Newborn resuscitation

• Most newborn babies don't need resuscitation — but always be ready
• If resuscitation needed — most babies only need Airway and Breathing support. Performed quickly these can prevent need for circulation support
• Bag-valve-mask resuscitation almost always successful if performed correctly — can be done for several hours while waiting to send to hospital
• Keep baby warm and dry but do not overheat — can depress respiration

What you need

• Newborn resuscitation equipment

Steps of resuscitation

• D – Dry and stimulate to get a response
• R – Response from baby - rapid assessment of breathing effort, heart rate, tone
• S – Send for help
• A – Airway — open and clear, sniffing or neutral position
• B – Breathing — positive pressure bag-valve-mask ventilation
• C – Circulation — chest compressions while continuing ventilation
• D – Drugs — give adrenaline (epinephrine) or fluid

• Reassess breathing effort, heart rate and tone every 30 seconds to decide whether to progress to next step

Improvement in baby’s condition are indicated by

• Spontaneous breathing
• Increasing heart rate
• Improving tone

Do — before birth

• Call for help 
• Warm room — close doors and windows to stop drafts or open doors and windows if air conditioner can't be turned off
• Get equipment ready and check it is working
• Identify flat surface for assessment and resuscitation if needed. Cover with towels if surface cold
• Try to get as much antenatal information as possible

Do — at birth

D – Dry stimulate baby with warm towel. Discard wet towel and cover baby in a clean warm towel. Cover baby's head

R – Response — Rapid assessment

• Breathing or crying
• Heart rate more than 100 beats/min — listen with stethoscope
• Good muscle tone

If answer is NO to ANY sign in rapid assessment — baby needs more help

• Have helper do urgent medical consult
• If doctor not on site — stay on phone
• Follow the steps below or see — Newborn resuscitation flowchart
• Assess breathing effort, heart rate and tone every 30 seconds
• Use results to guide progress through following steps or flowchart

If answer YES to ALL signs in rapid assessment — see Newborn care

Clamp and cut cord if needed

• Put 2 metal clamps on cord 5cm apart and at least 10cm from baby’s abdomen — Figure 1.7
• Cut cord between the 2 clamps with sterile blunt-end scissors
• Do not take clamps off after cutting

A – Airway

Establish an airway

• Put baby on flat, dry surface
• Put baby’s head in sniffing/neutral position to open airway — Figure 1.8
• Small towel under shoulders helps maintain position
• Do not tip head forward — Figure 1.9 or too far back — Figure 1.10

• Clear airway as needed
• If obvious signs of obstruction gently suction mouth then nose with 10–12F catheter for 5 seconds
• Reposition baby’s head to open airway
• Recheck breathing effort, heart rate, tone
• Continue to follow steps below or see — Newborn resuscitation flowchart

B – Breathing

Ventilation is the most effective action in newborn resuscitation — make sure assisted ventilation effective before continuing to circulation or see — Newborn resuscitation flowchart

If baby is not breathing effectively — bag-valve-mask ventilation at 40–60 breaths/min

• Start with room air for both term and preterm babies
• Check baby’s head in sniffing/neutral position — Figure 1.8
• Mask should cover nose and mouth —  Figure 1.11
• Need good seal between mask and face — Figure 1.12. Check for chest wall movement with each inflation — best indicator that mask is sealed and lungs are being inflated
• Put O₂ sats probe on baby's right hand or wrist
• After 30 seconds  — check breathing effort, heart rate, tone
• If no improvement after 30 seconds of effective ventilation — change from room air to oxygen at 10L/min

If chest not rising with each squeeze of bag — check for

• Poor seal - reapply mask to face to make better seal
• Blocked airway
• Reposition head
• If obvious signs of obstruction — gently suction mouth then nose with 10–12F catheter for 5 seconds
• Enough inflation pressure being used - squeeze bag more firmly to get an easy rise and fall of chest

C – Circulation

If heart rate less than 60 beats/min after 30 seconds of effective ventilation — continue bag-valve-mask ventilation with oxygen at 10L/min and start chest compressions

• Use 2 thumbs on lower third of sternum with fingers around chest — Figure 1.13 — best for 2-person resuscitation 
• Thumbs side-by-side or overlap for small baby

OR 2 fingers along sternum at right angle to chest — Figure 1.14 — best for single person resuscitation

• Can hold mask on with other hand — tuck bag under same arm

• Depth — 2–3cm (⅓ depth of chest) — Figure 1.15
• Ratio — 3 compressions to 1 breath
• Rate — 90 compressions + 30 breaths/min
• Leave space for each breath

• Use this rhythm in a 2 second cycle
• One-and-two-and-three-and-breath-and-one-and-two-and-three-and-breath-and … — Figure 1.16

If heart rate 60–100 beats/min — continue bag-valve-mask ventilation

• After 30 seconds — check breathing effort, heart rate, tone. Continue to follow steps below or see — Newborn resuscitation flowchart

If heart rate more than 100 beats/min, breathing 40 breaths/min or more and tone improving — put baby on mother's chest skin-to-skin

• If central cyanosis — give free flow oxygen
• See — Newborn care

If baby not improving

If heart rate less than 60 beats/min — usually ineffective ventilation (not enough oxygen)

• Continue bag-valve-mask ventilation and chest compressions
• Review resuscitation technique
• Is chest movement adequate — recheck seal, airway, inflation pressure
• Check oxygen is connected to bag-valve-mask at 10L/min
• Are chest compressions ⅓ depth of chest
• Are chest compressions and ventilation well-coordinated

D – Drugs

• If heart rate still less than 60 beats/min — continue chest compressions with bag-valve-mask ventilation
• Medical consult
  
• Give adrenaline (epinephrine) and fluids as directed by doctor
• Be ready to put in IV cannula or intraosseous needle as directed by doctor
• Adrenaline (epinephrine) IV/intraosseous 0.01-0.03mg/kg (0.3mL/kg of 1:10,000 solution) followed by a small normal saline flush every 3-5 minutes — repeat every 3-5 minutes if heart rate less than 60 beats/min despite effective ventilation and chest compressions

Ongoing resuscitation

• If prolonged bag-valve-mask ventilation needed — get helper to put in nasogastric tube, if skilled
• Stop ventilation for as short a time as possible
• Suction gastric contents, secure tube, leave tube on free drainage (unplugged)
• Reposition baby’s head and restart ventilation
• If no heartbeat after 15 minutes of resuscitation — medical consult about stopping resuscitation — outcome for baby is always poor 
• Talk with mother and family and explain situation

Pulse oximetry

• Use O₂ sats probe, if available
• When starting positive pressure bag-valve-mask ventilation
• If giving oxygen
• If persistent cyanosis suspected
• Put probe on baby's right hand or wrist
• See — Table 1.1 for target O₂ sats
• O₂ sats for normal newborns can take up to 10 minutes to rise above 90%
• If O₂ sats reach 90% — gradually reduce amount of oxygen being given
• If O₂ sats falling or less than 90% after 10 minutes — specialist consult

Post-resuscitation care

Babies who need full resuscitation have been severely stressed — monitor closely while waiting for evacuation

• See — Newborn care for monitoring and ongoing care
• Continue oxygen unless directed by doctor to stop
• Maintain baby's temperature between 36.5 and 37.5°C — see Keeping baby warm after birth
• Check baby's blood glucose level
• Put in nasogastric tube, if skilled and directed by doctor
• Size 6F for very small babies, size 8F for bigger babies
• Leave tube on free drainage (unplugged) to let out air in stomach (from bag-valve-mask ventilation)
• Baby may need fluid or medicines — be ready to put in IV cannula or intraosseous needle as directed by doctor