NEONATAL RESUSCITATION

Why learn neonatal resuscitation?

World wide 1 million babies die per year due
to asphyxia of which 1/3 rd is from India
For most of these babies appropriate
resuscitation was unavailable
Neonatal resuscitation means to revive or
restore life to a baby from state of asphyxia
Which babies require
resuscitation?
Approximately 10 % neonates require some
assistance to begin breathing at birth
1 % may need extensive resuscitation to
survive
90% of newly born babies make the
transition from intrauterine to extra uterine
life without difficulty
The aim of NRP is to teach steps necessary
to ventilate a newborn that is not breathing
and protect the life of baby
Preparation for Birth
A draught free, warm room with temperature >/=
25 degrees centigrade
A clean, dry and warm delivery surface
A radiant warmer
Two clean, warm towels/clothes
A folded piece of cloth
A newborn self inflating bag of volume 250500
ml and pressure of at least 35 cm of water
Infant masks in 2 sizes : 1 - Term and 0 Preterm
A suction device pressure 100 mmHg or 130 cm
water
Oxygen and a clock with seconds hand
 Birth
No Meconium
- Dry the baby
Meconium present
- Suction (if
not crying)
- Dry the baby

Assess Breathing Routine

breathing well/Crying Care
30
Not Breathing
sec
well
Initial Steps Of
Resuscitation
Assess Breathing Observatio
breathing well nal Care
 Provide BMV for
30 sec
Ensure chest rise
Assess Breathing Observatio
well
breathing nal Care
Not breathing
well :
30 sec
Call for help
Continue BMV
Breathing
well
Assess Heart
Heart rate 100
Rate
Heart orContinue
more
Continue
rate < BMV
BMV
100 Not Assess
well breathing
Advanced
care
 Assessment at birth
Deliver the baby on mothers abdomen or on a warm
clean and dry delivery surface
Dry the baby with a warm towel and remove the wet
towel and loosely wrap the baby in clean, dry and
warm towel

