Neonatal resuscitation

NEONATAL
RESUSCITATION
G R A N D R O U N D S
A H M A D A . A B O A Z I Z A , M D
2 / 2 5 / 1 6

DISCLOSURE
• I have nothing to disclose

OBJECTIVES
• Review the steps in neonatal resuscitation
• Focus on the new updates in 2015 NRP 7th edition guidelines

LECTURE GUIDE
• Preparation for resuscitation
– Getting ready to resuscitate
– Equipment
– Assessing risk
• Reviewing the algorithm
• Delayed cord clamping/milking
• Initial steps
– Maintaining temperature
– Assessing heart rate and the use of EKGs
– Clearing airway
– Meconium aspiration
• Assessing and providing Oxygen
• PPV/ PEEP/ CPAP
• Chest compressions
• Medications
• Post resuscitation care
• Withholding and discontinuing care
• Briefing and debriefing

READY TO RESUSCITATE
• Most important step in delivering effective neonatal resuscitation is being ready!
• Personnel trained in neonatal resuscitation should be readily available to perform neonatal
resuscitation whether or not problems are anticipated
• At least one healthcare provider is assigned primary responsibility for the newborn infant to
evaluate the infant, and if required initiate resuscitation procedures such as positive pressure
ventilation and chest compressions.
• In the presence of significant perinatal risk factors for the need for resuscitation, more
additional personnel with resuscitation skills should be immediately available

READY TO RESUSCITATE (CONT.’)
• All trained personnel who are immediately available should have the requisite
knowledge and skills to carry out a complete neonatal resuscitation including
endotracheal intubation and administration of medications.
• Equipment needed for resuscitation should be available at every delivery area
• Equipment need to be routinely checked to ensure they are functioning
properly

• Readiness for neonatal resuscitation requires:
– assessment of perinatal risk
– a system to assemble the appropriate personnel based on that risk
– an organized method for ensuring immediate access to supplies and
equipment
– standardization of behavioral skills that help assure effective teamwork and
communication.

• When perinatal risk factors are identified:
– A team should be mobilized and a team leader identified.
– If time permits, the leader should conduct a preresuscitation briefing
which would also include:
• identify interventions that may be required
• assign roles and responsibilities to the team members

• It is vital during resuscitation that the team demonstrates effective
communication and teamwork skills to help ensure quality and patient safety

EQUIPMENT
Suction Equipment
• Bulb syringe
• Mechanical suction, tubing, and catheters
• Meconium aspirator

EQUIPMENT
Intubation Equipment
• Laryngoscope with straight blades (with sizes)
• Face masks
• Oxygen source with flowmeter

EQUIPMENT
Medications Equipment
• Normal saline
• Epinephrine
• Needles, Syringes
• Umbilical vessel catheterizations supplies (sterile
gloves, antiseptic prep solution, umbilical catheter,
three-way stopcock

EQUIPMENT
• Radiant warmer
• Warm towels
• Pulse oximeter and probe
• Oropharyngeal airways
• Oxygen blender
• Plastic wrap
• Transport incubator

WHO IS AT HIGH RISK?
• Before Delivery
– Maternal causes
– Fetal causes
• During Delivery

Maternal Conditions
• Age (>40yrs, <16yrs)
• Socioeconomic status (poverty,
malnutrition)
• Detrimental habits (smoking, drugs,
alcohol abuse)

Maternal Medical Conditions
• DM
• HTN
• Chronic heart, lung, or kidney diseases
• Blood disorders (thrombocytopenia, anemia)
• H/O previous stillbirth/early neonatal death
• Antepartum hemorrhage
• Premature rupture of membranes
• Infections, UTIs, GBS carrier
• Placental Anomalies (previa, poly/oligohydramnios)

Fetal Conditions
• Pre/post-maturity
• IUGR
• Macrosomia
• Congenital anomalies

Fetal Conditions
• Hydrops
• Abnormalities of presentation (transverse lie, breech)

During birth
• Prolapsed cord
• Utero-placental bleeding
• Foul-smelling or meconium-stained amniotic fluid

During birth
• Abnormal fetal heart rate patterns
• Instrumented delivery (forceps, vacuum, or cesarean)

PREMATURITY
Preterm infants more likely to require resuscitation and develop complications
from the resuscitative process, particularly those with a birth weight <1000g
Why?
• Hypothermia–
– large body surface area to mass
– thin skin
– decreased subcutaneous fat
The smaller the infant, the more difficult it is to prevent hypothermia.

