-stimulates increase prolactin and oxytocin
NEONATAL RESUSCITATION
Dr. Gaspar
June 19, 2013
American Heart Association (AHA)
Guidelines for Cardiopulmonary Resuscitation (CPR) and
Cardiovascular Care (ECC) of Pediatric and Neonatal
Patients
Introduction
What happens during delivery?
Goal: to establish functional residual capacity (first
breath of the baby – expand the lungs)
a. Stress hormones released during delivery
- Epinephrine, norepinephrine
- Transferred during delivery (cut between 1 – 3
min after delivery to allow passage)
- Keeps the baby awake after delivery
b. active transport of sodium ions across gradient
c. 1st breath – gasping breath, succeeding breaths would
be easier for the baby
- lungs is non functional intrauterine
- Lung expansion with air
- air cell interface that develops
- need of surfactant to decrease surface tension
and prevent collapsing of the alveoli
d. Decrease in pulmonary vascular resistance causing air
to displace pulmonary fluid.
e. Release and transfer of glucagon
Normally: baby delivered head down
Initial newborn care
1.) Provide warmth – wipe dry to prevent cold
stress ( will also stimulate baby to breath
further)
- There is passive transfer of heat from the
mother during intrauterine life
2.) Cut the cord – allow pulsation to stop, usually
within 1 to 3 minutes
- Advantages of prolonging the cutting of the
cord:
a. allow transfer of blood flow
- 30-40cc/kg from placenta to baby
(good hemoglobin that persists until 6 months
of life which helps prevent anemia in infants)
- Transfer of hormones
- Transfer of stem cells
3.) Latching on – 90 minutes, skin to skin contact
with the mother,
production
-good thermostat
-transfer of bacterial flora
-able to maintain normoglycemia – because
infant is not stressed
*Oxytocin- biochemical hormone that promotes
bonding and love
4. Instinctive crawl –baby is alert because of transfer of
hormones, and increase sympathetic activity
*Vernix caseousa responsible for slippery movement
*baby is bathed 6 hours later
*After 90 minutes of latching – inject Vitamin K, Hep B,
and eye prophylaxis
If baby does not cry within the 1st 30 secs of life – cut
the cord, transfer to radiant warmer and resuscitate
*Baby transition from intrauterine to extraction
changes way of metabolism
- Aerobic- anaerobic- ketosis- metabolic acidosis
Need oxygen to uncouple brown adipose tissue
Neonatal Resuscitation Guidelines
Neonatal Resuscitation Skills:
Goal:
-inflate lungs, establishing oxygenation & ventilation
-establish adequate pulmonary flow
-support cardiovascular system
• Essential for health care providers involved in the
delivery of newborns
• Transition from fetus to newborn requires
intervention by skilled individual/team in 10% of all
deliveries
Birth Asphyxia: Failure to initiate and sustain breathing
at birth – cause by metabolic acidosis, hypercarbia
Extreme Prematurity: Half of newborn deaths occur
within 24H of life.
Only 60% of asphyxiated newborns predicted
antepartum. 80% of low birth weight requires
resuscitation and stabilization at delivery
Estimate of annual number of all newborns who require
assistance to breathe at birth and ranging levels of
neonatal resuscitation:
• < 1 million babies – 0.1% require chest compressions;
0.05 % require drugs
• Approx. 6 million babies – approx. 3-4% of babies
require basic resuscitation (bag-and-mask resuscitation)
• Approx. 10 million babies – approx. 5-10% of babies
require a simple stimulation at birth to help them
breathe (drying and rubbing)
• 136 million babies born – all babies require immediate
assessment at birth and simple newborn care (assess
breathing, dry and put the baby skin to skin with the
mother)
Goal of newborn resuscitation: Assist adaptation to
extrauterine life by:
-Inflating lungs, establishing oxygenation and ventilation
to
-Establish adequate pulmonary flow
-Support cardiovascular function
6. Do chest compression and ventilation via BVM
(bag-valve-mask) at a ratio of 3:1 for small
infants, 5:1 for big infants, 30: 2 for adults
a. Thumb encircling technique is preferred
for compressions of infants
7. Still if neonate does not cry, inject drug
a. Call for another personnel to access IV
line
8. If unresponsive, pronounced dead
a. New guidelines allow pronouncing of
death after 10 minutes of resuscitation
Always needed
- ASSESS BABY’S RESPONSE TO BIRTH
- KEEP BABY WARM, Position, clear the
airway, stimulate to breath by drying,
and give O2 (as necessary)