Drying itself provides sufficient stimulation for

breathing to start in mildly depressed newborn
babies
 Assess the babys breathing
Decision
Assessment
Crying No Resuscitation or
suctioning.
Provide routine care.
Not crying but No Resuscitation or
chest is rising suctioning.
regularly 30-60 Provide routine care.
times a minute
Gasping start resuscitation
immediately
Routine care
Provide warmth
Suction mouth and
nose (if necessary)
Cut cord in 1-3 minutes
Keep baby with mother
Initiate breastfeeding
Initial Steps of Resuscitation
Tie and cut the cord
Transfer the baby to a warm clean, flat and
dry surface
Provide warmth radiant warmer
Position the head so that it is slightly
extended
Clear the airway Suction mouth and then
nose
Stimulate
Provide Warmth
The radiant heat
will help to reduce
heat loss
The baby should
not be covered
with blankets or
towels
Leave the baby
uncovered to allow
full visualization
and to permit the
radiant heat to
reach the baby
 Position the head
The neck slightly
extended in the
sniffing position
This will bring the
posterior pharynx,
larynx, and trachea in
line, which will facilitate
unrestricted air entry.
This alignment is also the
best position for assisted
ventilation with a bag
and mask and/or to place
an endotracheal tube.
Prevent
hyperextensi
on or flexion
of the neck,
since either
may restrict
air entry
To help maintain
the correct
position, you may
place a rolled
blanket or towel
under the shoulders
This shoulder roll
may be particularly
useful if the baby
has a large occiput
resulting from
molding and edema
Clear the airway
The mouth is suctioned
before the nose to
ensure that there is
nothing for the newborn
to aspirate if he or she
should gasp when the
nose is suctioned
M before N Mouth
before Nose
If material in the mouth
and nose is not removed
before the newborn
breathes, the material
can be aspirated into the
trachea and lungs
Oropharyngeal suction by inserting the tube of device no
more than 5 cm beyond the lip
Then insert the suction tube 1-2 cm into each nostril
Apply suction while withdrawing the tube
Deep and vigorous suction can produce vagal response,
causing bradycardia or breathing to stop
If bradycardia occurs during suctioning, stop suctioning
and reevaluate the heart rate
Suctioning, in addition to clearing the secretions,
provides a degree of stimulation
Stimulate
Often, positioning the baby
and suctioning secretions
will provide enough
stimulation to initiate
breathing
Drying will also provide
stimulation
Tactile stimulation
Slapping or
flicking the
soles of the feet
Gently rubbing
the newborns
back, trunk, or
extremities
Reassess the Babys breathing
Suctioning may stimulate the baby to start
breathing place baby with mother and
provide Observational care
Provide warmth and allow skin-to-skin
contact with mother
Observe breathing and temperature
Watch for complications like convulsions,
poor feeding, lethargy, respiratory distress
Initiate breastfeeding, if well
 If the baby is still not
breathing
At the end of first 30 seconds
after providing initial steps of
resuscitation Start
Bag and Mask ventilation
Ventilation of
the lungs is the
single most
important step
in resuscitation
of a newborn
Preparation for BMV
Selection of mask
Clear airway
Position the babys head
Position yourself at the bedside
Positioning the bag and mask on face
Initiation of ventilation
Ensure chest rise
Selection of mask
Depends on how well
the mask fits the
newborns face.
The correct mask will
achieve a tight seal
between the mask
and the newborns
face.
Masks also come in
two shapes: round
and anatomically
shaped
the rim will
cover the tip of
the chin, the
mouth, and the
nose but not
the eyes
. Too large-
may cause
possible eye
damage and
will not seal
well.
. Too small-will
not cover the
mouth and
nose and may
 clear airway
Suction the mouth and nose one
more time to be certain there will
be no obstruction to the assisted
breaths that you will be delivering
by Bag and Mask
Position the babys head
The babys neck
should be slightly
extended (but
not
overextended)
into the
sniffing position
to maintain
an open airway
Position yourself at the bedside
Position yourself at the babys side or head to use a
resuscitation device effectively
If you are right-handed, you probably will feel most
comfortable controlling the resuscitation device with
your right hand and the mask with your left hand and
viceversa
Both positions
leave the chest
and abdomen
unobstructed for
visual monitoring
of the baby for
chest
compressions and
vascular access
via umbilical cord
Positioning the Bag and Mask on
the face
The mask usually is
held on the face
with the thumb,
index, and/or
middle finger
encircling much of
the rim of the
mask, while the
ring and fifth
fingers bring the
chin forward to
maintain a patent
airway
An airtight seal between the rim of the mask
and the face is essential to achieve the
positive pressure required to inflate the lungs
with the resuscitation devices.
Observe the following precautions
Do not jam the mask down on the face. Too
much pressure can mold (flatten) the back of
the head and bruise the face.
Do not allow your fingers or parts of your
hand to rest on the babys eyes.
Initiation of ventilation
Start ventilation by squeezing
the bag to deliver breath
How often should you squeeze
the bag?
During the initial stages of neonatal
resuscitation, breaths should be
delivered at a rate of 40 to 60
breaths per minute, or slightly less
than once a second
How do you know if the baby is
improving and that you can stop
positive-pressure ventilation?
Improvement is indicated by the following 4
signs:
Increasing heart rate
Improving color
Spontaneous breathing
Improving muscle tone
Check the 4 signs for improvement after 30
seconds of administering positive pressure.
If the heart rate remains below 60 bpm, you
need to proceed to chest compressions
If the heart rate is above 60 bpm, you should
continue to administer positive-pressure
ventilation and assess the 4 signs every 30
seconds.
As the heart rate increases towards normal,
continue ventilating the baby at a rate of 40 to
60 breaths per minute
When the heart rate stabilizes above 100 bpm,
reduce the rate and pressure of assisted
ventilation until you see effective spontaneous
respirations
Ensure chest rise
Too ensure adequacy of ventilation
look for chest movement
Reasons for inadequate or absent
chest movement
1) the seal is inadequate
2) the airway is blocked
3) not enough pressure is being
given
 Reasons for Inadequate/Absent
chest movements
Condition Actions