PREMATURITY (CONT.’)
• Inadequate ventilation–
– Immature lungs may be deficient in surfactant, and difficult to inflate/ventilate
– Immature respiratory drive and weak respiratory muscles-> increase the chance of having
apnea
The more premature the infant the more likely require intubation and positive
pressure support

• Infection–
– Maternal infection is associated with premature delivery, and offspring of infected
mothers are at risk for antenatal infection
– Have immature immune systems, which increases the risk of acquiring postnatal infection.
• Organ damage-
– Immature tissues and capillaries are more vulnerable to injury resulting in complications
– Example: retinopathy of prematurity in the retina and intracranial hemorrhage in the
germinal matrix

• Reduced antioxidant function
– Immature antioxidant defense systems maybe unable to counteract the effects of free
radicals.
– This may contribute to many of the morbidities of prematurity like BPD and NEC

CORD CLAMPING
• In 2010 there was increasing evidence of benefit of delaying cord clamping for
at least 1 minute in term and preterm infants not requiring resuscitation, but
insufficient evidence for the infants requiring resuscitation.

CORD CLAMPING (CONT.’)
• National recommendations were made for DCC to be practiced when possible-
Only for infants not requiring resuscitations
• No evidence regarding safety/utility for infants requiring resuscitation

CORD CLAMPING (CONT.’)
NRP 2015 Updates
• Delayed cord clamping after 30 seconds is suggested for both term and preterm infants who do not
require resuscitation at birth.
• Delayed cord clamping is associated with:
– Less intraventricular hemorrhage
– Higher blood pressure and blood volume
– Less need for transfusion after birth
– Less necrotizing enterocolitis
Only adverse consequence found was a slightly increased level of bilirubin -> need for more
phototherapy.

CORD MILKING
• Some studies suggested that cord “milking” might have same results as DCC
• No recommendations were made for its routine use, as there is insufficient
evidence its safety or utility

INITIAL STEPS
• Maintain normal temperature of the infant
• Position the infant
• Clear secretions if needed
• Dry the infant
• Stimulate to breathe

MAINTAINING
THE TEMP
Why is it important?
• Its been recognized since 1907 in Budin’s
publication of The Nursling that the
admission temperature of newborns is a
strong predictor of mortality at all
gestational ages
• Hypothermia is also associated with serious
morbidities such as IVH, Hypoglycemia,
late-onset sepsis

MAINTAINING THE TEMP (CONT.’)
The goal is to minimize heat loss
• Place in a warmed towel or blanket
• Under a pre-warmed radiant warmer
• Temperature control of the warmer should be regulated by servo-control to
which is monitored by a temperature skin probe placed on the infant's
abdomen

• Don’t place probe on:
– Bony prominences
– Areas of brown fat deposits(neck, mediastinum,
scapular, axillary areas, near kidneys, adrenals)
– Poorly vascularized areas
– Excoriated areas
• Keep probe exposed to heat source
• Make sure probe attached securely

Depending on the condition:
• Infants not requiring resuscitation
– Swaddling the infant after drying
– "Skin to skin” contact with mother
(if not the mother, even the dad can work)
• Infants with birth weights <1500g
– Use of polyurethane bags or wraps
– Raise the room temperature to 26°C (78.8°F)
– Warming pads

• Infants who require respiratory support
– Use of humidified and heated air
• All resuscitation procedures, including endotracheal intubation, chest
compression, and insertion of intravenous lines, can be performed with
temperature-controlling interventions in place

• Temperature of newly born nonasphyxiated infants be maintained between
36.5°C and 37.5°C after birth through admission and stabilization

WARMING THE COLD BABIES
• Previous recommendations for rewarming neonates who are hypothermic
after resuscitation was that slower is preferable to faster rewarming. To avoid
apnea and arrhythmias
• However, there is insufficient current evidence to recommend a preference for
either rapid (0.5°C/h or greater) or slow rewarming (less than 0.5°C/h) of
unintentionally hypothermic newborns (<36°C)
NRP 2015 Updates
• Either approach may be reasonable

MAINTAINING TEMP IN
RESOURCE-LIMITED SETTINGS
NRP 2015 Updates
• To maintain temperature during transition (birth until
1 - 2 hrs of life) in well newborns, it may be
reasonable to
– Put them in a clean food-grade plastic bag up to the
level of the neck
– Swaddle them after drying
– Nurse with skin-to-skin contact
• No data examining the use of plastic wraps or skin-to-
skin contact during resuscitation/stabilization in
resource-limited settings

