (5): Neonatal Resuscitation

b. Provide warmth with radiant heat, an exothermic mattress, and/or warm

dry linens.

c. If secretions are clearly interfering with breathing, clear the airway with a
bulb syringe or suction catheter. Suction the mouth first because
suctioning the nose causes the infant to gasp and may cause aspiration.
The practitioner may perform endotracheal suctioning in the presence of
meconium, if the infant is non-vigorous. Be cautious about applying
suction (including use of a bulb syringe) unless secretions are clearly
hampering breathing, because suction can precipitate bradycardia.

d. After 30 seconds, evaluate respirations and an auscultated heart rate or a

palpated umbilical pulse.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 6

 Lesson (5): Neonatal Resuscitation

Ventilation
1. If the infant is apneic or gasping, or has a heart rate lower than 100 bpm after
the initial steps, begin positive-pressure ventilation.

2. Assist ventilations with a self-inflating bag or a flow-inflating bag at a rate

of 40 to 60 b/min. The heart rate should promptly improve with adequate
ventilation.
3. Apply a preductal (right upper extremity) SpO 2 neonatal probe and titrate
oxygen administration to reach target ranges.
4. The resuscitation mask should be chosen based on the size of the infant.
▪ The mask should fit from the bridge of the nose to the chin, but not
covering the eyes. A good seal with the mask is necessary for
resuscitation.
▪ Squeeze the bag with two fingers only or with the whole hand,
depending on the size of the bag.

▪ Check the seal by ventilating two times and observing the rise of the
chest

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 7

 Lesson (5): Neonatal Resuscitation

▪ If the chest rises with rescue breathing, assess for signs of circulation
before beginning chest compressions.
▪ If the newborn’s chest is not rising:
▪ Check the position of the head again to make sure the neck is slightly
extended.
▪ Reposition the mask on the newborn’s face to improve the seal between
mask and face.
▪ Squeeze the bag harder to increase ventilation pressure.
▪ Repeat suction of mouth and nose to remove mucus, blood or meconium
from the airway.

5. If breathing is normal (30-60 breaths/minute) and there is no indrawing of the

chest and no grunting:
▪ Put skin- to- skin contact with mother.
▪ Observe breathing at frequent intervals.
▪ Measure the newborn’s axillary temperature and re-warm if temperature
is less than 36oC.
▪ Keep in skin-to-skin contact with mother if temperature is 36oC or less
▪ Encourage mother to begin breastfeeding
6. After 30 seconds, evaluate respirations, an auscultated heart rate, and
SpO2. The initial steps of resuscitation, including evaluation and beginning
of ventilation should be needed, should be completed in 60 seconds or less.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 8

 Lesson (5): Neonatal Resuscitation

Chest compressions
1. If the heart rate is less than 60 b/m after 30 seconds of effective ventilation with
supplemental oxygen, increase supplemental oxygen to 100% if lower amounts
are being used and start chest compressions.
a. Deliver chest compressions and ventilations at a 3:1 ratio at a rate that
delivers 90 compressions and 30 breaths/min. Avoid ventilating and
compressing simultaneously.
b. Use the two-thumb technique, with both thumbs on the lower third of the
sternum and fingers encircling and supporting the back (this is more
effective than the two-finger technique). Exert enough pressure to depress
the sternum to a depth approximately one third of the anterio-posterior
diameter of the chest and deep enough to generate a palpable pulse.

Two-thumb (A, preferred) and two-finger (B) methods of chest compression. C, The two-thumb method uses
two thumbs placed one over the other or side by side (depending on the size of the baby) to compress the
sternum; encircle the chest with the hands so that your fingers support the spine.

c. Allow the chest to completely re-expand between compressions, but do

not let the thumbs (or fingers) leave the chest.
2. Continue compressions and ventilations until the heart rate is 60 b/m or faster.
3. The practitioner may decide to insert an endotracheal ET tube. Confirm tube
placement with chest movement, presence of breath sounds, exhaled CO 2, and

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 9

 Lesson (5): Neonatal Resuscitation

an increasing heart rate. Have a laryngeal mask airway available in case ET

tube placement is not successful.
4. After 30 seconds, evaluate respirations, an auscultated heart rate, and SpO2.

