NEONATAL RESUSCITATION

PROGRAM

-Dr.Apoorva.E
• History
• Principles of Resuscitation
• Initial steps of resuscitation
• Positive – Pressure ventilation
• Endotracheal tube intubation and LMA insertion
• Chest compressions
• Medications
• Special considerations
• When to stop resuscitation
HISTORY
• Dr.William Keenan – Father of NRP

Professor of Pediatrics and

Director of the Neonatology
Department at Saint Louis
University in St. Louis, Missouri.
• Every five years, the International Liaison Committee on Resuscitation
(ILCOR) comprising representation from 13 countries worldwide reviews
the available resuscitation science.

• It provides recommendations based on the available evidence at that time.

• The ILCOR guidelines were published in October 2015 and the AAP
launched its 7th edition of NRP in May 2016.
PRINCIPLES OF RESUSCITATION

• Birth asphyxia accounts for about 1/4th of the neonatal deaths that
occur each year worldwide.
• 90% of newborns make smooth transition from intrauterine to
extrauterine life requiring little or no assistance.
• 10% of newborns need some assistance.
• Only 1% require extensive resuscitation.
WHAT CAN GO WRONG ?

• Compromise of uterine or placental blood flow  deceleration of FHR

• Weak cry  inadequate ventilation to push the alveolar fluid
• In utero hypoxia  Meconium passage may block the airways
• Fetal blood loss (abruption)  Systemic Hypotension
• Fetal Hypoxia/ischemia  poor cardiac contractility & fetal
bradycardia  Systemic Hypotension
• Pulmonary arterioles remain constricted  PPHN
CONSEQUENCES :
• Low muscle tone,apnoea /
tachypnea,bradycardia,hypotension,cyanosis

• Outcomes of these newborns can be improved with timely and

effective resuscitation.
NEWBORN RESUSCITATION PYRAMID
Assess baby’s need for resuscitation
Provide warmth
Position, clear airway if required May be needed
Dry, stimulate to breathe

Give supplemental oxygen, as required

PPV Needed less

frequently

Intubate the trachea

Provide chest
compressions Rarely needed

Medications
WHAT IS
NEW?
 INITIAL STEPS OF RESUSCITATION
• There is increased focus throughout the 7th edition NRP on team
preparation and role assignment.
• In anticipation of delivery, counselling should be done along with
team briefing, role assignment and equipment check.
• 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
present and a team leader identified.

• 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, the team should demonstrate effective

communication and teamwork skills to help ensure quality and patient
safety.

• MSAF is a risk factor for abnormal transition and team must ensure a
member with advanced airway and resuscitation skills is in attendance.
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
• Initial assessment of the neonate and initial resuscitation steps
remain unchanged.
• Emphasis on thermoregulation throughout resuscitation.
• Temperature should be maintained between 36.5 and 37.5 Celsius.
• For preterm infants, combination of interventions
1- Radiant warmers
2- plastic wrap with a cap
3- thermal mattress
4- warmed humidified gases
5- increased room temperature to 26 deg c
6- Portable incubator
• Routine Care for vigorous term infants with no risk factors &
babies who required but responded to initial steps , can stay
with mother, Skin to skin contact recommended, clear airway,
dry newborn, provide ongoing evaluation:
Breathing
Activity
Color .
• The Golden Minute (60-second) mark for completing the initial assessment,
initial steps, reevaluating, and beginning ventilation (if required) is retained.

• Evaluations and decision making are based on:

a) Respiratory effort
b) Heart rate

• For assessment of heart rate,the use of a 3-lead ECG is recommended.

• Pulse oximetry to evaluate the newborn’s oxygenation.

 PPV
• Indications for PPV remain unchanged,those being a heart rate less than
100 bpm or ineffective respirations.
• Initial PIP is suggested in the range of 20-25 cm H20.
• When PPV is administered to preterm infants, PEEP should be used.
Recommended starting PEEP is 5 cm H20.
• Rate of PPV is 40-60 / minute.
• Rising of HR
Improvement in Oxygen Saturation PPV
Equal and adequate breath sounds B/L EFFECTIVE OR
Good Chest rise
NOT?
Self Inflating bag T-Piece Resuscitator

