• Foundations of Neonatal Resuscitation
  • Most neonates do not need any interventions.
    • 5% may need positive pressure ventilation, 2% intubation,  0.3% may need chest compressions or emergency medications. Therefore, very few neonates will require chest compressions or medications.
  • Neonates usually need resuscitation because of RESPIRTORY failure, unlike adults. Therefore, the most important step in the neonatal resuscitation algorithm is to ventilate the lungs.
• Preparing for Resuscitation
  • Identify the risk factors by asking these 4 questions (A₂RU): Is the amniotic fluid clear? Age (gestation) expected for the neonate? Risk Factors of the pregnancy? Umbilical cord management?
    • Depending on the risk factors, you will need to assemble a team:
      1. No risk factors: Need at least 1 qualified individual at EVERY birth.
      2. Risk factors present: Need at least 2 qualified individuals at EVERY birth.
      3. However, a qualified team should be identified and immediately available for every resuscitation.
    • It is important to have a checklist of the equipment’s needed for neonatal resuscitation. Use the NRP Quick Equipment Checklist.
• Initial Steps 
  
  • For neonates that are VIGOROUS term and preterm, use delayed cord clamping (30-60 seconds).
  • All neonates need a “Rapid Evaluation” (TTB): Tone is good? Term? Breathing/Crying?
    • If the answer is “NO” to any of these questions, the neonate must be brought to the radiant warmer immediately and the “Initial Steps” should be followed. The “Initial Steps” include: WDS-PC
      1. Warmth provision
      2. Dry the neonate
      3. Stimulate the neonate
      4. Position the neonate in order to open up the airway
      5. Clear any secretions
    • Otherwise, if the Rapid Evaluation is normal for all three questions then the neonate can stay with the mother for the initial steps, offered routine care and ongoing evaluation. 
    • The evaluation to see whether the neonate is responding to your “Initial Steps” should take less than 30 seconds.
      • Techniques to check the heart rate: Auscultation, Palpation (umbilical cord), Pulse Oxymetry, Cardiac Monitors (ECG), Doppler U/S
  • A pulse oximetry and the Target Oxygen Saturation Table should be used in the following situations:
    1. During a recusation.
    2. To confirm persistent central cyanosis.
    3. At any point when you are giving supplemental oxygen.
    4. If positive pressure ventilation is required.
  • Routine laryngoscopy with or without intubation for tracheal suction is not suggested in ALL cases. If the neonate is not vigorous and there is meconium-stained fluid, first bring the neonate to the radiant warmer and perform the initial steps. You will then clear the secretions (Moth before Nose) and start PPV if required. Only if PPV is not effective, you may need to intubate and apply tracheal suction.
• Positive Pressure Ventilation (PPV)
  • Always remember that ventilation of the neonate’s lung is the most important step!
  • Before starting PPV, you should have done the Rapid Evaluation (TTB) followed by the Initial Steps (WSD-PC).
  • Positive Pressure Ventilation indication:
    1. Neonate is not breathing OR
    2. Neonate is gasping OR
    3. Neonate’s heart rate is less than 100 beats per minute
  • While performing PPV, the initial oxygen concentration settings are as follows:
    • 21% if the gestational age is ≥ 35 weeks
    • 21% – 30% for preterm less than 35 weeks
  • Ventilation settings
    • Rate 40 – 60 breaths per minute.
      • Therefore, one breath every second. 
    • Initial Ventilation Pressures 20 – 25cm H₂0
  • Indication of good PPV
    • A rising heart rate!
  • You will check the neonate’s heart rate after 15 seconds:
    • If you do not see a rise in the within the first 15 seconds of performing PPV AND you are not observing chest movements, then it means that you are not ventilating the patient well. You need to start the “Ventilation Corrective Steps”, known as MR. SOPA.
      • Mask Adjustment
      • Reposition the head and neck
      • Suction the mouth THEN the nose (M > N)
      • Open the mouth
      • Pressure increase
      • Alternative airway
        • If the neonate cannot be successfully ventilated with a face mask and intubation is not possible or not successful, then we can use a laryngeal mask airway (LMA) as a rescue device.
      • After each step, give 5 PPV breaths in order to assess chest movement.
      • If you do not see a rise in the heart rate in the first 15 seconds of performing PPV but there is adequate chest movement:
        • Continue PPV and recheck after 30 seconds of PPV.
    • If the neonates heart rate is increasing after 15 seconds, then continue with the PPV.
    • Keep in mind that after 30 seconds of PPV, the neonates heart rate should be > 100 bpm.
