NEWBORN RESUSCITATION

Dr. Dhana Raj Aryal

Chief Consultant Paediatrician
Head, Dept. of Neonatology
Maternity Hospital

W.H.O. estimates
Seven million perinatal deaths/year
mostly in developing countries
4 million newborns suffer
moderate/severe birth asphyxia
About 800,000 babies die and about the
same number develop sequelae
epilepsy, mental retardation, c.p., learning
disabilities etc.

In Nepal
Perinatal asphyxia is one of the
commonest causes of perinatal
death
Equipment for neonatal resuscitation
are lacking in many health facilities in
Nepal
Very few are trained in the correct
technique of neonatal resuscitation

 Neonatal mortality constitutes 66% of IMR

Birth asphyxia is one of the commonest
causes of neonatal mortality (25-33%)
Reduction in deaths due to asphyxia will
have significant impact in reduction of IMR

Neonatal and Infant Mortality Rate in

Nepal
Year

IMR

NMR

% of
IMR

1991

80

46

58

1996

79

50

63

2001

64

39

60

2006

48

33

66

Goal

34

17

33

 Nearly 90% of babies do not require any

resuscitative measures
About 10% require some resuscitation and
1% will require advanced resuscitation

There is a very important relation

between the duration of asphyxia and
initiation and establishment of normal
breathing following assisted
ventilation
A slight delay in starting assisted
ventilation results in much longer time
in starting and establishing normal
breathing

Duration of
Asphyxia

Time of assisted ventilation

Mins

Gasping

Breathing

10

2.3

9.7

12.5

9.4

20.5

15

13.6

30

Being Prepared
While in 2/3 of the births, asphyxia
could be anticipated, in 1/3, it cant be
anticipated
Therefore one should be prepared to
deal with birth asphyxia in all births
promptly and adequately

Being Prepared
Anticipation Medical history
Equipment Essential equipment of
neonatal resuscitation
Skilled personnel 2 persons; and at least
one should be skilled in all aspects of
neonatal resuscitation

Initial Steps

Initial Steps
Decide if newborn needs resuscitation
Provide Warmth
Open airway and provide the initial steps of
resuscitation
Resuscitate when meconium is present
Provide free-flow oxygen when needed

Birth
Term Gestation?

30 seconds

Clear of Meconium?

Routine Care
Provide warmth
Clear Airway if needed
Dry
Assess color

Yes

Breathing or crying?
Good Muscle Tone?
No
Provide warmth
Position clear airway
(as necessary)
Dry, stimulate, reposition
Evaluate Resp, HR and
Color

Breathing, HR>100,
Pink

Observational Care

Breathing, HR>100,
Cyanotic

Pink

Give Supplementary Oxygen

Endotracheal intubation may be

considered at several steps

Ask following questions within

few seconds of birth
Is the baby born at Term gestation?
Is the amniotic fluid clear of
Meconium ?
Is the baby breathing or Crying ?
Is the Muscle tone good?
Gasping is a significant problem and

What do you do after

resuscitation
Routine Care
Nearly 90% of newborns need this
Provide warmth by keeping the baby over mothers
chest and abdomen
Clear the airway by turning head to one side
Clear airway by wiping the babys mouth and nose
Dry
Evaluate color

Initial Steps
Provide warmth
Position; clear airway as necessary
Dry, stimulate and reposition

Provide warmth
Placed under radiant warmer
Leave the baby uncovered
under warmer:
- to allow full visualization
- to permit radiant heat to
reach the baby

Contd...
Premature babies more vulnerable to cold stress
Larger body surface area, thin skin
Less subcutaneous fat, decreased metabolic
response
Additional warming techniques: Plastic bags
Monitor for Hyperthermia

Initial Steps
Provide warmth
Position; clear airway as necessary
Dry, stimulate and reposition

Position by slightly extending the

neck
Sniffing Position
Shoulder Roll

Position by slightly extending the

neck

Clear Airway
Secretions removed from airway with a
towel/ bulb syringe/ suction catheter
Copious secretions- turn face to side
Gentle suction- Pressure < 100 mm Hg
Mouth before Nose (M before N)
Stimulation of posterior pharynx causes
Vagal stimulation and bradycardia- stop

Clear Airway
Method depend on:
1. Presence of meconium
2. Babys level of activity

Clear Airway

Mouth First
and
Then Nose

Clear Airway
Meconium Stained Amniotic Fluid

Routine intrapartum suctioning of

Mouth and Nose of babies born
through MSAF is no longer advisable

Meconium present and baby is

Vigorous
12F or 14F suction catheter or bulb
syringe for suction of mouth or nose
ET suction not required

Vigorous Baby- Definition

Strong respiratory
efforts
Good muscle tone
Heart rate > 100 bpm

Meconium present and baby is

Not Vigorous
Administer free flow oxygen throughout
Clear mouth and posterior pharynx
Insert endotracheal tube into the trachea
Attach the ET tube to suction source
Apply suction as ET is slowly withdrawn for
not more than 3 5 seconds
Repeat as necessary until no meconium or
heart rate indicates further resuscitation

