NEONATAL RESUSCITATION

INTRODUCTION

The successful transition from intrauterine to extra

uterine life is dependent upon significant physiologic
changes that occur at birth. In almost all infants (90
percent), these changes are successfully completed at
delivery without requiring any special assistance.
However, about 10 percent of infants will need some
intervention, and 1 percent will require extensive
resuscitative measures at birth.

There is a broad consensus on the evidence based resuscitation of newborn babies at birth.
The American Heart Association have recently updated the resuscitation guidelines that are
being propagated worldwide through the Neonatal Resuscitation Program (NRP).

Neonatal resuscitation skills are essential for all health care providers who are involved in
the delivery of newborns.

DEFINITION

Newborn resuscitation is a series of actions which are used to assist newborn babies who
have difficulty with making the physiological ‘transition’ between the womb and ‘the
outside world’.

OR

Neonatal Resuscitation is intervention after a baby is born to help it breathe and to help its
heart beat.

OR

The process of sustaining the vital functions of a person in respiratory or cardiac failure
while reviving him or her, using techniques of artificial respiration and cardiac massage
correcting acid base imbalance and treating the cause of failure.
PUPROSE:

 To establish effective circulation and respiration promptly.

 To prevent irreversible cerebral anoxic damage.

RISK FACTORS ASSOCIATED WITH THE DELIVERY OF HIGH RISK BABIES

1. Antepartum Factors
a) MATERNAL FACTORS:
Age <16 or >35 years.
Infection.
Diabetes.
Hypertension.
Cardiac, renal, pulmonary or neurologic disease.
Bleeding in 2nd or 3rd trimester.
Pregnancy induced hypertension.
Eclampsia.
Substance abuse.
Polyhydramnious.
Premature rupture of membrane.
b) FETAL FACTORS:
Preterm or term baby.
Multiple gestation.
Malformation.
Diminished foetal activity.
Previous foetal or neonatal death.

2. Intrapartum factors:
a) MATERNAL FACTORS:
Assisted delivery
Chorioamnionitis
Prolonged rupture of membrane >18 hours
Prolonged labour >24 hours
Placenta previa
Antepartum haemorrhage
 b) FETAL FACTORS:
Bradycardia
Foetal arrhythmia
Meconium stained amniotic fluid
Prolapsed cord

PRINCIPLES OF RESUSCITATION

1. Adequate preparation
 Communication: Proper communication between healthcare member caring
for the mother and infant, details of antepartum and intrapartum maternal
medical condition and foetal condition should be known.
 Availability of trained personnel.
 Getting ready: Always be ready with an unforeseen delivery with the
resuscitation tray.
2. Anticipation and immediately recognising the infant in need of resuscitation.
3. Initiating the procedure promptly.
4. Performing the procedure skilfully.

ARTICLES AND SUPPLIES NEEDED FOR NEWBORN RESUSCITATION

a. Suction Equipment
Meconium aspirator
Mechanical suction
Suction catheter
Feeding tube 6F and 20 ml syringe
b. Bag And Mask Equipment
Neonatal resuscitation bags
Face mask, newborn and premature size
Oxygen With flow meter and tubing
c. Intubation Equipment
Laryngoscope with blade 0(preterm) and size 1(term)
Extra bulb and batteries for laryngoscope
Endotracheal tubes 2.5, 3, 3.5, 4 mm ID
Stylet
Scissors
 d. Medications
Epinephrine
Naloxone hydrochloride
Volume expanders
 Normal saline
 Albumin 5%
 Ringer lactate
Sodium bicarbonate4.2%
Dextrose water 10%
Sterile water
e. Miscellaneous
Watch with seconds hand
Radiant warmer
Linen, shoulder roll
Stethoscope
Adhesive tape
Syringes of different sizes
Butterfly needles
Umbilical artery catheterization tray
Umbilical catheter 3 & 5 Fr
Feeding tube
Spirit sponges
Gloves
3 way stopcock
Gauze

NEONATAL ADVANCED LIFE SUPPORT (NALS): NEONATAL ALGORITHM

The ABC of Resuscitation

The steps in resuscitation of newborn infants follow the well-known ABCs of resuscitation.

A. Establish an open airway by:

- Positioning the infant
- Suctioning the mouth, nose and sometimes trachea.
B. Initiate breathing by
 - Use of tactile stimulation to initiate respiration
- Positive pressure ventilation by bag and mask/intubation
C. Maintain circulation with chest compressions.
D. Medications.

NEONATAL RESUSCITATION PROGRAM GUIDELINES

Basic steps include rapid assessment, initial steps and stabilization.

