Neonatal

resuscitation

Lungs and fetal blood flow

In

the utero the infant is

dependent by placenta like
organ through the gas exchange
occurs

All

alveoli are full with fetal

lung fluid

Theres

arterial vasoconstriction

Pulmonary

diminished

Blood

blood flow is

flow in the ductus

arteriosus is bridged

Major changes that take place within

seconds after birth

Here occur air intake

The fluid in the alveoli is absorbed into the lung tissue and replaced by air

The umbilical arteries and vein are clamped. This remove the the low-rezistance
placental circuit and increases systemic blood pressure.

Major changes that take place within

seconds after birth

Pulmonary blood vessels dilates

(as a result of gaseous
distension and increased
oxygen in the alveoly)

Increse pulmomary rezistance

Blood flow dramatically

increase

And blood is redirectioned to

the lungs

Major changes that take place within

seconds after birth

As oxygen blood levels increase,

pulmonary blood vessels relax

The ductus arteriosus begins to

constrict

The blood previously deverted

through the ductus arteriosus now
flow to the lungs, were it pick up
more oxygen

Signs of a compromised baby

Cyanosis

Decreased muscular tonus

Depression of respiratory drive from insufficient

oxygen delivery to the brain

Bradycardia from inssuficient delivery oxygen to

the heart muscle or brain stem

Low blood pressure from insufficient oxygen to

the heart muscle, blood loss, or insufficient blood
return from the placenta before or during birth

Tahipnoe

Thirst vital sign to cease when a newborn

is deprived of oxygen - Apnea
Primary apnea

It occurs after an initial period of rapid attempts to breathe

Breaths dont disappear

Cardiac frequency decrease

Blood pressure in often menteined at the normal level

Responds to tactil stimulation.

Secondary apnea

Breaths stops

Cardiac frequency decrease

Blood pressure decrease

And theres no any respons to stimulation

For the procces to reverse must be provided assisted ventilation

Birth

Presense of meconium
Color pink
Breathing or crying
Good muscle tone
Term gestation

Assessment

No

Provide warmth
Position; clear airway* (if necessary)
Dry, stimulate, reposition
Give O2 (if neccesary)
Evaluate respiration, heart rate and
color

Provide O2

Provide positive-pressure
ventilation VPP*

Persistent cyanosis
FCC>60

VPP*
Administer chest
compressions*
FCC<60
Administer
epinephrine*

Evaluation
Breathe, FCC>100, cyanosis

Apnea, FCC <100

FCC<60

B
Evaluation

C
Evaluation

Key point in neonatal resuscitation

Cardiac Frequency <60 b/min - there are necessity of

additional steps

Cardiac Frequency >60 b/min Chest compressions may

stop

Cardiac Frequency >100 b/min Pozitive-pressure

ventilation may stop

Every steps take no longer than 30 second. This time should be

enough to achieve a respons and decide whether you need to go
on to the next.

Indications for neonatal

resuscitation

Apnea / inefficient breathing

Bradycardia FCC <100 b/min

Generalised cyanosis

Why are premature babies at higher

risk?
Their

lungs may be deficient in surfactant and

therefore may be more difficult to ventilate

Their

skins particularities make them more likely

to lose heat

They
Their

are more likely to be born with an infection

brains have very fragile capillaries that may

bleed during periods of stress

New born evaluation

Immediately after delivery, must put the following questions:

Birth

Presense of meconium
Color pink
Breathing or crying
Good muscle tone
Term gestation

Yes

-Provide warmth
-Position; clear
airway* (if necessary)
-Dry, stimulate,
reposition

Step A Airway 1st step in

newborn resuscitation

Provide warmth
Position; clear airway* (if
necessary)
Dry, stimulate, reposition
Give O2 (if neccesary)
* Endotracheal intubation my be considered at several steps

Warmth providing
Method:

Baby

should be placed
under a radiant warmer,
uncovered

Dried

thoroughly

Removed
Radiant warmer for resuscitating newborns

from wet linen

Dry thoroughly

Remove wet linen

Head reposition
Drying and removing wet linen to prevent heat loss and repositioning
the head to ensure an open airway

Clear the airway

The

baby should be positioned on the back or side

Neck

should be slightly extended in the sniffing

position.