DEVICES
Flow Inflating Bag
USED
• After PPV started, reassess in 15 seconds.
• If no response, MR SOPA corrective measures should be incorporated.
SUPPLEMENTAL OXYGEN
• If HR is >100 but has labored breathing
Term infants start resuscitation with 21% O2,
Preterm less than 35 Weeks should be initiated with low oxygen (21%
to 30%) and the oxygen titrated to achieve preductal oxygen saturation
similar to that in healthy term infants.
• Initiating resuscitation of preterm newborns with high oxygen (65% or
greater) is not recommended.
• If HR is >100 but 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).
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%
 ADVANCED AIRWAY
• Intubation is recommended prior to chest compressions.
• If intubation is not feasible, the laryngeal mask airway should be
used as an alternate advanced airway.
• Recommendations for depth of insertion are gestation-based or
based on formula using nasal-tragus length (NTL) measurement.
• If heart rate is not increasing and there is no chest movement, despite MR
SOPA corrective steps including intubation,
obstruction should be considered and suction can be performed either
using a catheter through the ETT or a meconium aspirator.
CHEST COMPRESSIONS
• The indication for chest compressions remains unchanged, this being
a heart rate less than 60 bpm in spite of 30 seconds of effective PPV.
• 100% oxygen continues to be recommended when administering
chest compressions.
• The 2-thumb technique is recommended and once the airway has
been secured, the team member administering compressions should
switch to the head of the bed and the team member providing PPV
should move to side.
• Compress 1/3rd diameter of chest.
• Do not lift the fingers off the chest.

• 90 compressions to 30 ventilations/minute
(3:1- One & two & three & breathe & One & two & three & breathe…)

• Chest compressions should be continued for 60 seconds before

reassessment of heart rate.
• Electronic cardiac monitor preferred for assessment of heart rate.
MEDICATIONS
1.EPINEPHRINE
• Indicated if HR remains <60 bpm after at least 30 secs of effective PPV and
another 60 seconds of chest compressions using 100% oxygen
• One dose may be given through ETT.
• If no response, give intravenous dose via emergency UVC or IO access.
• 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 .
• Can repeat every 3-5 minutes.
2.OTHERS
• For treatment of hypovolemic shock, normal saline and blood are the
solutions of choice and the recommended volume is 10 ml/kg.
• Ringer’s lactate is no longer recommended.
• The routine use of NaHCO3 to correct metabolic acidosis is not
recommended.
• The use of naloxone to manage respiratory depression in infants born
to mothers with narcotic exposure in labour is not recommended.
SPECIAL SCENARIOS
• 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.
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.
• MECONIUM STAINED LIQUOR :
If the infant born through meconium-stained amniotic fluid is 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 is not suggested.

• Pneumothorax : Percutaneous needle aspiration
• Pleural effusion : Percutaneous needle aspiration
• Congenital Diaphragmatic hernia : Intubation
• Therapeutic hypothermia for HIE : used for >/= 36wks & should meet
special criteria,initiated before 6 hours after birth,in facilities with
multidisciplinary care.
WHEN TO STOP 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.
• Where GA ( < 23wks ), B.wt ( < 400g) and / or Cong. Anomalies are
associated with early death and high morbidity,resuscitation is not
indicated.
Resuscitation Recommendatio Recommendations Latest
step ns (2005) (2010)

First step Counselling,team

briefing,equipment check
Four questions Three questions
• Amniotic fluid- • Gestation-term or not? • Term/not?
Assessment clear or not? • Breathing /Crying? • Tone-good?
• Tone- Good? • Breathing/crying?

Assessment Look for 3 signs Look for 2 signs =

(after • Hear rate • Heart rate
initial steps ) • Color • Respiration( Labored,
• Respiration unlabored, apnea,
gasping)

HR Palpation of Auscultation of heart Auscultation + 3 -lead ECG

umbilical cord
pulsations
Resuscitation Recommendation Recommendations (2010) Latest
step s (2005)

Oxygenation Pulse oximetry pulse oximetry

recommended for for both term and preterm =
only
preterm <
32weeks with
need for PPV

Target saturation Not defined Target SpO2 ranges provided as =

(pre-ductal) a part of algorithm

Intubation Before chest

compressions
Therapeutic No sufficient Recommended for infants ≥ =
Hypothermia evidence 36weeks with moderate to
severe HIE
THANK YOU !