Rapid Assessment

Assessment of the newborn begins at the time of birth. The type of following five
questions clearly differentiate the baby in need of assistance from the baby who can
receive routine care.
- Is the amniotic fluid clear of meconium?
- Is the baby crying or breathing well?
- Is there good muscle tone?
- Is the baby’s colour pink?
- Is the baby term?
If in rapid assessment baby is found normal, give only routine care, warmth, drying
and clearing the airway. All other babies go through the following steps.

Initial Steps

A. Provide Warmth
B. Clear the airway
C. Tactile stimulation (if needed)
D. Oxygen administration (if required)

PROVIDE WARMTH
Amniotic fluid temperature may be 37ºC while outside the temperature will be 23 to
25ºC.
Do not give the baby a cold welcome. Cold babies are difficult to resuscitate.
They use up oxygen, glucose stores and become acidotic and have decreased
surfactant production and increased mortality.
 Keep the warmer on at least 15 minutes before delivery. Keep two pre-warmed
towels ready.
Receive the baby in the pre-warmed towel and place under the radiant warmer.
Rapidly dry the baby with the pre-warmed towel and immediately remove the wet
towel and place the baby on another dry warm cloth,
I. CLEARING THE AIRWAY
Place the baby supine on a firm surface with the neck slightly extended (in a sniffing
position).
Avoid hyperextension of the neck which will occlude the trachea.
A fold of cloth or towel approximately 2 cm thickness canbe placed under the
shoulder and not under the neck, which may be helpful in maintaining proper head
position.
This is very important in newly born babies who have a large head due to caput or
small for gestational age.
II. SUCTIONING THE AIRWAY
Suction the mouth first and then the nose.
If the nose is sucked first, the baby may take gasp or deep breath and aspirate the
secretions in the mouth.
Gentle and intermittent suctioning only is needed.
An electric suction may be used, negative pressure should not exceed 100 mm Hg.
Take only 2-3 seconds for suctioning. Suction tube should go only about 3 inches.
Healthy vigorous crying babies do not need any suctioning.

TACTILE STIMULATION:
Drying and suctioning stimulate most babies to start breathing or crying; if not, then
give gentle tactile stimulation.
Rubbing the babies back firmly, slapping or flicking the heels of the baby twice are
enough and effective.
Slapping the baby vigorously on the back and buttocks, dilating the anal sphincter,
pouring cold water on the baby, holding the baby upside down or rocking the baby
violently are harmful procedures.
III. EVALUATION
Evaluate the baby simultaneously for respiration, heart rate and colour.
If the respiration is irregular, gasping or no respiration, start ‘bag and mask’
ventilation.
If the heart rate is less than 100, even if respiration is present, start bag and mask
ventilation.
If the heart and respiratory rates are good but there is central cyanosis, then give free-
flow oxygen.
IV. OXYGEN ADMINISTRATION
Free-flow oxygen needs to be administrated at 5 litres per minute and be provided by
face mask or oxygen tubing with cupped hand, holding the tube close to the nose or
mouth without dangling.
Once cyanosis disappears, wean the baby of oxygen slowly over a period of minutes
instead of withdrawing it suddenly.
The bag and mask should not be used to deliver free-flow oxygen as there is an inlet
valve preventing the entry of oxygen into the mask unless the bag is squeezed.
The basic step should not take more than 30 seconds.

BAG AND MASK VENTILATION

Indication:

If after tactile stimulation, baby is apnoeic or gasping and respiration is spontaneous but
heart rate is below 100 beat/minute.

Parts of an Ambu Bag

Self-inflating bag 250 ml to 500 ml. use 500 ml capacity bag for term babies.
Air inlet.
Oxygen reservoir – to connect the air inlet two types – corrugated tube or closed bag.
Oxygen inlet.
Connecting oxygen to the inlet increases the oxygen supply to the baby by 35-40%. If
the oxygen reservoir is connected to Ambu bag, it will increase to 90%. The reservoir
has higher concentration of oxygen at the bag end and every time the bag inflates, it
receives the oxygen by venture effect.
 {NOTE: Air Mask Bag Unit (patient ventilator), Artificial Manual Breathing Unit
(ventilation)}

INLET VALVE OF THE BAG

When squeezing the bag, this valve opens allowing oxygen mixed air to enter the bag. That
is why a self-inflating bag and mask should not be used for free flow oxygen.

FACE MASK

Cushioned round mask are more efficient than non-cushioned anatomical masks as they do
not cause injury to the face when firmly held. Ensure that the baby lies in proper position
with the neck slightly extended. Stand at the head end of the baby. Place the mask at the face
so that it covers the tip of the chin, the mouth and the nose. Ensure a good seal by light
downward pressure on the mask so that the air does not leak from the side. The mask can be
held on face with the thumb and index finger encircling its rim like a figure of C, while the
ring finger lifts and maintains the neck in a mildly extended position.