Indequate Reapply mask to face and lift
seal the jaw forward
Blocked Reposition the head.
airway Check for secretions; suction if
present.
Ventilate with newborns
mouth slightly open
Not Increase pressure until there is
enough a perceptible
pressure movement of the chest.
Consider endotracheal
Chest compressions should
be started whenever the
heart rate remains less than
60 bpm despite 30 seconds of
effective positive- pressure
ventilation
Endotracheal intubation at
this time may help to ensure
adequate ventilation and
Post-resuscitation care
Provide warmth
Observe breathing, temperature, color, CFT
Monitor blood sugar
Watch for complications like convulsion, poor feeding,
lethargy, respiratory distress
Initiate breast feeding, if well
2012 WHO recommendations
on Basic Newborn Resuscitation
In newly-born term or preterm babies who do not
require positive-pressure ventilation, the cord should
not be clamped earlier than one minute after birth
When newly-born term or preterm babies require
positive-pressure ventilation, the cord should be
clamped and cut to allow effective ventilation to be
performed
Newly-born babies who do not
breathe spontaneously after thorough
drying should be stimulated by
rubbing the back 2-3 times before
initiating positive-pressure ventilation
In neonates born through clear amniotic fluid who start
breathing on their own after birth, suctioning of the
mouth and nose should not be performed.
In neonates born through clear amniotic fluid who do
not start breathing after thorough drying and rubbing
the back 2-3 times, suctioning of the mouth and nose
should not be done routinely before initiating positive
pressure ventilation.
Suctioning should be done only if the mouth or nose is
full of secretions.
In the presence of meconium-stained amniotic fluid,
intrapartum suctioning of the mouth and nose at the
delivery of the head is not recommended
In neonates born through meconium-stained
amniotic fluid who start breathing on their own,
tracheal suctioning should not be performed.
In neonates born through meconium-stained amniotic
fluid who start breathing on their own, suctioning of the
mouth or nose is not recommended.
In neonates born through meconium-stained amniotic
fluid who do not start breathing on their own, tracheal
suctioning and suctioning of the mouth and nose should
be done before initiating positive pressure ventilation.
In newly-born babies who do not start breathing
despite thorough drying and additional stimulation,
positive-pressure ventilation should be initiated
within one minute after birth
Stopping resuscitation
In newly-born babies with no detectable heart rate
after 10 minutes of effective ventilation, resuscitation
should be stopped.
In newly-born babies who continue to have a heart
rate below 60/minute and no spontaneous breathing
after 20 minutes of resuscitation, resuscitation should
be stopped.
Resuscitation flow diagram
RESUSCITATION FLOW DIAGRAM
Initial Assessment Block: At the time of
birth, ask yourself three questions about the
newborn. If any answer is No, continue to
the initial steps of resuscitation.
Block A (Airway): These are the initial
steps to establish an Airway and begin
resuscitating a newborn.
Provide warmth.
Position the babys head to open the
airway; clear the airway as necessary.
Dry the skin, stimulate the baby to breath,
and reposition the babys head to open the
airway.
Evaluation of the effect of Block A:
Evaluate the newborn during and immediately
following the first interventions, takes no more than 30
seconds to complete. If the newborn is not breathing
adequately(has apnea or is gasping), has a heart rate of
less than 100 bpm proceed to Blocks B(left side). If
respirations are labored or the baby appears
persistently cyanotic, proceed to Block B (right side)
Block B (Breathing):
If the baby has apnea or has a heart rate below 100
bpm, assist the babys Breathing by providing positive-
pressure ventilation. If baby is breathing but had
persistent respiratory distress, administer continuous
positive airway pressure(CPAP) with a mask ,
particularly for a preterm. Attach an oximeter to
determine the need for supplemental oxygen.
Evaluation of the effect of Block B:
After about 30 seconds of effective PPV, CPAP and/or
supplemental oxygen evaluate the newborn again to
ensure the ventilation is adequate. Effective
ventilation should be provided before moving next
step. If the heart rate is below 60 bpm, proceed to
Block C.
Block C (Circulation):
Support Circulation by starting chest compressions
while continuing positive pressure ventilation.
Endotracheal intubation is strongly recommended at
this point to coordinate effective chest compressions
and PPV
Evaluation of the effect Block C:
After about 45 to 60 seconds of chest
compressions and positive pressure ventilation,
evaluate again. If the heart rate is still below 60
bpm, you proceed to Block D.
Block D (Drug)
Administer epinephrine continuing
positive-pressure ventilation and chest
compressions.
Ventilation of the babys lungs is the most
important and effective action in neonatal
resuscitation
 Evaluation after initiation of each action is
based on 3 signs
1. Respirations
2. Heart rate
3. Assessment of oxygenation(colour,
preferably oxymetry reading)
Prioritization of actions
Perform initial steps with in approximately 30 seconds,
slight more time if meconium stained
Next 30 seconds for further stimulation of the baby to
breathe
The first 60 seconds after birth, is called The Golden
Minute
If clearing of airway, stimulating the baby has resulted in
no improvement after no more than 60 seconds from
birth, begin PPV
Next 30 seconds evaluate respirations, heart rate and
oxygenation
If heart rate not responded with PPV, correct the
technique and evaluate effectiveness again in 30 seconds
INITIAL STEPS OF
RESUSCITATION
How do you determine whether the baby requires
resuscitation ?
Was the baby born at term?
Is the baby breathing or crying?
A vigorous cry indicates breathing. Dont be misled by
a baby who is gasping. Gasping is a series of deep
single or stacked inspirations that occur in the
presence of hypoxia and/or ischemia , which indicates
severe neurologic and respiratory depression and
requires same intervention as apnea.
Is there good muscle tone?
Healthy term babies should have flexed extremities and
be active.
INITIAL STEPS
Provide warmth
Position; clear airway(as necessary)
Dry, stimulate.
Clear airway (as necessary) :
clearing the airway depend on the
1. The presence of meconium
2. The babys level of activity