Meconium Present and Baby

is Not Vigorous

Visualizing the glottis and suctioning

meconium from the trachea

Meconium Aspirator

Meconium Aspirator

Meconium Aspirator

Meconium Aspirator

Meconium Aspirator

Recommendations
Current guidelines not based on meconium
consistency
Techniques such as squeezing the chest,
occluding the airway, inserting a finger in
the babys mouth harmful not
recommended

Initial Steps
Provide warmth
Position; clear airway as necessary
Dry, stimulate and reposition

Dry, stimulate to breathe

and reposition
Use pre-warmed absorbent towels or
blankets
Keep head in sniffing position to maintain
good airway

Dry, Stimulate to breathe

and Reposition
Dry
thorough
ly

Remove wet
linen
Reposition the
head

Stimulation to Breathe
Suction and drying sufficient stimulation
If inadequate respiration then additional
tactile stimulation given briefly by
Slapping or flicking the soles of the feet
Gently rubbing the back, trunk or extremities
Overly vigorous stimulation harmful

Acceptable methods of
stimulation

Evaluate: Resp, HR & Color

Count the Rate for 6 seconds and multiply by
10 to get the Heart rate

Initial Steps
Provide warmth
Position; clear airway as necessary
Dry, stimulate and reposition
Give oxygen, as necessary

Free Flow Oxygen

If after Initial Steps:
Baby breathing well
Heart Rate > 100 bpm
Central Cyanosis

Give Free Flow Oxygen

Flow Rate: 5 Litres / minute
Oxygen tubing
Oxygen mask
Flow-inflating bag and mask
T-piece Resuscitator
CAN NOT be given reliably with a mask attached to
a Self Inflating Bag

Giving Free Flow Oxygen

Giving Oxygen
Provide enough oxygen for the baby to
become pink
Oxygen given for long periods must be
Heated and Humidified
Avoid unheated oxygen at high flow rates
(10L/min) to decrease heat loss
Gradually withdraw oxygen when baby pink

Oxygen
For Very Preterm Babies
Use an oxygen blender and pulse oximeter during
resuscitation
Begin PPV with oxygen concentration between
room air and 100% oxygen
Increase oxygen concentration up or down to
achieve saturations between 90 95%
If HR does not respond by increasing rapidly to >
100, correct any ventilation problem and use 100%
oxygen
If no facility of blender use 100% oxygen

Further Evaluation
Respiration
Heart Rate
Count for 6 seconds and multiply by 10
Feel pulse at base of umbilicus or auscultate
>100 bpm normal

Color
If any of these is abnormal initiate positive
pressure ventilation

Birth
Term Gestation?
Yes

T
A

30 seconds

Clear of Meconium?
Breathing or crying?
Good Muscle Tone?

Routine Care
Provide warmth
Clear Airway if needed
Dry
Assess color

No
Provide warmth
Position clear airway

C
D

Breathing, HR>100,
Pink

Evaluate Resp, HR and

Color

Observational Care

Breathing, HR>100,
Cyanotic

Pink

Give Supplementary Oxygen

Apnea

HR < 100

Provide positive pressure ventilation

30 seconds

30 seconds

(as necessary)
Dry, stimulate, reposition

HR < 60

HR > 60

Provide positive pressure ventilation

Administer Chest Compressions
HR < 60
Medications, continue PPV, CC

Persistent cyanosis
Ventilating
HR > 100 & Pink

Post resuscitation
Care

Endotracheal intubation may be

considered at several steps

Concentration of oxygen
Liter flow : 5 per minute

Approximately 80%

Approximately 60%

Approximately 40%

100% Oxygen at 5 litres per min.

O2 concentration

Tubing

Mask

Approx, 80%

from nose

Approx, 60%

1 from nose

Mask held firmly on

face

Approx, 40%

2 from nose

Mask held loosely on

face

Bag and Mask

Ventilation

Self-Inflating Bag
1. Parts
Air inlet
Oxygen inlet
Patient outlet
Valve assembly

2. Safety Features
Pressure release valve
Pressure gauge

3. Oxygen Reservoir

Resuscitation masks
1. Shape
Round
Anatomical

2. Size
Must cover chin, mouth and nose

Preparing equipment
1. Selection of bag
Right size
Oxygen reservoir
Safety features

2. Selection of mask
3. Oxygen source
4. Assembling and testing

Forming seal
1.
2.
3.

Positioning the infant

Position of the resuscitator
Positioning the mask

4. Checking the seal

Finger tip control

Chest movements
Abdominal movements
Breath sounds

Bag - Mask ventilation

1. Rate
40 / minute

2. Pressure
1st breath 30-40 cm water
There after 15-20 cm water

If the babys chest is not rising;

Check the position of the head
Reposition the mask
Increase the pressure
Repeat Suction

After each 30 seconds of

ventilation reassess the
babys respiration

Improvement

Increasing HR
Spontaneous respiration
Improving colour

Deterioration

Chest movement not adequate

Reapply mask
Reposition head
Repeat Suction
Increase pressure
Ventilate with open mouth
Pass orogastric tube

Deterioration
2.Oxygen delivery unsatisfactory

Check oxygen reservoir

Check oxygen flow
Check oxygen tubing

Chest Compressions

Birth
Term Gestation?
Yes

30 seconds

Clear of Meconium?
Breathing or crying?
Good Muscle Tone?

