Newborn Resuscitation

Key Principles

  • Most term babies need no resuscitation
  • Prevent heat loss
  • Delay cord clamping ≥1 minute
  • Dry and assess first

Thermal Care

  • Maintain 36.5-37.5°C
  • Dry term infants
  • Polywrap preterm infants
  • Head covering essential

Initial Assessment

  • Tone, Breathing, Heart Rate
  • APGAR at 1 & 5 minutes
  • HR <100 = intervention
  • HR <60 = compressions

Ventilation

  • 5 inflation breaths first
  • 30cm H2O for term infants
  • 20-25cm H2O for preterm
  • Use PEEP if possible

Chest Compressions

  • Two-thumb technique
  • 3:1 compression:ventilation
  • Lower third of sternum
  • 1/3 chest depth compression

Drugs

  • Adrenaline 1:10,000
  • Sodium bicarbonate 4.2%
  • Glucose 10%
  • Umbilical venous route

Newborn Resuscitation

Comprehensive guide to neonatal resuscitation and transition support

Introduction

Key Message

Most babies born at term need no resuscitation and can usually stabilise themselves during the transition from placental to pulmonary respiration very effectively.

Risk Factors for Resuscitation

Intrapartum Factors

  • Significant fetal compromise
  • Breech vaginal delivery
  • Maternal infection
  • Multiple pregnancies
  • Caesarean before 39 weeks

Neonatal Factors

  • Gestation < 35 weeks
  • Low birth weight
  • Congenital anomalies
  • Meconium staining

Initial Stabilization Approach

Newborn Initial Stabilization

Proper positioning and thermal management for newborn stabilization

Cord Clamping & Thermal Care

Cord Clamping

  • Uncompromised infants: Delay clamping ≥1 minute
  • Benefits: Gradual transition, better blood pressure stability
  • Compromised infants: Resuscitation takes priority
  • Preterm infants: Particularly benefit from delayed clamping

Thermal Management

  • Target temperature: 36.5-37.5°C
  • Term infants: Dry and cover with dry towels
  • Preterm infants: Polyethylene wrap under radiant heater
  • All infants: Head covering with appropriate hat
  • Document: Admission temperature as quality indicator

Thermal Care Techniques

Thermal Care Methods

Different approaches for term vs preterm thermal management

APGAR Assessment

Clinical Assessment Guide

  • Healthy infant: Blue but good tone, cries within seconds, HR 120-150/min
  • Less healthy: Blue, reduced tone, HR <100/min, poor breathing at 90-120s
  • Unwell infant: Pale and floppy, not breathing, very slow/absent HR

APGAR Scoring System

Sign/Score 0 1 2
Appearance (colour) Pale blue Body pink, extremities blue Completely pink
Pulse rate Absent < 100 > 100
Grimace (reflex irritability) No response to stimulation Grimaces when stimulated Cries when stimulated
Activity (muscle tone) Limp Some flexion of extremities Active
Respiratory effort Absent Slow/irregular Strong cry

APGAR Timing

  • Routinely assessed at 1 and 5 minutes after birth
  • If 5-minute score <7, continue every 5 minutes up to 20 minutes
  • APGAR is an assessment tool, not a determinant for resuscitation
  • Resuscitation should begin before 1-minute APGAR

Newborn Life Support Algorithm

🕒 START THE CLOCK / NOTE TIME

Consider need for help and call immediately if needed

🌡️ INITIAL STEPS

  • Dry the baby thoroughly
  • Maintain normal temperature
  • Assess tone, breathing, and heart rate

💨 BREATHING ASSESSMENT

If gasping or not breathing:

  • Open airway (neutral position)
  • Give 5 inflation breaths
  • Consider SpO2 ± ECG monitoring

🔄 REASSESS HEART RATE

If no increase in HR, check chest movement:

  • Recheck head position
  • Consider 2-person airway control
  • Repeat inflation breaths

❤️ HEART RATE MANAGEMENT

When chest is moving:

  • HR <60/min: Ventilate for 30 seconds
  • Still <60/min: Start chest compressions (3:1 ratio)
  • Reassess every 30 seconds

💊 DRUG THERAPY

If HR remains <60/min despite ventilation and compressions:

  • Consider venous access
  • Administer drugs as needed
  • Senior help should be involved

NLS Algorithm Visual Guide

NLS Algorithm Flowchart

Complete Newborn Life Support algorithm decision pathway

Airway Management

Optimal Airway Position

  • Infant on back with head in neutral position
  • Neck neither flexed nor extended
  • Support under shoulders to prevent neck flexion
  • Avoid overextension
  • Jaw thrust for floppy infants

Suction Guidelines

Indications for Suction

  • Obvious airway obstruction
  • Visible material in airway
  • Failed airway positioning
  • Meconium, blood, or mucus obstruction

Suction Techniques

  • Direct visualization of oropharynx
  • Suction under direct vision
  • Intubation for tracheal obstruction
  • Do not delay inflation breaths
  • Trained staff only for advanced procedures

Airway Positioning Techniques

Airway Positioning Techniques

Correct neutral position and jaw thrust techniques

Breathing & Ventilation

Initial Assessment

Most infants establish breathing by 90 seconds with HR >100/min

Inflation Breaths

5 initial breaths at 30cm H2O for 2-3 seconds (20-25cm H2O for preterm)

Response Assessment

HR should increase as oxygenated blood reaches heart

Continuing Ventilation

If HR improves but no spontaneous breathing: Continue at 30-40/min

Ventilation Pressures

Infant Type Initial Pressure Inspiration Time PEEP
Term Infant 30 cm H2O 2-3 seconds 4-5 cm H2O (if possible)
Preterm Infant 20-25 cm H2O 2-3 seconds 4-5 cm H2O (recommended)

Oxygen Therapy

Term Infants

  • Start resuscitation in air (21% O2)
  • Increase if oxygenation remains poor
  • Guide by pulse oximetry
  • Increase during chest compressions

Preterm Infants

  • Start with 21-30% oxygen
  • Use blended oxygen/air
  • Guide by pulse oximetry
  • Consider CPAP for breathing infants

Chest Compressions & Drugs

Two-Thumb Chest Compression Technique

Chest Compression Technique

Correct hand position for two-thumb chest compressions

Chest Compression Guidelines

  • Indication: HR <60/min despite effective ventilation
  • Technique: Two-thumb method, hands encircling chest
  • Location: Lower third of sternum
  • Depth: 1/3 of anteroposterior chest diameter
  • Ratio: 3 compressions : 1 ventilation
  • Rate: 90 compressions + 30 ventilations = 120 events/min
  • Coordination: Avoid compressions during ventilation breaths

Resuscitation Drugs

Drug Concentration Dose Route Notes
Adrenaline 1:10,000 10-30 mcg/kg IV/IO First-line drug for asystole/bradycardia
Sodium Bicarbonate 4.2% 1-2 mmol/kg IV For prolonged arrest, metabolic acidosis
Glucose 10% 2.5 ml/kg IV For hypoglycemia

When to Stop Resuscitation

Decision Guidelines

  • No cardiac activity for 10 minutes: Consider stopping resuscitation
  • HR persistently <60/min for 10-15 minutes: Case-by-case decision
  • Senior involvement: Essential for complex decisions

Factors Influencing Decision

Medical Factors

  • Gestational age
  • Presumed aetiology of arrest
  • Presence of complications
  • Availability of therapeutic hypothermia
  • Intensive care facility access

Ethical Considerations

  • Parents' previously expressed wishes
  • Risk of significant morbidity
  • Quality of life considerations
  • Multi-disciplinary team input

Important Notes

  • Outlook is poor for infants requiring drugs during resuscitation
  • Some infants have good outcomes with therapeutic hypothermia
  • No universal approach - each case must be individually assessed
  • Senior neonatal/paediatric input is crucial