ASSESSING THE HEART RATE
• Auscultation of the precordium and the use of pulse oximetry have been
routinely used to assess heart rate in the delivery room
• Per the 2010 guidelines
– Assessment of heart rate should be done by intermittently auscultating the
precordial pulse
– If pulse is detectable, palpation of the umbilical pulse can provide a rapid estimate
of the pulse
– A pulse oximeter can provide a continuous assessment of the pulse without
interruption of other resuscitation measures
• The use of ECG was not mentioned in 2010

THE USE OF 3-LEAD ECG
Why consider it?
• The ECG has been found to display an accurate heart rate faster than
pulse oximetry
• Pulse oximetry may often display a lower rate in the first 2 minutes of
life
• Pulse oximetry may not function during states of very poor cardiac
output or perfusion
• Underestimation of the heart rate may lead to unnecessary
resuscitation

THE USE OF 3-LEAD ECG (CONT.)
• Study show that auscultation and palpation is inaccurate and unreliable
• Other studies shown ECG to be a must faster way (within 1min) and more reliable way to
assess HR

THE USE OF 3-LEAD ECG (CONT.)
• The new guidelines suggest that electrocardiography (ECG) may be a
reasonable option to provide rapid and accurate estimation of neonatal heart
rate in the delivery room

WHAT’S THE BEEF WITH USING
ECGS
• ECG does not replace the need for pulse oximetry, which is still important to
assess oxygenation
• Would the extra time needed to place ECG leads be detrimental?
• Is information provided by ECG will be more beneficial?
• Would the leads injure the fragile skin of very premature infants?

CLEARING THE AIRWAY
• The proper position aligns the posterior pharynx, larynx, and
trachea, and facilitates air entry
Per 2010 guidelines
• Suctioning immediately after birth for:
– Babies with obvious obstruction due to secretions
– Babies who require positive pressure ventilation
• The mouth is suctioned first and then the nares to decrease
the risk for aspiration. M->N

CLEARING THE AIRWAY (CONT.)
• Suctioning should be avoided if not indicated!
But Why?
• It can produce a vagal response, resulting in apnea and/or bradycardia

CLEARING THE AIRWAY (CONT.)
• Same goes for tracheal suctioning in intubated infants as it can cause
deterioration of:
– pulmonary compliance
– oxygenation
– cerebral blood flow velocity

IS WIPING
MOUTH/NOSE
EFFECTIVE?
• Randomized, not masked, equivalency trial conducted in a single
center n=488
• Wiping the face, mouth, and nose with a towel was equivalent to
suctioning the mouth and nose with a bulb syringe after delivery in
babies >35week gestation
• Primary outcome based on mean respiratory rate in the first 24 hrs
• Nonvigorous babies with meconium-stained amniotic fluid and
babies with major malformations were excluded
• No significant differences in APGAR scores and secondary outcomes:
babies requiring intubation, PPV, chest compression, and NICU
admissions
• There were protocol deviations in 117 of the 488 cases (24 %), and
almost all occurred in patients assigned to wiping who received
suctioning.
• Further investigations are needed to compare wiping to suctioning

WHAT TO DO WHEN MECONIUM
HITS THE FAN?
2015 Guidelines
• If baby is born through meconium stained amniotic fluid and presenting with
poor muscle tone and inadequate breathing efforts -> initial steps of
resuscitation:
– warming and maintaining temperature
– positioning the infant & clearing the airway of secretions if needed
– dry and stimulate the infant

HITS THE FAN?
• PPV should be initiated if the infant is not breathing or the
heart rate is less than 100/min after the initial steps are
completed
• Routine intubation for tracheal suction in this setting is
NOT suggested
• Evidence suggests that resuscitation should follow the
same principles for infants with meconium-stained fluid as
for those with clear fluid

HITS THE FAN?
Why not routinely intubate and mec aspirate?
• Avoid potential harm in:
– Delays in providing bag-mask ventilation
– The procedure itself
• Because there is insufficient evidence to continue
recommending this practice

MECONIUM VIDEO
• https://youtu.be/bSg48AQTRsA

DIGITAL INTUBATION
• Technique that uses the index and middle
finger to blindly direct the endotracheal tube
into the larynx
• Don’t try this at home!