WHO Recommendations
In the presence of meconium-stained amniotic
fluid, intrapartum suctioning of the mouth and nose
at the delivery of the head is not recommended.
In neonates born through meconium-stained
amniotic fluid who start breathing on their own,
tracheal suctioning and suctioning of mouth and
nose should not be performed.
In neonates born through meconium-stained
amniotic fluid who do not start breathing on their
own, tracheal suctioning followed by suctioning of
the mouth and nose should be done before
initiating positive pressure ventilation.
What do you do if meconium is present
and the baby is not vigorous?
Direct suctioning of the trachea soon after delivery is
indicated before many respiration have occurred to
reduce the chances of the baby developing meconium
aspiration syndrome-
STEPS
Insert a laryngoscope and use a 12F or 14F suction
catheter to clear the mouth and posterior pharynx so
that you can visualize the glottis
Insert an endotracheal tube into the trachea.
Connect the endotracheal tube to a meconium
aspirator, which has been connected to a suction
source
Steps cont,,
Occlude the suction-control port on the
aspirator to apply suction to the
endotracheal tube, and gradually withdraw
the tube continuing suctioning any
meconium that may be in the trachea.
Repeat as necessary until little additional
meconium is recovered, or until the babys
heart rate indicates that resuscitation must
proceed without delay.
Guidelines:
Do not apply suction to the endotracheal
tube for longer than 3 to 5 seconds as you
withdraw the tube.
If no meconium is recovered, dont repeat
the procedure; proceed with resuscitation.
If meconium is recovered with the first
suction, check the heart rate. If the baby
does not have significant bradycardia, re
intubate and suction again. If the heart rate
is low, administer positive pressure without
repeating the procedure.
Visualizing the glottis and suctioning meconium
from the trachea using a laryngoscope and
endotracheal tube
Evaluate the baby after initial
steps
Respirations
There should be good chest movements, and the
rate and depth of respirations should increase
after a few seconds of tactile stimulation.
Heart rate
The heart rate should be more than 100 bpm. For
determining the heart rate is to feel for a pulse at
the base of the umbilical cord, where it attaches
to the babys abdomen or listen for the heart beat
over the left side of the chest using stethoscope.
Counting the number of beats in 6 seconds and
multiplying by 10 can provide a quick estimate of
the beats per minute.
If the baby is not breathing (apnea), or has
gasping respirations, or if the HR is below
100 bpm, despite stimulation , proceed
immediately to providing PPV
The most effective and important action in
resuscitating a compromised newborn is to
assist ventilation
If the baby is breathing and HR is above
100 bpm, but the respirations are labored
or persistent central cyanosis confirmed by
oximetry, administer CPAP by face mask
using a flow inflating bag or T- piece
resuscitator
Indications of PPV
Not breathing or gasping
HR is below 100 bpm even with breathing
Saturations remains below target values
despite free flow supplemental oxygen
being increased to 100 %
Assessment of effectiveness of PPV
Initiate PPV with an inspiratory pressure of about 20
cm H2O , at a rate of 40 -60 breaths per minute.
The most important indicator of successful PPV is
rising Heart rate. Listen for heart rate and assess
for improving saturation.
If HR is not rising with PPV (with in first 5-10
breaths) assess for effective ventilation by listening
for bilateral breath sounds and looking for chest
movement with each Positive Pressure breath
If the chest is not moving with each breath and
there are poor breath sounds begin with ventilation
corrective sequence MR SOPA
Ventilation corrective steps
MR SOPA
M- Adjust Mask in the face
R- Reposition the head to open airway
Re-attempt to ventilateif not effective then
S- Suction mouth then nose
O- Open mouth and lift jaw forward
Re-attempt to ventilateif not effective then
P- Gradually increase Pressure every few
breaths until visible chest rise is noted
Max Pip 40cmH2O
If still not effective then
A- Artificial Airway (ETT or LMA)
If heart rate is below 60bpm
Despite 30 seconds of
effective ventilation begin chest
compressions
If heart rate is more than 60bpm but
less than 100bpm
continue to administer PPV as long as the
baby is showing steady improvement.
Monitor O2 saturation and adjust the
oxygen concentration to meet the target
range
Consider inserting an oro gastric tube if
ventilation continues
Consider decreasing inspiratory pressure if
chest expansion seems more
As ventilation continues, reassess
respiratory effort, heart rate and O2
saturation continuously, or atleast every 30
