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Key messages

  • Effective ventilation is the key to successful resuscitation.
  • The need for neonatal resuscitation at birth cannot always be anticipated or predicted.
  • At every birth, suitable equipment and staff must be available and prepared to resuscitate the newborn infant.
  • Ten per cent of newborns require resuscitation.
  • Newborn resuscitation is a critical skill that requires constant practice.

The aim of neonatal resuscitation is to prevent neonatal death and adverse long-term neurodevelopmental sequelae associated with perinatal asphyxia.

Substantial physiologic changes occur in the transition from fetal to extrauterine life including:

  • the role of the placenta in gas exchange is taken over by the lungs
  • changes from fluid-filled to air filled lungs
  • dramatic increase in blood flow to the lungs with reversal, then closure of intra- and extra-cardiac shunts.

Failure or disruption of these changes may result in further difficulties with resuscitation in the newborn infant. For example, failure to increase alveolar oxygen and reduce pulmonary vascular resistance may lead to persistence of fetal circulation or persistent pulmonary hypertension (PPHN).

Preparation

Personnel

At least two trained people are required for adequate resuscitation involving positive pressure ventilation and chest compressions. Therefore, always call for help. Issues to note:

  • The most senior person available needs to coordinate resuscitation.
  • Each person must have a dedicated job, for example with three people, one should be solely responsible for airway, one solely responsible for chest compressions and the third person should coordinate the resuscitation and administer medication as necessary.
  • If possible have another person record events including time of administration of drugs, and the infant's response to interventions.

Check equipment

Checking equipment is essential. Issues to note:

  • Resuscitation equipment should be checked at least daily and after each usage.
  • When use is anticipated at a birth recheck equipment including medical air and oxygen supply, suction, positive pressure devices, laryngoscope and endotracheal tubes.
  • If an infant is expected to be in poor condition have medication readily available (E.g. adrenaline 1:10,000, O negative red blood cells and 0.9 per cent normal saline in the presence of massive antepartum haemorrhage).

Communication

Communication is vital to smooth resuscitation. Ensure clear communication with:

  • anaesthetic and obstetric staff regarding maternal condition, fetal condition, maternal therapies
  • the family, meet with resuscitation team before the birth if there is time.

Environment

Pay careful attention to the environment including:

  • prevention of heat loss
  • a warm draft free environment
  • the ambient temperature of the room should be at least 26°C for very preterm infants.

Assessment 

Evaluation begins immediately after birth with assessment of tone, breathing and heart rate.

Key features in ongoing evaluation are:

  • Breathing - the newly born infant should establish regular respirations in order to maintain HR > 100 bpm.
  • Heart rate determined from auscultation over the apex with a stethoscope or direct palpation of base of cord in first few minutes after birth. Peripheral pulses are often difficult to feel. If no pulsation is felt on palpation of the cord do not assume there is no heartbeat. The HR should be > 100 bpm in a well newly born infant.
  • Colour - assessment of colour is a poor proxy for oxygenation. Assess the oxygenation by use of a pulse oximeter with neonatal probe attached to the infant's right hand or wrist.

Management

Download the ANZCOR Neonatal flowchart from the Australian Resuscitation Council website

Temperature control

A warm draft free environment should be available. Drying the infant with prewarmed towels will help minimise heat loss in addition to use of a radiant warmer. The wet towel should then be replaced with a warm, dry one to prevent inadvertent heat loss. 

Premature infants, especially those less than 28 weeks' gestation should be placed immediately after birth in a polyethylene bag or wrap (appropriate size, food grade, heat resistant) with their head out and the body completely covered. Drying the infant's body prior to covering is not recommended. The bag/wrap should not be removed during resuscitation and should be kept in place until the temperature has been checked and other measures in place to prevent heat loss. 

Stimulation

Drying with a soft towel will stimulate most newborns to breathe.

If meconium is present in a non-vigorous infant, there is no evidence of the value of repeated endotracheal suctioning to prevent meconium aspiration. Clear the oro-pharynx if there is meconium present prior to providing tactile stimulation. Repeated suctioning of the trachea is not recommended.

Airway

The head should be in a neutral or slightly extended 'sniffing' position.

Suction is rarely required and should not exceed -100 mmHg. It should be limited in depth to 5 cm below the lips.

Breathing

Guidelines for breathing include:

  • Attend to adequate inflation and ventilation before oxygenation
  • The rate for assisted ventilation is 40-60 inflations per minute.
  • Positive pressure ventilation should be commenced in air (21 per cent oxygen) initially for the term infant and air or blended 30% oxygen for the preterm infant. 
  • Supplemental oxygen administration should be guided by pulse oximetry.
  • Hyperoxia should be avoided as even brief exposure to excessive oxygenation can be harmful to the newborn during and after resuscitation.
  • Regardless of gestation, aim for oxygen saturations of 91-95 per cent.
  • Wean supplemental oxygen once the saturations reach 90 per cent and heart rate has recovered.