PROCEDURE:

The baby’s neck should be slightly extended to ensure an open airway while he lies on his
back. An appropriate sized bag and mask is selected. The mask is placed in position so that it
covers the mouth and the nose but not the eyes. Then, bagging is started at a rate of 40-
60/minute for 15-30 seconds, using enough pressure to cause chest movements.

EVALUATION: If heart rate˃ 100/minute and infant having spontaneous breathing, stop
bagging (ventilation). If heart rate ˃100 but infant yet not having spontaneous breathing or is
gasping, continue ventilation. If heat rate 60-100/minute and not increasing, continue
ventilation and check for adequacy of ventilation from chest elevation. If heart
rate˂80/minute, start chest compressions. If heart rate˂60/minute, continue to ventilator,
start chest compressions and consider intubation.

Sign of Improvement:

Rising heart rate

Spontaneous breathing
Improving color

Do Not
 Flex the neck while bending over the baby.
Put pressure on the throat.
Traumatize the eyes using a large face mask.
Use the palm of the hand while squeezing the bag.
Remember the baby’s lungs need only 20-30 ml of air and the bag capacity is 500 ml.
The ‘bag and mask’ procedure should take only 30 seconds. Time is precious and
delay can be damaging. At the end of 30 seconds quickly auscultate the heart or feel
the umbilical cord for pulsation (at the base for 6 seconds and multiply by 10).

Contraindication:

Diaphragmatic hernia antenatally diagnosed or suspected at birth. During bagging, some air
will go into the intestine and the intestine is already in the mediastinum, thus compromising
ventilation.

Meconium aspirationor any other aspiration (blood, milk etc.). Bagging should be avoided
before thorough oropharyngeal, nasopharyngeal and endotracheal suctioning has been done.

CHEST COMPRESSION

Chest compression consist of rhythmic compression of the sternum pressing the heart against
the spine. It results in rise of intrathoracic pressure and circulation of blood to the vital
organs. Chest compression are used to increase circulation and oxygen delivery. Chest
compression must always be accompanied by ventilation with 100% O2. This ensures that
the blood being circulated during chest compression is adequately oxygenated.

Indication:

If the heart rate is less than 60/minute after 30 seconds of adequate positive pressure
ventilation with 100% oxygen.

Once the heart rate increases above 60/minute, discontinue chest compressions but continue
with ventilation till the heart rate is ˃100/minute and baby has spontaneous breathing.

Technique:

Compress the lower third of the sternum. Lower third of sternum is located by running finger
along the lower edge of ribs till xiphoid and the area just above the xiphoid are used for chest
compressions or to identify the nipple line and do the chest compressions one finger breadth
below.

TWO METHODS ARE:

Two-thumb technique.
Two-finger technique.
1. Two-thumb technique preferred as it is more effective and less tiring.

The second resuscitator stands at the foot and encircles the chest with both hands
and compresses over the lower third of the sternum with the tips of his or her thumb to a
depth of 1/3rd of the anteroposterior diameter of the chest. It should generate palpable pulse.
Do not lift the fingers of the chest in between chest compressions. The rate of compression is
120/minutes, but after every three chest compressions, do one ventilation, i.e. squeeze 1-2-3
times. This results in 90 chest compressions and 30 ventilations per minute.

2. Two-finger technique useful when there is only one resuscitator.

Note: After 30 seconds, discontinue chest compressions and auscultate for 6 seconds and
multiply by 10. Discontinue chest compressions, if the heart rate is 60/minute.

Evaluation: 30 seconds of chest compression should be followed by rechecking of the heart

rate. If it is below 80/minute, the procedure should continue along with bag and mask
ventilation with 100% oxygen, plus medication. If heart rate is ˃80/minute, stop chest
compression but continue ventilation until heart rate crosses 100/minute and the baby is
breathing spontaneously.

Complications of Chest Compressions:

Laceration of liver
Fracture ribs
Pneumothorax
Haemorrhage.

ENDOTRACHEAL INTUBATION

Purpose

To suction trachea in the presence of meconium when the newborn is not vigorous.
 To improve efficacy of ventilation after fewer minutes of ‘bag and mask’ ventilation
or ineffective ‘bag and mask’ ventilation.
To facilitate coordination of chest compressions and ventilation and to maximize the
efficiency of each ventilation.

Steps for Intubating a Newborn

Ideally, it should be completed within 20 seconds.