If heart rate is more than
60bpm but less than 100bpm
Ensure effective ventilation
Consider complications, such as
pneumothorax or hypovolemia
When heart rate is above 100bpm and
stable
Reduce the rate and pressure of
PPV while observing for effective
spontaneous respirations and
stimulating the baby to breathe
effectively
Positive pressure ventilation may be
discontinued when
a heart rate continuously over 100bpm
and Sustained spontaneous breathing
CHEST COMPRESSIONS
What are chest compressions?
Chest compressions (or) external cardiac
massage, consist of rhythmic compressions
of the sternum that
. Compress the heart against the spine.
. Increase the intrathoracic pressure.
. Circulate blood to the vital organs of the
body
How many people are needed to
administer chest compressions, and
where should they stand?
2 people are required to
administer effective chest
compressions-one to
compress the chest and one
to continue ventilation.
The person performing chest
compressions must have
access to the chest and be
able to position hands
correctly. The person assisting
ventilation is positioned at the
babys head to achieve an
effective mask-face seal (or to
stabilize the endotracheal
tube) and watch for effective
chest movement
Techniques for performing chest
compression.
Thumb technique:
2 thumbs are used to
depress the sternum,
while the hands encircle
the torso and the fingers
support the spine
2-finger technique: the
tips of the middle finger
and either the index finger
or ring finger of one hand
are used to compress the
sternum, while the other
hand is used to support
the babys back
 Where on the chest should you position
your thumbs or fingers?
When chest
compressions are
performed on a
newborn, pressure
is applied to the
lower third of the
sternum, which lies
between the
xyphoid and a line
drawn between the
nipples
How much pressure do you use
to compress the chest?
Pressure used to
depress the sternum up
to a depth of
approximately one
third of the anterior-
posterior diameter of
the chest, and then
release the pressure to
allow the heart to refill.
One compression
consists of the
downward stroke plus
the release.
Contd..,
The thumbs or the tips of
fingers should remain in
contact with the chest at
all times during both
compression and release .
Allow the chest to fully
expand by lifting thumbs or
fingers during the release
phase to permit blood to
reenter the heart .
Do not take off thumb or
fingers completely off the
sternum after
compressions
How often to compress the chest and
coordinate
compressions with ventilation?
Simultaneous compression and ventilation should be
avoided because one will decrease the efficacy of the
other.
Compression and ventilation must be coordinated,
with one ventilation interposed after every third
compression, One cycle of events will
consist of 3 compressions plus one ventilation.
. There should be approximately 120 events per 60
seconds (1 minute) 90 compressions plus30 breaths.
The compressor should count One-and-Two-and-
Three-and-Breathe-and while the person ventilating
squeezes during Breathe-and and release during
One-and.
Coordination of chest compressions and
ventilations
When to stop chest
compressions?
Atleast 45 to 60 seconds of well coordinated
chest compressions and ventilations should be
done, before pausing briefly to determine the
heart rate again because,,,
there is delay of 45 to 60 seconds or longer
after the compressions are resumed before the
coronary perfusion pressure returns to its
previous value
If the heart rate increases to above 60bpm
discontinue chest compressions, but
continue PPV at the rate of 40 to 60 breaths
per minute
If the heart rate remains below 60bpm
insert an umbilical catheter and give
EPINEPHRINE- When is indicated
when heart rate remains below
60bpm after 30 seconds of effective
assisted ventilation (preferably after
endotracheal intubation) and atleast
another 45 to 60 seconds of coordinated
chest compressions and effective
ventilation.
Why epinephrine?
It increases the strength and rate of cardiac
contractions
It causes peripheral vasoconstriction which
increases systemic blood pressure, thus
improving myocardial and cerebral blood
Recommended route :
1. Intra venous route(through umbilical vein)
2. Endotrachel route - fast to establish but
results in lower and less predictable blood
levels and often not effective
3. Intraosseous access
Recommended concentration : 1:10,000
solution
Recommended dose :
Intravenous 0.1 to 0.3 mL/kg(0.01 to
0.03 mg/kg)
Endotracheal 0.5 to 1 mL/kg(0.05 to
Assess heart rate about 1 minute after
administering epinephrine (longer if given
endotracheally)
If heart rate increases to more than 60bpm
with in 1 minute after intravenous
epinephrine continue PPV with 100% O2
and stop chest compressions