Target saturations

Time from birth Target saturations during resuscitation
 2 minutes  65-85%
 3 minutes  70-90%
 4 minutes  75-90%
 5 minutes  80-90%
 10 minutes  85-90%

Effective ventilation is confirmed by observing these three signs: 

  • increase in the heart rate to above 100/min
  • a slight rise in the chest and upper abdomen with each inflation
  • Improvement in oxygenation.

Few infants require immediate intubation. The majority of infants can be managed with positive pressure ventilation via a face mask. ANZCOR recommend positive inspiratory pressure (PIP) 30cm H2O for a term baby and 20-25cm for a preterm baby.

See intubation for technical details.

PEEP

Positive end-expiratory pressure issues to note: 

  • PEEP has been shown to be very effective for establishing and maintaining lung volume and improving oxygenation. 
  • ANZCOR recommend the use of PEEP (5 -8 cm H2O) during resuscitation if appropriate equipment is available. 
  • High levels of PEEP (>8 cm H2O) have the potential to reduce pulmonary blood flow and cause pneumothorax, and should be used with great caution.

Circulation

In the majority of infants establishment of adequate ventilation will restore circulation.

Begin chest compressions for:

  • HR < 60 despite effective positive pressure ventilation for at least 30 seconds.

Aim for approximately a ratio of 90 chest compressions to 30 breaths per minute (3:1).

Supplemental oxygen should be increased to 100 per cent when compressions are commenced and titrated with guidance of pulse oximetry.

The ‘two thumb’ technique is preferred. Both thumbs meet over the sternum with fingers around the chest wall. The sternum should be compressed to one-third of the anteroposterior chest dimension.

Medications

Route of delivery

Routes of delivery for medications include:

  • umbilical venous (UV) catheter preferred route
  • ET for adrenaline only, although there is little research to support the use of endotracheal adrenaline and there are concerns that even in higher doses, it may still result in lower levels of adrenaline than the intravenous or UV route
  • intraosseous needle for failed or unsuccessful umbilical venous catheterisation
  • umbilical arterial catheter should not be used for drug administration during resuscitation.

Adrenaline

Given if HR < 60 for > 30 sec despite adequate compressions and positive pressure ventilation.

Dosage:

  • 0.1 to 0.3 mL/kg of 1:10,000 as a quick push IV repeated at 3-5 minute intervals if the HR remains <60 / minute despite effectiveventilation and cardiac compressions. It should be followed by a small saline flush.
  • 0.5-1.0 mL/kg of 1:10,000 ET (if no IV or UV access).

Volume (preload)

10-15 mL/kg normal saline IV push over several minutes, dose may be repeated two or three times.

This may need to be followed with O negative red blood cells in the setting of massive blood loss, especially in babies who are not responding to resuscitation interventions.

Naloxone

Naloxone does not form part of the initial resuscitation of newborns with respiratory depression in the delivery room.

Points to note about Naloxone:

If the baby is narcotised (that is, mother has been given opiates, the baby does not breathe reliably but has a good heart rate, and is usually quiet), then naloxone has a role in:

  1. Ensuring the baby does not require ventilator support 
  2. Ensuring that when breathing is established, apnoea does not recur
  3. Naloxone may result in rapid withdrawal with seizures if given to infants of narcotic dependent women.

Dosage - 0.1 mg/kg of 0.4 mg/mL solution

Bicarbonate

Bicarbonate is not indicated for routine use in resuscitation.

Ongoing care

Infants require careful observation and management in a special or intensive care nursery following active resuscitation. Attention to management of temperature, cardiorespiratory status (oxygenation, heart rate, respiratory pattern, and blood gas analysis), blood glucose levels and infection risk are required.

Term infants at risk of hypoxic ischaemic encephalopathy should be considered for therapeutic hypothermia therapy.

Prompt discussion with PIPER is recommended as cooling must be initiated within six hours of birth.

Stopping resuscitation

Issues to note about stopping resuscitation:

  • It is difficult to accurately define a time beyond which active support worsens brain injury.
  • It is reasonable to consider stopping treatment if the infant has not responded with a spontaneous circulation by 10 minutes of age.
  • It is helpful to be able to review events during resuscitation and this is made easier when events are recorded during resuscitation.

Get in touch

Centre of Clinical Excellence - Women and Children
Safer Care Victoria

Version history

First published: December 2015

Last reviewed: October 2018

Review by: July 2019

Uncontrolled when downloaded

Page last updated: 12 Nov 2020

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