Helping Babies Breathe

A healthy first cry represents a baby

with unlimited potential
Golden minute

At no other time in ones life will necessary critical

concepts in resuscitation have a potential lifelong
impact

A babys first cry is one of the most anticipated and

welcome sounds in all the world

Appropriate interventions can make the difference

between life or death, or normal life vs. life of
disability

!"#$ % &' (
Inverted Pyramid
of Neonatal Resuscitation
Medication
s
Chest
Compressions
Positive-Pressure
Ventilation
Initial Steps: Drying,
Warmth, Clearing the
Airay, Stimulation
Assessment at !irth and
Simple "e#orn Care
All infants All infants
Some infants Some infants
Few infants Few infants
Wall, Lee, Niermeyer et al. IJGO 2009
136 million
babies born
Approx 10
million babies
Approx 6 million
babies
< 1.4 million
babies
What Can Go Wrong During
What Can Go Wrong During
Transition
Transition

Inadequate ventilation; oxygen may not reach

Inadequate ventilation; oxygen may not reach
blood in lungs
blood in lungs

Systemic hypotension from excess blood loss or

Systemic hypotension from excess blood loss or
neonatal hypoxia and ischemia
neonatal hypoxia and ischemia

Pulmonary arterioles may remain constricted after

Pulmonary arterioles may remain constricted after
birth PP!"#
birth PP!"#

$ac% of perfusion and oxygenation may cause

$ac% of perfusion and oxygenation may cause
brain damage or death
brain damage or death
Signs of a Compromised Newborn
Signs of a Compromised Newborn

&epressed respiratory
&epressed respiratory
drive
drive

Poor muscle tone

Poor muscle tone

'radycardia
'radycardia

(achypnea
(achypnea

Persistent cyanosis
Persistent cyanosis

$ow blood pressure

$ow blood pressure
Good Good
tone with tone with
cyanosis cyanosis
Bad tone Bad tone
with with
cyanosis cyanosis
Perinatal Compromise
Perinatal Compromise
Primary Apnea
Primary Apnea

)xygen deprivation
)xygen deprivation

Period of attempted rapid breathing

Period of attempted rapid breathing

Primary apnea and dropping !*

Primary apnea and dropping !*

+ill improve with tactile stimulation

+ill improve with tactile stimulation
Secondary Apnea
Secondary Apnea

,ontinued oxygen
,ontinued oxygen
deprivation leads to
deprivation leads to
secondary apnea
secondary apnea

!eart rate and blood

!eart rate and blood
pressure fall
pressure fall

Secondary apnea cannot be

Secondary apnea cannot be
reversed with stimulation
reversed with stimulation

Assisted ventilation must

Assisted ventilation must
be provided
be provided
The Theme of Neonatal
resuscitation

ircle of

!valuation

"ecision

Action

Timely manner

Team wor#
TABs

Temperature

Airway

Suction secretions- assess for anomalies

Breathing

Stimulate respiratory effort

(actile

'ag.mas% positive pressure ventilation PP/#

irculation

Assess heart rate

,hest compressions if PP/ ineffective at restoring heart rate

Term gestation
Breathing or
crying$
%ood tone$
&!'
R()TIN! AR!

Stays with mother

Provide +armth

,lear Airway

&ry

)ngoing evaluation
Initial steps
N(
!valuate HR
Respirations
*armth
(pen Airway
"ry
'timulate

NP algorithm !"#$# (
HR below +,,-
gasping- or apnea$
PP.- 'po/ monitoring
HR below +,,$
Ta#e ventilation
corrective steps
0abored breathing
or persistent
cyanosis$
lear airway-
'po/ monitoring-
onsider PAP
Post Resuscitation are
YES
NO
NO
Yes
Ineffecti%e
PP& !'
S(PA)
HR below +,,$
(a%e ventilation corrective
steps
HR below 60 $
onsider intubation
hest compressions
oordinate with PP.
HR below 60 $
i.v. epinephrine
Ta#e ventilation
corrective steps
Intubate if no chest rise!
onsider
.Hypovolemia
. Pneumothora1
yes
Yes
Yes No
No
Yes
Mask Adjustment
Reposition head
Suction upper airway
Open mouth and lift Jaw
Pressure increase
Airway alternative
Plan and prepare for birth