This

will bring the posterior pharynx, larynx, and

trachea in line

Suctions

first mouth and then nose

Correct

Incorrect
(Hyperextension)

Incorrect
(Flexion)

Correct and incorrect head position for resuscitation

Clear the
airway

Mouth thirst

Then nose.
Suctioning the mouth and nose. M
before N

Management in
case of
meconium
presence

Management in case of meconium

presence and baby is vigorous.
If Meconium was present in the amniotic fluid, but:

The breathing is present and respiratory effort is strong

Muscular tone is good

Heart Rate >100 b/min

Then

The person delivering the baby should have suctioned the

oropharynx and nares with a catheter or bulb serynge before
delivering the shoulders.

Management in case of meconium

presence and baby isnt vigorous.

Administer free-flow oxygen throughout the suctioning procedures

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

Attach the endotracheal tube to a suction source

Aplly suction as the tube is slowly withdrown

Repeat if necessary until little additional meconium is recovered, or

until the babys heart rate indicates that resuscitation must proceed
without delay

Stimulation Methods
Slapping

or flicking the
soles ( plants) of the feet

Gently

rubbing the
newborns back, trunk or
extremities

Form of stimulation wich may be

hazardous
Slapping

the back

Squizing

the rib cage

Forcing

things onto abdomen

Dilating
Ussing

the anal sphincter

cold or hot compresses or baths

Shaking

Giving free-flow oxygen

If

newborn breaths but central cyanosis occurred

He

requires humidified, heated oxygen

Flow

rate should be at 5 l/ min

Continue

until stabilize the newborns condition

Giving free-flow oxygen

Flow-inflating bag

Oxygen mask

Oxygen delivered by tubing held in

cupped hand over babys face

Evaluate

Evaluate

Step B - initiation breathing initiation

Ventilation with positive pressure (VPP)
Bag and Mask

Flow-inflating bag

ADVANTAGES:

Delivers 100% oxygen all the time

Easy to determine when there is a

seal om the patient s face

Stiffness of the lung can be felt

when squeezing the bag

Can be used to deliver free-flow

100% oxygen

Self inflating bag

ADVANTAGES:

Will always refill after being

squeezed, even with no
compressed gas source

Pressure-relax valve makes

overinflation more likely

The mask

Cover mouth, nose, and chin but

not eyes

Keep in mind!

Dont jam the mask down on

the face

Dont allow your fingers or part

of your hand to rest on the
babys eyes

Dont press on neck (trachea)

Right use of the mask

Intake
(Compress the mask )

two
..three
(Relax)........

If theres a positive response to PPV

Chest movements ocurrs

Symmetrical auscultation

Improving of the skin colour

Heart Rate normalise

Signs of improvement
Increasing

the heart rate

Skin color is good
Autonomic breathing ocurrs

Posible causes for inadequate cheast

movements
The

face mask dont stay seal

Airway blockage
Inadequate pressure used

If the baby is not improving :

Chech

the oxygen, bag, contact and

pressure
Are chest movement adequates ?
Is 100% oxygen being administrated

Evaluation

Step C Circulation
Chest compression.

Indications for cheast compression:

HR < 60 b/ min after 30 sec. PPV (Positive

pressure ventilation)

Olways

perform PPV during chest compression

For performing cheast compression needs 2

persons:
One

person perform cheast compression

The

other - Positive pressure ventilation

Coordination of cheast compression

and ventilation
The ratio CC/ PVV = 3/1 performed in 3 sec

2 sec for one cycle

Chest compresion

How to position hands on the chest to

begin chest compression!

There are two different techniques

1. Thumb

technique
2. Two-finger technique

Presure and depth of compressions

We

press between the lower third of the

sternum and the spine

Time

of compression is shorter than

releasing time

Fingher

shoud keep the contact with the

chest when release

Presure and depth of compressions

Methods of chest compression

Thumb technique 1st

Methods of chest compression

Two-finger technique

 Thumb
Easier

technique

to tolerate

Better

control depht Two-finger technique

of compressions
Easier to be performed
by one person

Better
Allow

for small hands

the way to
umbilicus for doctor

Thumb technique

Thumbs compress
the sternum

Fingers support
the back

Thumb technique

Two-finger technique
2

finger
compress the
sternum

The

other hand
support the
back

Two-finger technique

Potential complications of CC
Liver

rupture
Ribs broken

 If

HR stays <60 b/min

despite of ventilation and
cardiac compresions
performed during 30
seconds then administer
epinephrine

Step D Drugs/ Medications

Indications for drug administration
!!! HR <60 despite PPV i CC during30 sec
Epinephrine: indications

HR < 60 b/min after:

30 sec of PPV

30 sec of CC + PPV

________________

Total 60 sec

Note: Epinephrine is Not indicated before restoring adequate ventilation

Epinephrine: administration ways

1.