Routine Care
Provide warmth
Clear Airway if needed
Dry
Assess color

No
Provide warmth
Position clear airway

30 seconds

(as necessary)
Dry, stimulate, reposition

Breathing, HR>100,
Pink

Evaluate Resp, HR and

Color

Observational Care

Breathing, HR>100,
Cyanotic

Pink

Give Supplementary Oxygen

Apnea

HR < 100
Persistent cyanosis

Provide positive pressure ventilation

HR < 60

HR > 60

Provide positive pressure ventilation

Administer Chest Compressions

Ventilating
HR > 100 & Pink

Endotracheal intubation may be

considered at several steps

Post resuscitation
Care

Chest Compressions
When to begin chest compressions during
resuscitation
How to administer chest compressions
How to coordinate chest compressions with PPV
When to stop chest compressions

Indications
Heart rate less than 60 bpm despite 30
sec of effective positive-pressure
ventilation

Indications
Endotracheal intubation at this time may
help to ensure adequate ventilation
and facilitate the coordination of
ventilation and chest compressions

Why perform Chest

Compressions

Myocardium is depressed because of poor

oxygen levels - Low cardiac output
Mechanical pumping of heart required to
improve perfusion to the lungs

What are Chest Compressions

Also referred to as External Cardiac
Massage
Rhythmic compressions of sternum that
Compress the heart against the spine
Increase the intrathoracic pressure
Circulate blood to the vital organs

Phases of chest compressions

Fig 4.1

Compression

Release

How many people required

Chest
compressions and
PPV should be
simultaneous
Two people
required

Technique
Position of Hands on Chest

Thumb technique
( preferred )

Technique
Position of Hands on Chest

Two finger

Thumb Technique
Cant be used effectively if infant is big and
hands of operator small
Access to umbilical cord more difficult
Less tiresome than two finger technique
Better control over depth of compression
Press only sternum
Pressure on ribs can cause fractures

Two Finger Technique

More convenient if baby is large or hands
of operator are small
Better access to umbilicus
Better control over depth of compression
Cant be used by people with long finger
nails

Common Things In Two

Techniques
Position of Baby
Firm support for the back
Neck slightly extended

Compressions
Same location, depth and rate

Position of Thumb or Fingers on

the Chest

Location of Compression
Heart lies between sternum and spine
Pressure is applied on lower third of
sternum
Avoid Xyphoid

Position of Thumbs or
Fingers
Essential to
Locate the position of Xyphoid
Intermammary Line
Go along the costal margin identify the Xyphoid
and just above this point
Place your thumbs for fingers immediately
above Xyphoid
Avoid putting direct pressure on Xyphoid

Position of thumbs

Position of thumbs

Position of thumbs

Pressure from tips of Thumbs at right angles to Sternum

Position of thumbs

Positioning during
Two Finger
Technique

Two fingers (tips of index & middle fingers)

Position perpendicular to the chest
Support the back from hand
Be cautious of putting pressure of whole of
your hand on chest

Position of Fingers

Position of Fingers

Correct

Position of Fingers

Incorrect

How much pressure needed

Approximately 1/3rd of anteroposterior
diameter of the chest
One Compression
Downward Stroke plus the Release

How much pressure needed

Correct Method
DONOT Lift Thumb / Fingers off the chest between
compressions
Waste time relocating compression area
Lose control over Depth of compression
May Compress Wrong Area - Chance of Trauma

Correct Method

Incorrect Method

Dangers associated with Chest

Compressions
Trauma
Liver - Laceration
Ribs - Fracture

Structures That May Be Damaged

During Chest Comp.

Structures That May Be Damaged

During Chest Comp.

Frequency
Coordinate with IPPR
One ventilation interposed after every third
compression
Total of 120 events
30 breaths
90 compressions

Frequency

When to Stop
Chest Compressions
After approx. 30 sec of CC & PPV
Count Heart Rate
If > 60 - Stop Chest compressions
Continue PPV at 40 - 60 bpm Till
Baby breathing spontaneously
Heart rate >100 and
Baby pink

CB- NCP
Community Based Neonatal
Care Package

Causes of Neonatal Mortality in

Nepal

Sepsis
Asphyxia
Preterm/ LBW
Cong. Anomalies
Others

36%
--23%
27%
7%
-7%

Component of CB- NCP

Training programme

Universal Precaution
Essential Newborn Care
Neonatal Sepsis
LBW
Asphyxia

Signs of Possible severe Bacterial

Infection

Lethargy/ Unconcious
Tachypnoea (RR > 60/min)
Severe Chest Retraction
Nasal inflaration
Grunting
Bulged fontanel
Less Movement

Signs of Possible Severe Bacterial

Infection ( Cont.)

Fever / Hypothermia
Lethargy/ Unconscious
More than 10 boils
Umbilical infection with involvement
surrounding skin
Jaundice up to Palm/Sole