If heart rate does not increases to above

60bpm after the first dose of epinephrine,
Repeat the dose every 3 to 5
minutes
Volume expansion
Indications
Baby is not responding to resuscitation
AND
Baby appears in shock
OR
History of condition associated with fetal blood loss
Recommended solution
0.9% NaCl (Normal saline)
Ringers lactate.
O-Rh negative packed red blood cells should be
considered as part of the volume replacement when
severe fetal anemia is documented or expected.
Recommended dose : 10ml/kg
The initial dose is 10 mL/kg. However, if
the baby does not improve significantly
after the first dose, give another dose of
10 mL/kg.
Recommended route : Umbilical vein
Recommended rate of administration :
Over 5 to 10 minutes
If the heart rate is absent, or no progress is
being made in certain conditions, such as
extreme prematurity, it may be appropriate
to discontinue resuscitative efforts.
STOPPING RESUSCITATION
In newly-born babies with no detectable
heart rate
after 10 minutes of effective ventilation,
resuscitation
should be stopped.
In newly-born babies who continue to
have a heart
rate below 60/minute and no
Endotrachel intubation
Endotracheal intubation may be performed
at various points during a resuscitation
Positive-pressure ventilation not resulting in
adequate clinical improvement
If chest compressions are necessary, for
effective coordination of chest compressions
and ventilation .
Non vigorous baby with meconium stained
amniotic fluid
Endotracheal administration of epinephrine
Endotracheal tube sizes
How do you hold the laryngoscope?
Hold the laryngoscope in left hand, between
thumb and first two or three fingers, with the
blade pointing away.
One or 2 fingers should be left free to rest on
the babys face to provide stability.
The laryngoscope is designed to be held in the
left hand by both right and left handed
persons.
If held in the right hand, the closed
curved part of the blade will block view of
the glottis and makes insertion of the
endotracheal tube
impossible.
steps
First, stabilize the babys head with right
hand. Second person hold the head in the
desired sniffing position. Free-flow
oxygen should be delivered throughout the
procedure.
Second, slide the laryngoscope blade over
the right side of the tongue, pushing the
tongue to the left side and advance the tip
lies in the vallecula
Third, lift the
blade slightly,
thus lifting the
tongue out of
the way to
expose the
pharyngeal area
Do not elevate
the tip of the
blade by using a
rocking motion
and pulling the
handle toward
Fourth, look for landmarks
Fifth,
Insert the tube by holding the tube in
right hand, and introduce it into the right
side of the babys mouth with the curve of
the tube lying in the horizontal plane.
Insert the tip of the endotracheal
tube until the vocal cord guide is at the
level of the cords.
Sixth,
Stabilize the tube with one hand, and
remove the laryngoscope with the other
Correct placement of the endotracheal tube is
indicated by
Improved vital signs (heart rate, color, activity).
Breath sounds over both lung fields but decreased
or absent over the stomach.
No gastric distention with ventilation.
Vapor in the tube during exhalation.
Chest movement with each breath.
Direct visualization of the tube passing between
the vocal cords.
Tip-to-lip measurement: add 6 to newborns weight
in kilograms.
Laryngeal mask airway
Air way device
consists of a soft
elliptical mask with
an inflatable cuff
attached to a
flexible airway
tube.
It is a successful
rescue airway when
u cannot ventilate
and cannot
intubate
INDICATIONS
When positive pressure ventilation with a face
mask fails to achieve effective ventilation, and
endotracheal intubation is either not feasible or
unsuccessful.
When facial or upper airway malformations
render ventilation by mask ineffective
How LMA works ?
The soft mask functions like a cap that fits over
the larynx. The inflated cuff makes good
seal over the larynx
When positive pressure is applied to the airway
tube the pressure is transmitted through the
airway tube and mask in to the trachea
How to insert LMA?
It is inserted in to baby's mouth with index
figure guided along the baby's hard palate
until the tip reaches the esophagus
Once the mask is fully inserted, the cuff is
inflated
The inflated mask covers the laryngeal
opening, the cuff conforms to the contours
of the hypopharynx, occluding the
esophages with a low pressure seal
2012 NRP 6th Edition Review of
Changes
1. The following are no longer optional but
should be available for every birth
.Compressed gas source
.Blended Oxygen with flowmeter
.Pulse Oximetry
.LMA size 1 (Laryngeal Mask Airway)
 2.There are 2 levels of post-resuscitation care (instead of the 3
levels of care)
Routine Care:
Vigorous term infants with no risk factors
Babies who required but responded to
initial steps
They now can stay with Mother
Skin to skin contact recommended
Clear airway, dry
newborn,
provide ongoing evaluation:
Breathing Activity Colour
Post-Resuscitation Care:
Babies with depressed breathing or activity
Those requiring supplemental oxygen &/or ongoing nursing
care
Those with high risk factors to be evaluated in an ICU setting
Those who require frequent evaluation
Baby may possibly then transfer to routine care after a period
of time
Transfer to NICU
IT INCLUDES
Temperature control
Close monitoring of vitals
Awareness of potential complications
Lab studies, hematocrit and blood glucose levels
Blood gas analysis
3.What to ask Obstetrician prior to delivery
What is the gestational age?
Is the fluid clear?
How many babies are expected?
Are there any additional risk factors?
4.At birth, answer 3 questions to determine the need
for the initial steps at the Radiant warmer
Is the newborn term?
Is the newborn breathing or crying?
Does the newborn have good muscle tone?
If the answer is NO to any questionthe newborn
should receive the initial steps
5. Suctioning after birth : Bulb or Catheter
Should be reserved for babies who have
Obvious obstruction to spontaneous
breathing
Those requiring PPV (positive pressure
ventilation)
6. Vigorous Meconium-Stained newborns are
NO longer required initial steps at radiant
warmer. May receive Routine Care with
Mother right after birth with appropriate
monitoring
7.PPV & CPAP
If HR <100 or if newborn is apneic or gasping-
PPV
If HR >100 but respirations are labored-CPAP
(continuous positive airway pressure)
especially with preterm infants