!2uipment chec#
before birth - you should as#
%estational age
lear fluid
How many babies
(ther ris# factor
Need additional e2uipment
Need more people
*uic+ pre resuscitation chec+list

*arm- dry

'uction

Auscultate

(1ygenate

.entilate

Intubate

3edicate

Thermoregulate
Plastic wrap in 4 /5 w#s

Polythene wrap or bag up to their necks

without drying.

Infants should be kept wrapped until

admission and temperature check.
'anagement of 'econium
0121
333
,ag - mas+ %entilation . in 'SA/ ??

If attempted intubation is
prolonged and unsuccessfull
0

- if there is persistent
bradycardia0
Indications for PP.

Apnea

%asping respirations

Heart rate 4 +,,

Positi%e Pressure &entilation

*hen done appropriately- PP. should result in

improvement in heart rate and color

Appropriate si4e mas% and bag

Self.inflating vs5 flow.inflating bag

Forming a good seal with mas%

Achieve adequate chest rise

61.71 breaths per minute

Positi%e Pressure &entilation
inflation pressure?
initial inflation pressure of
"# cm 1"(
2# to 3# cm 1"( may be re4uired in some term
babies without spontaneous %entilation
5ffecti%e &entilation

'ilateral breath sounds

,hest movement !* may rise without visible

chest movement- especially with preterm baby#

8ost important indicator of successful PP/ is

improving heart rate

9se lowest inflation pressure to maintain !*

above 211
Ineffective PP. 63R '(PA

3as# Ad7ustment

Reposition head

'uction upper airway

(pen mouth and lift 8 aw

Pressure increase

Airway alternative
When to use
P67S5 (8I'5T9
- Anticipated resuscitation
positive pressure respiration is administered
- hen cyanosis is persistent
- hen supplemental o!ygen is administered
(:imetry and (:ygen Supply

For all compromising babies pulse oximetry should be

used to detect the preductal saturation and heart rate
28
(89G5N ASS5SS'5NT

Insufficient "!cessive
o!ygenation o!ygenation
#armful to neonate
hest ompressions

ompression of sternum +9: depth of AP diameter of

chest

Increase (/ to +,,;
Chest Compressions

Begin chest compressions when

HR is below <, despite at
least :, seconds of effective PP.
oordinate with ppv at + =:

Two thumb method is preferred

Provides more consistent pressure

Better control of compression depth

/>?inger Techni2ue

Better for small hands

Provides access to umbilicus for

medications

Depress sternum to approimately one

third of the anterior!posterior diameter
of the chest

"##$ oy%en should &e %iven with

chest compressions

'ontinue chest compressions for ()!*#

seconds &efore stoppin% to evaluate the
+R

,ntu&ation is hi%hly recommended

with chest compressions
5ndotracheal Intubation
5ndotracheal Intubation; Indications

(o suction trachea in presence of meconium when the

baby is not vigorous

(o improve efficacy of ventilation after several

minutes of bag.and.mas% ventilation

(o facilitate coordination of chest compressions and

ventilation

(o administer epinephrine while I/ access is being

established
-imit attempt to .# seconds
5ndotracheal Intubation;
adiographic Confirmation
Correct Incorrect Correct Incorrect
Indications for !pinephrine