The newborn is placed on a resuscitation table (high enough and with flat surface) in
a supine position with full extended neck at the edge of the table. It is good to place
folded towel or blanket beneath the shoulders to facilitate thus position.
The operator sits on a stool at the head end.
As he opens the infant’s mouth with the index finger and the thumb of the right hand,
his left hand introduces the lighted laryngoscope (infant size) into the nasopharynx
up to the epiglottis.
The glottis is cleared by gentle suction. This makes it easier to clearly see the
epiglottis and the surrounding structures.
When the glottis is visible, a curved endotracheal tube is gently inserted through the
larynx. Make sure that it is not pushed too far to prevent its entry into the right
bronchus.
The laryngoscope is now withdrawn.
The intermittent positive pressure respiration is given through the tube either by
simply puffing in air from operator’s mouth or with a bag or mechanical respirator, as
soon as respiration gets established, the tube should be withdrawn.
If the response is poor, still efforts have got to be continued as long as the heart beat
exists.

Precaution during intubation:

In order to prevent hypoxia during intubation, provide free-flow oxygen, limit

intubation attempt to 20 seconds and avoid excessive flexion of neck.

Precaution during Extubation:

1. Give free-flow oxygen through the lid of the endotracheal tube for a few seconds.
2. Always take help of a laryngoscope during extubation.
 3. Continue bag and mask ventilation for 15 seconds after extubation.

Don’ts in Neonatal Resuscitation

Don’t administer heavy sedation to the mother.

Don’t do heavy and continuous suction.
Don’t let the neonate develop hypothermia.
Don’t carry on with tactile stimulation beyond 2 and never beyond 4 flicks.
Don’t delay endotracheal intubation in an apnoeic neonate.
Don’t blow your lungs into neonate’s mouth.
Don’t use full palmar grasp for giving bag and mask ventilation.
Don’t give respiratory stimulants.
Don’t suck the nose first and the mouth later. The breathing effort that follows sucking
the nose first may allow secretions in the mouth to be suddenly aspirated into the lower
airway.
Don’t slap the back.
Don’t squeeze the rib cage
Don’t force thighs on the abdomen.
Don’t dilate the anal sphincter.

Management of Newborn after Resuscitation

Cut the umbilical cord and tie it.

Examine the baby completely (malformation and sign of sickness)
Weigh the baby, take weight, note sex and show the baby to the attenders and
mother. Apply identification tags.
Administer 1 mg of vitamin K IM.
Decide whether this is a normal, at risk or sick neonate and accordingly decide the
level of care.
If normal: Cloth the baby and transfer the baby to mother initiate breastfeeding and
KMC, administer vaccination, follow up care, and communicate with mother and
family.
FOLLOW UP CARE

For the baby

The mother and baby should be kept together with the baby in skin-to-skin contact.
Encourage the mother to breastfeed her baby as soon as it is ready. This will help to
prevent hypoglycaemia.
Help the mother breastfeed her baby, if needed.
Good suckling is a sign of recovery. If the baby is unable to suck effectively, ask the
mother to express colostrum; help her in expression of milk.
Record all the events in baby’s record book

For the mother and family

After resuscitation, explain to the mother and family what has happened and how the
baby is now.
Keep the mother and baby in the delivery room and do not separate them.
Never leave the newborn and woman alone. Monitor them every 15 minutes during
the first hour.
a. Record the events.
b. Examine the baby before discharge.

COMPLICATIONS OF RESUSCITATION

Hypoxia
Liver laceration
Rib fracture
Pneumothorax
Intraventricular haemorrhage
SSUMMARY

Newborn resuscitation is a series of actions which are used to assist newborn babies who
have difficulty with making the physiological ‘transition’ between the womb and ‘the
outside world.

We discussed the definition, purposes, articles, risk factors, procedure, management and care
and complication of neonatal resuscitation.

CONCLUSION
Neonatal resuscitation is a very important procedure to save lives of newborn which require
special skills and trained personnel. A trained personnel should be available in each delivery
room every time. A resuscitation trolley should be available24 hours suspecting each
newborn baby may be in need of resuscitation.

BIBLIOGRAPHY
1. Gupta Piyush. Essentials of Pediatric Nursing.1st edition (2004). AP Jain. Page No:
23-31.
2. Marlow Dorothy. Textbook of Pediatric Nursing. 6t edition. Page No: 315.
3. Ghai O.P.Essential of Pediatrics. 6th edition. CBS Publishers and distributors New
Delhi.Page No: 137-147.
4. Susamma Varghese. Textbook of Pediatric Nursing. Page No: 188-194.
5. www.scribd.com