8. Evaluation Process
Subsequent evaluations and decision-making
are based on
Respiratory effort
Heart rate
Oxygenation (Based on Pulse Oximetry)
9. Pulse Oximeter & Oxygen Administration
Term infants may be resuscitated with 21%
O2
Preterm infants may begin with a somewhat
higher oxygen concentration

10. Pulse Oximeter probe on right hand or

wrist .(Measures the pre-ductal saturation )
Place on baby before connecting to Pulse
oximeter machine to achieve the fastest
readings
11. Pulse Oximetry & Evaluation of Color
Use Pulse oximeter when:
Resuscitation is anticipated
PPV is required for more than a few breaths
Central cyanosis is persistent
To confirm your perception of central
cyanosis
Whenever supplemental oxygen is
administered
12. Pulse oximetry & Oxygen Administration
Supplemental oxygen concentration should
be adjusted gradually to achieve pre-ductal
Saturations summarized in the NRP
diagram below (Both Term & Preterm)
Target Spo2 after birth:
1min 60-65%
2min 65-70%
3min 70-75%
4min 75-80%
5min 80-85%
10min 85-95%
13.PPV Indications
Apnea/Gasping
Heart rate <100 even with strong
respiratory drive
low oxygenation despite free-flow oxygen
increased to100%

14. All positive-pressure devices, including

the self-inflating bag, should have an
integral pressure gauge, or if there is a site
for attaching a pressure gauge
(manometer).
15. PPV Assessment
PIPs of 20cmH2O should be sufficient for
good chest rise in most newborns
Best indicator that you are bagging
correctly is an increase in heart rate
evident within 5-10 breaths
If not-then following the corrective actions
MR SOPA
 MR. SOPA
M- Adjust Mask in the face
R- Reposition the head to open airway
Re-attempt to ventilateif not effective then
S- Suction mouth then nose
O- Open mouth and lift jaw forward
Re-attempt to ventilateif not effective then
P- Gradually increase Pressure every few
breaths until visible chest rise is noted
Max Pip 40cmH2O
If still not effective then
A- Artificial Airway (ETT or LMA)
18.Highest Priority in Neonatal Resuscitation
Establishing EFFECTIVE Ventilation
It may take longer than 30sec to establish
effective ventilations .
DO NOT start chest compressions without
1st ensuring effective ventilations
19. If heart rate is still below 60 bpm despite
30 seconds of effective positive pressure
ventilation, increase the oxygen
concentration to 100% and begin chest
compressions.
CHEST COMPRESSIONS
20. HR <60bpm despite effective ventilation
Coordinate with ventilations for at least 45-
60sec before stopping briefly to assess
heart rate because interruption may result
in a decrease in coronary perfusion
pressure

