ALGORITM : NEONATAL RESUSCITATION

Approximate time
Birth

Clear of meconium ? Yes Routine care

Breathing or crying ? Provide warmth
Good muscle tone? Clear airway
Color pink? Dry
Term gestation ?

No
30 sec Breathing
Provide warmth
Position, clear airway* Supportive care
(as necessary)
Dry, stimulate, reposition
Give O2 (as necessary) HR > 100
& pink

Evaluate respirations,
heart rate, and color

Apnea/ gasping or HR <100

Breathing
30 sec Provide positive Ongoing care
pressure ventilation*
HR > 100
& pink
HR < 60 HR > 60

Provide positive pressure ventilation*

30 sec Administer chest compressions

HR < 60

Administer epinephrine* could be repeated every 5

*Endotracheal intubation may be HR < 60

considered at several steps

Check effectiveness of
Ventilation
Chest compression
Endotracheal intubation
Epinephrine administration
Consider the possibility of
Hypovolemia
Severe metabolic acidosis

HR<60 or persistent cyanosis or

ventilation failure

Consider :
Depression of respiration neuromuscular system
Airway problem
Lungs problems : pneumothorax, hernia diaphragmatica
Congenital heart disease

Adapted from : Textbook of Neonatal Resuscitation, American Academy of Pediatrics, 2000

SIS, 2005
KEY POINTS IN NEONATAL RESUSCITATION

1. Initial assessment, performed within a few seconds, determines if routine care

is indicated or if some degree of resuscitationis required. The five questions
to ask are
- Is the amniotic fluid clear of meconium ?
- Is the baby breathing or crying ?
- Is there good muscle tone ?
- Is the color pink ?
- Was the baby born at term ?
If the answer is NO to any of these questions, begin resuscitation
2. All newborn with meconium in the amniotic fluid should have the meconium
suctioned from the pharynx before delivery of the shoulders
3. If meconium is present and the newborn is not vigorous, suction the babys
trachea before proceeding with any other steps. If the newborn is vigorous,
suction the mouth and nose only, and proceed with resuscitation as required.
4. Vigorous is defined as a newborn who has strong respiratory effort, good
muscle tone, and heart rate greater than 100 beats per minute.
5. Open the airway by positioning the newborn in a sniffing position
6. Suction the newborns mouth before his nose
7. Appropriate forms of tactile stimulation are
- Slapping or flicking the soles of the feet
- Gently rubbing the back
8. Continued use of tactile stimulation in an apneic newborn wastes valuable
time. For persistent apnea, begin positive-pressure ventilation promptly.
9. Free-flow oxygen is indicated for central cyanosis.
Acceptable methods for administering free-flow oxygen are
- Oxygen mask held firmly over the babys face
- Oxygen tubbing cupped closely over the babys mouth and nose
10. Free-flow oxygen cannot be given reliably by a mask attached to a self-
inflating bag.
11. Decisions and actions during newborn resuscitation are based on the
newborns :
- Respirations
- Heart rate
- Color
12. Determine a newborns heart rate by counting how many beats are in 6
seconds, then multiplying by 10. For example, if you count 8 beats in 6
seconds, announce the babys heart rate as 80 beats per minute.
13. Ventilation of the lungs is the single most importanat and most effective step
in cardiopulmonary resuscitation of the compromised infant.
14. Indications for positive-pressure ventilation are
- Apnea/gasping
- Heart rate less than 100 bpm even if breathing
- Persistent central cyanosis despite 100% free-flow oxygen
15. Preterm newborn are more likely to require assisted ventilation and
endotracheal intubation than term infants
16. Corrective actions for no chest rise during bag and mask ventilation are
- Reapply mask to face using light downward pressure
- Reposition the head
- Check for secretions, suctions mouth and nose
- Ventilate with mouth slightly open
- Incresase pressure of ventilation
- Recheck or replace the resuscitation bag
- After reasonable attemps fail intubate the baby

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17. Improvement during bag and mask ventilation is indicated by
- Increasing heart rate
- Improving color
- Spontaneous breathing
18. Chest compressions are indicated when the heart rate remains less than 60
bpm despite 30 seconds of effective positive-pressure ventilation
19. Chest compressions
- Compress the heart against the spine
- Increase intrathoracic pressure
- Circulate the blood to the vital organs, including the brain
20. There are two acceptable techniques for chest compressions-the thumb
technique and the two-finger techniques, but the thumb technique is usually
preferred.
21. Locate the correct are for compressions by running your finger along the
lower edge of the ribs until you locate the xyphoid. Then place your thumb of
finger on the sternum immediately above the xyphoid.
22. To ensure proper rate of chest compressions and ventilation, the compressor
repeats One-and-Two-and-Three-and-Breathe-and.
23. During chest compressios, the breathing rate is 30 breaths per minute and
the compression rate is 90 compressions per minute. This equals 120 events
per minute. One cycle of three compression and one breath takes 2 seconds.
24. During chest compression, ensure that
- Chest movement is adequate during ventilation
- 100% oxygen is being used
- Compression depth is one third the diameter of the chest.
- Thumbs or finger remain in contact with the chest at all times
- Duration of the downward stroke of compression is shorter than
duration of release
- Chest compressions and ventilation are well-coordinated
25. After 30 seconds of chest compressions and ventilation, check the heart rate.
If heart rate is
- Greater than 60 bpm, discontinue compressions and continue
ventilation at 40-60 bpm
- Greater than 100 bpm, discontinue compressions, and gradually
discontinue ventilation if the newborn is breathing spontaneously
- Less than 60 bpm, intubate the infant, if not already done. This
provide a more reliable method of continuing ventilation and route for
epinephrine.
26. Epinephrine, a cardiac stimulant, is indicated when the heart rate remains
below 60 bpm despite 30 seconds of assisted ventilation and another 30
seconds of coordinated chest compressions and ventilations
27. Recommended epinephrine
- Concentration : 1 : 10000
- Route : Endotracheal tube or intravenously
- Dose : 0.1 0.3 ml/kg
- Dilute the 1 : 1000 preparation of epinephrine in 1 ml syringe by
adding 0.9 ml NaCl 0,9% to 0.1 ml epinephrine 1:1000

SIS, 2005