Heart rate persists 4 <, after

Initial steps @:, secondsA

PP. @:, secondsA

hest compressions @BC><, secondsA

"osage given I. 6). preferredD- or endotracheal

6higher dose givenD
5pinephrine Administration
Dilute 1:1000 concentration of epinephrine to
Dilute 1:1000 concentration of epinephrine to
1:10,000
1:10,000
eco!!ended concentration: 1:10,000 eco!!ended concentration: 1:10,000
eco!!ended route: Intra"enously eco!!ended route: Intra"enously
eco!!ended dose: 0#1 to 0#$ !%&'( eco!!ended dose: 0#1 to 0#$ !%&'(
eco!!ended preparation: 1:10,000 solution in 1 !% syrin(e eco!!ended preparation: 1:10,000 solution in 1 !% syrin(e
eco!!ended rate of ad!inistration: eco!!ended rate of ad!inistration: Rapidly Rapidly
Consider endotracheal route )*%+ while I, access -ein( o-tained Consider endotracheal route )*%+ while I, access -ein( o-tained
eco!!ended dose: 0#. to 1!%&'( eco!!ended dose: 0#. to 1!%&'(
/repare 1:10,000 solution in $ !% syrin(e /repare 1:10,000 solution in $ !% syrin(e
5pinephrine; Poor esponse
!1eart ate < =# bpm (
Rechec# effectiveness of=

/entilation

,hest compressions

:ndotracheal intubation

:pinephrine delivery
onsider possibility of hypovolemia
Indications for &olume Administration

No response to above resuscitation measures

History of blood loss at delivery suggesting

hypovolemia

Infant appears to be in shoc# 6pallor- poor perfusion-

failure to respond appropriately to resuscitation
effortsD

I.- +,>/, m09#g- Normal saline- Ringers lactate- or

(> blood
Withhold > discontinue resuscitation ?

Age of viability in your institution5

Parental informed decision

In a newly born baby with no detectable heart rate- it is

appropriate to consider stopping resuscitation if the heart
rate remains undetectable for +, minutes
Eey Points

Resuscitation re2uires a rapid series of assessments-

interventions- and reassessments

Prompt initiation of respiratory support with positive

pressure ventilation by bag>mas# is the #ey to
successful resuscitation of most infants

Always consider corrective steps in ventilation and

hypovolemia and pneumothora1 6other causesD
Recommendation
Routine intrapartum oropharyngeal and nasopharyngeal
suctioning for infants born with clear and9or meconium>stained
amniotic fluid is not recommendedF

If attempted intubation is prolonged or unsuccessful- mas#

ventilation should be implemented- particularly if there is
persistent bradycardiaF

The 03A should be considered during resuscitation of the

newborn if face mas# ventilation is unsuccessful and tracheal
intubation is unsuccessful or not feasibleF
5ndotracheal Intubation

(racheal suctioning for non.vigorous

meconium.stained newborn

:ffective PP/ with bag and mas% and no clinical

improvement

PP/ lasting more than a few minutes

+hen chest compressions are needed

Special indications diaphragmatic hernia- etc#

6se of (:ygen

*esuscitation of term newborns should begin with

02; oxygen

*esuscitation of preterm newborns may begin with

slightly higher oxygen

It may ta%e up to 21 minutes for a healthy newborn

to become well oxygenated on room air

Place oximeter if available# and increase oxygen

gradually to meet target saturations
6mbilical cord clamping

For healthy term infants delaying cord clamping for at

least one minute or until the cord stops pulsating
following delivery improves iron status through early
infancy5

For preterm babies in good condition at delivery-

delaying cord clamping for up to : min results in
increased blood pressure during stabilisation- a lower
incidence of intraventricular haemorrhage and fewer
blood transfusions

3ost infants successfully transfer from intrauterine to e1trauterine life without

any special assistanceF

+, percent of newborns will need some interventionF

+ percent will re2uire e1tensive resuscitative measures at birthF

personnel who are ade2uately trained should be readily available to perform

neonatal resuscitation at every birthing location

GInfants who are more li#ely to re2uire resuscitation can be identified by

maternal and neonatal ris# factors

are providers s#illed in neonatal resuscitation should be present and e2uipment

should be prepared prior to the birth of the high>ris# infantF

GPreterm infants are more li#ely to re2uire resuscitation and develop

complications from resuscitation than term infants
Please ta+e good care of me?
Im the Future!