APNEA Less frequently needed

- Bag and mask
Secondary Apnea: - Endotracheal intubation
• Respiration ceases
• Heart rate decreases Rarely needed
• Blood pressure decreases - CHEST COMPRESSION
• No response to stimulation - MEDICATIONS

Chronology of events Initial steps to take in an emergency situation

Unable to breath (with good heart rate) – patient 1. Anticipation
undergoes primary apnea – stimulation of patient to 2. Adequate preparation
increase heart rate (patient at this point already has low 3. Timely recognition
heart rate)- * if progresses – secondary apnea 4. Quick and correct action

Important steps in resuscitation!

NEONATAL RESUSCITATION 1. Prevention of HEAT LOSS
2. Opening the AIRWAY
Chronological order 3. Positive pressure VENTILATION that starts with
1. Wipe the infant in the 1st minute of life
2. Stimulate the baby to cry by rubbing the back or 4. Support CIRCULATION
flipping the soles
3. If baby still doesn’t cry for 30 secs, suction If the answer is NO, infant should receive 1 or more of
mouth first then nose the following actions in sequence:
(do not suction vigorously may stimulate *initial steps in stabilization (provide warmth, position,
vasovagal reflex which may further lower heart clear airway, dry, stimulate, reposition)
rate) *ventilation
4. If baby still doesn’t cry after suctioning, *chest compressions
reposition head by placing shoulder roll *administration of epinephrine and/or volume
(maintain head in neutral position; avoid Expanders
hyperextension)
5. Observe –HR, RR, Pulse(pulse oximeter)
a. Count HR for 6 seconds then multiply by
ten
b. Watch for chest rise
INITIAL STEPS
Provide warmth
Prevent heat loss by:
- Place under radiant warmer
- Drying thoroughly
- Removing wet towels
1. Opening the airway
2. Dry, stimulate to breathe, reposition
3. Clear airway, no meconium present. Suction mouth
first, then nose
4. Tactile stimulation
Temparature Control
- VLBW Prematures (<1500 g): hypothermic despite
traditional techniques for decreasing heat loss
- Additional Warming techniques:
- Covering infant in plastic wrapping
(food-grade , heat-resistant plastic)
-Place under radiant heat
- Temperature monitored closely because of
described (LOE 2) risk of hyperthermia w/ this
technique
- Other techniques:
-Drying & swaddling
-Warming pads
-Increased environmental temperature
-Infant skin-to-skin w/ mother & covering
both w/ a blanket
- All resuscitation procedures; performed w/
temperature-controlling interventions
Clear Airway: No Meconium Present
Suction mouth first, then nose
Clearing the airway of meconium
- Meconium aspiration causes severe aspiration
pneumonia.
- Intrapartal suctioning: Suctioning meconium
from the airway after head delivery but before
delivery of the shoulders.
-studies (LOE3) show effective for
decreased risk for aspiration syndrome
but subsequent evidence from a large
MCT-RCT (LOE1) did not show such an
effect.
- Current recommendations: no longer advice
routine intrapartum oropharyngeal and
nasopharyngeal suctioning for infants born to
mothers with meconium staining of amniotic
fluid (class1)
Suctioning Meconium
EVALUATION
After these initial steps further actions are based on the
evaluation of:
- Respiration
- Heart rate
- Pulse( using pulse oximeter) - *new
Color removed because, delay normal coloration of the
infant, newborn cyanotic, but takes:
7 minutes to reach 88% o2 saturation
10 minutes to reach 98%o2 saturation and above
POSITIVE PRESSURE VENTILATION
The most important aspect of newborn
resuscitation for ensuring adequate ventilation of the
lungs, oxygenation of vital organs, and initiation of
spontaneous breathing.
Ventilation can almost always be initiated using
a bag and mask and room air. (it is rarely necessary to
intubate)
If the infant remains:
- Apneic or gasping
- Heart rate remains <100 bpm 30 seconds after
administering the initial steps
- Persistent central cyanosis despite
administration of supp O2 (targeted Sao2 low pulse
oximetry)