Endotracheal tube
2. Umbilical vein

Epinephrine administration with

endotracheal tube
Might

be introduced
direct in ET or
through a catheter
inserted into ET

Use

an 5F feeding
tube

After

this procedure,
provide PPV

Epinephrine administration trough

umbilicus
Insert

the
catheter in chuted
umbilical stump
using sterile
technique

Epinephrine administration trough

umbilicus

Epinephrine

Recommended concentration

Recommended concentration

Volume expansion:
Normal

saline
Ringer Lactate Solution
Blood group 0 (I) Rh neg

Volume expansion:

Normal saline recomanded

Medication Volume- expansion

Volume- expansion
Signs that indicates a good response

Blood pressure increase

Strong puls

Pallor diminishes

If hypovolemia persists:

Repeat Volume-expansion

Give Sodium bicarbonate for babies with severe metabolic acidisis

Prolonged reanimation
Consequences:
Establishment
Cardiac

contractility weakness

Reduced
If

of lactic acidosis

pulmonary blood flow

lactit acidosis its suspected then give

Sodium Bicarbonate

Medication Sodium bicarbonate

Interruption resuscitation measures

We stop reanimations measures if:

Convince yourself that recovery processes are
adequate
- You can turn off after 15 minutes of asystole
-If necessary unclear prognosis of continuous
condition assessment,
-

Discussions with parents and team

Oro tracheal intubation

Indications
If

there is meconium and the baby has depressed

respirations, muscle tone or heart rate

If

PPV with bag and mask had no good result in

chest rise, or if the need of PPV lasts beyond few
minutes

If

require epinephrine (it has only through

endotracheal tube administration )

Endotracheal intubation :
equipment and supplies
Equipment

should be clear

Sterilized
One

use only

Preferable

with uniform diamitre

Endotracheal tube
Black

line
near the tip
of the tube,
called vocal
cord guide

Endotracheal tube: sizes

Select it up to body wight and gestational age

Tube size (mm) Weight

(intern diametre)

GA
(g)

(weeks)

2.5

Sub 1,000

<28

3.0

1,000-2,000

28-34

3.5

2,000-3,000

34-38

3.5-4.0

Peste 3,000

>38

IF the tube is correct introduced

then:
Every

ventilation chest rises

Breathing
During

is symmetrical on both lung fields

ventilation stomach distends

Condensation

forms on the tubes walls

during exhalation

How to prepare laryngoscope and

additional supplies

Select blade and attach to handle

Check light

Prepare suction equipment

Prepare resuscitation bag and mask

Turn on oxygen

Get stethoscope

Cut tape or prepare stabilizer

Babys positioning

Intubation steps
1.

Stabilize the babys head

2.

Give free-flow oxygen

3.

Slide the laryngoscope blade over the right side

of the tongue

4.

Lift the blade slightly

5.

Look for landmarks

6.

Insert the tube

7.

Use a fingher to keep the tube hold to hard

palate and remove the laryngoscope without
displacing the tube

Intubation steps
3. Slide the laryngoscope blade over the right side of
the tongue
4. Lift the blade slightly

Intubation steps
1.

Stabilize the babys head

2.

Give free-flow oxygen

3.

Slide the laryngoscope blade over the

right side of the tongue

4.

Lift the blade slightly

5. Look

for
landmarks

6.

Insert the tube

7.

Use a fingher to keep the tube hold to

hard palate and remove the laryngoscope
without displacing the tube

Intubation steps
1.

Stabilize the babys head

2.

Give free-flow oxygen

3.

Slide the laryngoscope blade over the

right side of the tongue

4.

Lift the blade slightly

5.

Look for landmarks

6. Insert
7.

the tube

Use a fingher to keep the tube

hold to hard palate and remove
the laryngoscope without
displacing the tube

Intubation steps
1.

Stabilize the babys head

2.

Give free-flow oxygen

3.

Slide the laryngoscope blade over the right

side of the tongue

4.

Lift the blade slightly

5.

Look for landmarks

6.

Insert the tube

7.

Use a finger to keep the tube

hold to hard palate and remove
the laryngoscope without
displacing the tube

Very important to check for sure that

the tube is in the trachea
A

rise in the chest with each breath

Breath sounds over both lungs fields but
decreased or absent over the stomach
Theres No gastric distension with
ventilation
Vapor condens on the inside of the tube
during exhalation

Radiological confirmation