21. Increase FiO2 to 100% once you begin

compressions until the oximeter is giving a
reliable signal and can guide the
appropriate adjustment of supplemental
oxygen.
22.Intubation is strongly recommended
when chest compressions begin to
help ensure effective ventilation.
23.The intubation procedure ideally
should be completed within 30
seconds (not 20 seconds). Do not
administer free-flow oxygen during the
intubation procedure to an apneic newborn.
24. Consider placement of Umbilical Venous
Catheter once compressions are initiated or if
extended resuscitation is anticipated .
25. while placing umbilical venous catheter,
continue chest compressions by moving to the
head of the bed (near the infants head) and
continuing the 2-finger technique.
26. Epinephrine is indicated when the heart rate
remains below 60 bpm after 30 seconds of effective
assisted ventilation (preferably via endotracheal
tube) and at least another 45-60 seconds of
coordinated chest compressions and effective
ventilation.
27. Epinephrine administration (IV parameters
unchanged; note new dose for intratracheal
epinephrine)
a. Recommended concentration: 1:10,000 (0.1
mg/mL)
b. Recommended route: Intravenous (umbilical vein).
Consider endotracheal route ONLY while IV access
being obtained
c. Give rapidly as quickly as possible.
d. Recommended IV dose: 0.1-0.3 mL/kg of 1:10,000
solution per umbilical vein in a 1-mL syringe. Follow
IV administration of epinephrine with 0.5 1 mL
flush of normal saline. E.
Recommended intratracheal dose: 0.5 1
mL/kg of 1:10,000 solution per endotracheal
tube in a 3-6 mL syringe.
28. Therapeutic hypothermia following
perinatal asphyxia , instituted after
resuscitation, improves neurological
outcome.
Body temperature of 33.5C to 34.5C
criteria :
a. Gestational age >/= 36 weeks
b. Evidence of acute perinatal hypoxic
ischemic event
c. Ability to initiate before 6 hours after birth
 29. To help keep the preterm baby warm,
a. Increase the temperature of the
delivery room and the area where the
baby will be resuscitated to
approximately 25C to 26C (77F-79F)
b. Use polyethylene plastic wrap for babies
delivered at less than 29 weeks gestation
(or 28 weeks and less).
c. Place a portable warming pad under layers
of towels on the resuscitation table.
Resuscitatio Recommendati Recommendatio
n step ons (2005) ns (2010)
1) Assessment Four questions Three questions
for need Gestation-term or Gestation-term or not?
of resuscitation not? Tone- Good?
Amniotic fluid- clear Breathing /Crying?
or not?
Tone- Good?
Breathing /Crying?
2) Routine care .Provide warmth Provide warmth
Clear airway Assure open airway
Dry Dry
Assess color Ongoing
evaluation(color,
activity and breathing)
3) Initial steps Provide warmth Provide warmth
Position; Clear Open airway( no
airway(if routine
required) suction)
Dry, stimulate, Dry , stimulate
reposition
Assessment for Look for 3 signs Look for 2 signs
5) Positive Indications Indications
pressure Hear rate < Hear rate < 100/min
ventilation (PPV) 100/min Apnea or gasping
5.1) Indication for Apnea or
PPV gasping
Persistent
central cyanosis Heart rate
despite free flow Pulse oximetry
5.2) Assessment of oxygen Respiration
effectiveness of
resuscitation Heart rate
steps once PPV is Color
started Respiration
5) Oxygenation Based on color Based on pulse oximetry
5.1) Assessment of Pulse oximetry for both term and preterm
Oxygenation recommended for in case of following
only situations
preterm < 32weeks a.Anticipated need for
with resuscitation
need for PPV b. Need for PPV for more
than few breaths
c. Persistent cyanosis
d. Supplementary oxygen
6) Initial oxygen Term babies( 37 Term babies( 37
concentration for weeks) weeks)
resuscitation in Start with 100% O2 Start with 100%
case during PPV O2 during
of PPV Preterm PPVPreterm(<32we
babies(<32weeks) eks)
Start with oxygen Initiate with O2
concentration concentration
between 21-100% between 30-90%

CPAP in delivery Suggested for preterm Spontaneously

room babies breathing
( < 32 weeks) with preterm infants with
respiratory respiratory
distress distress
Delayed cord Not recommended For uncomplicated
clamping births both
term and preterm not
requiring
resuscitation delay
cord clamping by at
least 1 minute
Changes in ongoing 3 types of care Post resuscitation two
Thank you