    • If face mask PPV or CPAP is used for several minutes then an orogastric tube should be inserted. This will decrease gastric distension and prevent aspiration, as well as improve ventilation.
• Endotracheal Intubation (ETT)
  • You should insert an ETT if the neonate’s heart rate remains < 100 and it is not increasing with PPV. ETT it is strongly recommended before you begin chest compression (alternatively use an LMA).
    • You may also insert an ETT for the suctioning of thick sections, for the administration of surfactant or if the neonate is suspected of having a diaphragmatic hernia.
  • Laryngoscope size blade:
    • Term = No. 1
    • Preterm = No. 0
    • Extremely Preterm = No. 00
    • Intubation should be done within 30 seconds.
  • Capnography should be used.
  • Use the Nasal-Tragus Length (NTL) +1 or the gestational age chart to determine the depth of the ETT.
  • Once the neonate is intubated, if there is no chest movement then you should suction the trachea either with a suction catheter or a tracheal aspirator.
  • At any point in time if there is deterioration, follow the DOPES mnemonic: Displaced tube, Obstructed tube, Pneumothorax, or Equipment failure and Suction.
  • Indicators that the tube is in the trachea:
    • Demonstration of exhaled CO2 on capnograph.
    • Heart rate is rising
    • Breath sounds equal bilaterally.
    • Chest Movements with each PPV.
    • No leaks were heard.
• Chest Compressions
  • Indications: Heart rate remains less than 60 bpm despite at least 30 seconds of PPV that inflates the lungs (visible chest movements).
    • Therefore, if you don’t assess the heart rate adequately you might perform unnecessary chest compressions.
  • Before moving to chest compressions, ensure that you have adequate ventilation.
  • Once the heart rate is less than 60 bpm, then the pulse oximeter may no longer be reliable.
  • During chest compression, ventilation should be done with 100% oxygen until the heart rate becomes at least 60 bpm.
  • Chest compressions should be performed by placing thumbs on the sternum, in the center just below an imaginary line joining the neonate’s nipples. The sternum should be depressed one-third of the anterior-posterior diameter (AP).
  • The rate of compression is 90 compressions per minute, while the breath rate is 30 compressions per minute.
    • Take note that this is a slower ventilation rate (30) than during assisted ventilation without compression (40-60).
    • “One-and-two-and-three-breath and…”
  • Only check for the heart rate once you have done chest compressions for 60 seconds.
  • If the heart rate becomes 60 bpm or more, then discontinue chest compressions and resume PPV at 40-60 breaths per minute.
  • If the neonate’s heart rate remains less than 60 bpm, despite 60 seconds of effective ventilation and high-quality chest compression then epinephrine is indicated.
•  Medications
  • Indications for epinephrine:
    • Heart rate less than 60 beats per minute AND
    • At least 30 seconds of PPV that inflates the lungs (chest movement) with 100% oxygen AND
    • Chest compressions were performed for 60 seconds.
  • The PPV by this time should have been done either using an LMA or an ETT.
  • Adrenaline IS NOT indicated in cases where you have not yet established effective ventilation. Remember, ventilation is the most important aspect of neonatal resuscitation.
  • Dose of Adrenaline
    • Dilute the 1mg adrenaline ampule into a 10 ml syringe to get a concentration of 0.1mg/ml.
    • Intravenous Route:
      • Use an umbilical catheter or intraosseous needle (IO) (NB no time for the peripheral line here!)
      • The dose is 0.02mg/kg = 0.2ml/kg, may be repeated every 3-5 minutes. Given RAPIDLY followed by a 3 ml saline flush.
      • Range 0.01 – 0.03mg/kg (0.1ml – 0.03ml/kg)
    • Endotracheal Route:
      • Use this route while you are still trying to get the intravenous route ready
      • Dose: is 0.1mg/kg (1ml/kg)
      • Range 0.05 to 0.1mg/kg (0.5-1ml/kg)
    • When to administer volume expanders
      • This is indicated if the neonate is NOT responding to the resuscitation steps AND there are signs of shock or a history of acute blood loss.
      • Use Normal Saline or type O Rh negative blood IV/IO
      • Dose at 10ml/kg over 5 – 10minutes
  • Cessation of Resuscitation
    • A reasonable time to consider cessation of resuscitation is around 20 minutes after birth. This is done if there is a confirmed absence of a heart rate after all the appropriate steps of resuscitation have been performed. However, this should be individualized for each patient and contextual factors should be assessed as well.

The book covers other important aspects to neonatal resuscitation and this is not described here. This includes resuscitation and stabilisation of babies born preterm, post-resuscitation care, special considerations, ethics and other important concepts.