Drugs
Administration of epinephrine and/or volume expanders
1. If the heart rate remains slower than 60 b/m after ventilation and chest
compressions, administer epinephrine, volume expanders, or both.
a. Epinephrine is the first-line medication (Increase heart rate and strength
of cardiac contractions), and IV administration is preferred over
endotracheal administration. The IV dose is 0.01 to 0.03 mg/kg of
1:10,000 solutions.
b. Administer volume expanders when blood loss is known or suspected
(Fluid replacement for hypovolemia). The initial dose is 10 ml/kg of a
crystalloid solution. This dose may be repeated. IV umbilical venous
catheter is (UVC preferred)
Endotracheal intubation:
(Endotracheal intubation should be considered as prolonged ventilation becomes
apparent)

Anatomic landmarks that relate to intubation

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 10

 Lesson (5): Neonatal Resuscitation

When Endotracheal Intubation is needed:

• Meconium suctioning
• Ineffective bag- mask ventilation
• If prolonged ventilation
• Secure airway during compressions
• Medications into trachea (Epinephrine)

The endotracheal tube is chosen based on the baby's birth weight.

Weight ETT
If the baby weighs... <1.0 kg use a 2.5
If the baby weighs... 1.0 - 2.0 kg use a 3.0
If the baby weighs... 2.0 - 3.0 kg use a 3.5

If the baby weighs... >3.0 kg use a 4.0

• The primary methods of proper ETT placement are an increasing heart rate.
• Tube placement is also determined by the baby's birth weight.
• Formula: add six to the baby's weight (in kg).
• Example: 2 kg baby 6 + 2 = 8 cm at gums

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 11

 Lesson (5): Neonatal Resuscitation

Assess, Assess, Assess!

• Assess the infant every 30 seconds to determine effectiveness of resuscitation.

• If the heart rate rises above 60, discontinue compressions.
• If the heart rate rises above 100, discontinue compressions and gradually
discontinue ventilation, based on the infant's spontaneous respirations.

Special Considerations

1. What if PPV isn't making the chest to rise?

• Think about a blocked airway (either position of the infant or meconium/mucus
plugs) or impaired lung function
2. What if the baby is still cyanotic or bradycardic?
• Think about congenital heart disease
3. What if the baby won't breathe on his own?
• Think about brain injury or maternal sedation
4. If newborn is breathing but severe chest indrawing is present:
- Ventilate with oxygen, if available.
- Arrange immediate transfer for special care.
5. Indications of Signs of Improvement
- Heart rate is maintaining with resuscitative efforts.

- Respiration, spontaneous without flaring and grunting etc.

- Color, central cyanosis resolving.

Discontinuation of resuscitation

• If there is no heart rate after 10 minutes of complete and adequate resuscitation

efforts, and there is no evidence of other causes of newborn compromise,
discontinuation of efforts may be appropriate.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 12

 Lesson (5): Neonatal Resuscitation

After the procedure:

1- Dispose suction catheters & other equipment
2- For reusable catheters and other equipment
o Wash in water and detergent.

o Boil or disinfect in an appropriate chemical solution and check for damage.

3- Wash hands
4- Test the functioning of all equipment & return it to their place
5- Record the following details:
• Condition of the newborn at birth
• Procedures necessary to initiate breathing
• Time from birth till initiation of spontaneous breathing
• Clinical observations during and after resuscitation measures
• Outcome of resuscitation measures
• In case of failed resuscitation measures, possible reasons for failure

Resuscitation checklist
Steps:
1- Wash hand
2- Wear gloves.
3- Prepare the necessary equipment and supplies.
4- Explain the procedures to the child’s parents.
5- Provide dryness and stimulate the baby to breathe (tactile stimulation).
6- Position the head is slightly extended .
7- Clear the airway by suctioning the mouth first and then the nose.
8- Evaluate respirations, heart rate and color; give oxygen as needed.
9- If the baby is apneic, or heart rate is less than 100 b/m provide positive
pressure ventilation with a resuscitation bag and 100% oxygen.
10- The resuscitation mask should be chosen based on the size of the infant.

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 13

 Lesson (5): Neonatal Resuscitation

11- If breathing is normal (30-60 b/m) and there is no indrawing of the chest and
no grunting:
a. Put skin- to- skin contact with mother.
b. Observe breathing at frequent intervals.
c. Measure the newborn’s axillary temperature and re-warm
d. Encourage mother to begin breastfeeding.
12- If the heart rate is less than 60 b/m:
− Give chest compressions with positive pressure ventilation at a rate of 3:1
compressions to every breath.
13- Give drugs as prescribed
If the heart rate remains slower than 60 b/m after ventilation and chest
compressions, administer epinephrine, volume expanders (blood or
plasma), or both.
Discontinuation of resuscitation
14- If there is no heart rate after 10 minutes and there is no evidence of other
causes of newborn compromise, discontinue efforts.
15- Dispose suction catheters & other equipment
16- For reusable catheters and other equipment
- Wash in water and detergent.
- Boil or disinfect in an appropriate chemical solution and check for damage.
17- Wash hands
18- Test the functioning of all equipment & return it to their place
19- Recording

Dr. Atyat Mohammed Hassan (NRSG-3302) Page 14