*Start positive-pressure ventilation
Bag and mask- the most important tool in newborn
resuscitation.
Bag/Mask Ventilation
- Cushioned, anatomically shaped mask
- Mask must cover nose & mouth completely
- Bottom rim should cover the edge of the chin
- Avoid pressure over the eyes
- A well-fitting mask help ensure a good seal
-reservoir bag important to preserve 100% oxygenation,
if no bag mask oxygen concentration decreases to 21%
or atmospheric oxygen concentration
Chest Compressions
- Compress the heart against spine
- Increase intra thoracic pressure
- Circulate blood to vital organs
Comparison of Chest Compression Techniques
Thumb Technique (preferred) airway pressure (CPAP) is used.
- Less tiring
- Better control of compression depth Targeted Preductal Spo2 After Birth
Two-finger Technique 1 min 60%-65%
- More convenient with only one rescuer 2 min 65%-70%
- Better for small hands 3 min 70%-75%
- Provides access to umbilicus for medications 4 min 75%-80%
5 min 80%- 85%
Room air vs. 100% Oxygen 10 min 85%-95%
Oxygen – drug w/ potential serious adverse effects
Oxygen free radicals: tissue injury New Ballard Score
Use of lower 02 conc. In resuscitation -> dec. 02 free Maturation Assessment of Gestational Age
radicals and dec. Adverse effects Physical Characteristics:
Study: resuscitation w/ RA as effective as 100% oxygen Key in determining gestational age
at lowering PVR -eyes transform from being fused in premature infants,
Studies: No benefits in raising the P02 >50 mmhg to wide open in full term babies.
1 meta-analysis, 4 studies: dec. Mortality and no -the skin and hair give important information in
evidence of harm when ___ting with RA vs. 100% 02 determining gestational age.
Resuscitation:
Resuscitation (term infant) to begin with 21% 02 ( to
100% when chest compression starts) use of pulse 1. Posture
Oximetry -Total body Muscle tone is reflected in the infant's
*if no response after 90 minutes give 100% 02 - preferred posture at rest and resistance to stretch of
intubation individual muscle groups.
-as maturation progresses, the fetus gradually assumes
Science: increasing passive flexor tone that proceeds in a
centripetal direction, with LE slightly ahead of UE.
Saturation targets
Corrective actions: MR SOPA 2. Square Window
Intubation attempts to 30 secs -Wrist Flexibility and/or resistance to extensor
Free flow oxygen during intubation: no longer astretching are responsible for the resulting angle of
recommended when baby is not breathing flexion at the wrist.
-The examinar straightens the infant's fingers and
*Intubation before chest compression applies gentle pressure on the dorsum of the hand close
to the fingers. From extremely pre-term to post-term,
MR SOPA the resulting angle between the palm of the infant's
-Mask- reapply hand and forearm is estimated at >90o, 90◦, 60o, 45o,
-Reposition – airway 30o, 0o
-Suction mouth and nose
-Open infant’s mouth 3. Arm recoil
-Pressure increase
-Alternative airway -evaluates, passive flexor tone of the biceps
-test arm one at a time to avoid moro’s reflex
Others -briefly flex arm – momentarily extend and the release

4. Popliteal Angle
Therapeutic hypothermia as treatment modality
CPAP becomes a “formal” part of resuscitation (and -test for hamstring muscle
post resuscitation care) -thigh placed knee chest position
ETT doses of epinephrine have changed (0.05-0.1 -Frankbreech delivery affect popliteal angle
mg/kg)
Pulse Oximetry 5. Scarf Sign
Use pulse oximetry when resuscitation is anticipated or
when supplemental oxygen, PPV, or continuous positive
-throw elbow on the same side
-point to which elbow moves easily prior to significant
resistance is noted

(-1) = neck, (0) = axilla contralateral side, (1)= nipple line

contralateral side, (2)= xiphoid, (3)= nipple ipsilateral
side, (4) = axillary ipsilatel side

6. Heal to Ear – flexion/ resistance to extension of

posterior hip muscle (Gluteus)
- unreliable with Frank breech delivery

Transcribed by: 7up