ASSESSMENT OF OXYGEN NEED
• Blood oxygen levels generally do not reach
extrauterine values until approximately 10
minutes following birth
• O2 sats may remain in the 70% - 80% range for
several minutes following birth
• Both insufficient or excessive oxygenation can be
harmful to the newborn infant

PLACING THE PULSE OXIMETRY
• Probe should be placed on
preductal location (right
upper extremity, usually
wrist or medial surface of
the palm)
• 100% sats = not good

GIVING OXYGEN TO TERM INFANTS
• Two meta-analyses of several randomized controlled trials comparing neonatal
resuscitation with room air vs. 100% oxygen showed increased survival when
resuscitation was initiated with air
No change in the 2010 guidelines
• Initiate resuscitation with air (21% oxygen at sea level)
• May titrate the oxygen concentration to achieve an SpO2 in the target range
• May give oxygen if baby is bradycardic

GIVING OXYGEN TO PRETERM
INFANTS
• Meta-analysis of 7 randomized studies
• Initiating resuscitation of preterm newborns
(<35 weeks of gestation) with high oxygen
(≥65%) and low oxygen (21%-30%) showed
no improvement in survival to hospital
discharge with the use of high oxygen.
• No benefit was seen for the prevention of
BPD, IVH, or retinopathy of prematurity.

INFANTS (CONT.)
• When oxygen targeting was used as a
cointervention, the oxygen concentration of
resuscitation gas and the preductal oxygen
saturation were similar between the high-
oxygen and low-oxygen groups within the
first 10 minutes of life
• In all studies, irrespective of whether air or
high oxygen (including 100%) in initiating
resuscitation, most infants were in
approximately 30% oxygen by the time of
stabilization.

INFANTS (CONT.)
• Resuscitation of preterm newborns should be initiated with low oxygen (21%-
30%), and the oxygen concentration should be titrated to achieve preductal
oxygen saturation approximating the interquartile range
• Initiating resuscitation of preterm newborns with high oxygen (≥65%) is NOT
recommended.

POSITIVE PRESSURE VENTILATION
(PPV)
• Initial inflation pressure of 20 cm H2O may be effective, but ≥30 to 40 cm H2O may be
required in term babies without spontaneous ventilation
• Insufficient evidence to recommend an optimum inflation time
• Quick improvement in heart rate is the primary measure of adequate initial ventilation
• Assess the chest wall movement if the heart rate does not improve
• Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to
achieve/maintain a heart rate >100 per minute

(PPV) (CONT.)
• Animal studies suggested that a longer sustained inflation may be beneficial
for establishing functional residual capacity during transition from fluid-filled
to air-filled lungs after birth

(PPV) (CONT.)
• 2015 review of literature includes 3 randomized controlled trials and 2 cohort
studies which shown:
– A benefit of sustained inflation for reducing need for mechanical ventilation
– No benefit in reduction of mortality, BPD, or air leak.
• The low quality of evidence was downgraded for variability of interventions
• Insufficient data to support routine application of sustained inflation of greater
than 5 seconds’ duration to the transitioning newborn

END-EXPIRATORY PRESSURE
(PEEP)
• One trial states that when using PEEP, the maximum supplementary oxygen
required to achieve target oxygen sats may be slightly less (low-quality
evidence)
• In 2015, the 2010 recommendation was repeated:
– ~ 5 cm H2O PEEP is suggested when administering PPV to preterm newborns
• This will require the addition of a PEEP valve for self-inflating bags

UPDATES ON THE LARYNGEAL
MASK
• Can achieve effective ventilation in term and preterm
newborns at ≥34 weeks gestation
• Data are limited for their use in preterm infants
delivered at <34 weeks of gestation or weigh <2000 g
• Recommended when tracheal intubation is
unsuccessful or not feasible
• Its use has not been evaluated during chest
compressions or in administering emergency meds

ENDOTRACHEAL INTUBATION
• Indicated when bag-mask ventilation is ineffective or prolonged, or for special
circumstances such as CDH
• CO2 detectors are effective even in the very low-birth-weight infants
• Causes of undetected exhaled CO2:
– esophageal intubation
– Poor or absent pulmonary blood flow (ex. during cardiac arrest)
• Additional indicators for correct tube placement include:
– Chest movement
– Presence of equal breath sounds bilaterally
– Condensation in the endotracheal tube

CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
• 3 randomized controlled trials enrolling 2358 preterm
infants born <30 weeks of gestation demonstrated that
starting newborns on CPAP may be beneficial when
compared with endotracheal intubation and PPV
• Starting CPAP resulted in :
– Decreased rate of intubation
– Decreased duration of mechanical ventilation
– No significant increase in air leak or severe IVH

CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
Based on this evidence NRP 2015 updates:
• Spontaneously breathing preterm infants with
respiratory distress may be supported
with CPAP initially rather than routine intubation
for administering PPV

CHEST COMPRESSIONS
• Indicated if HR <60/min despite adequate ventilation
• Make sure that assisted ventilation is being delivered
correctly before starting chest compressions

CHEST COMPRESSIONS
• Compressions are delivered on the lower third of the
sternum to a depth of approximately one third of the
anterior-posterior diameter of the chest
• 2-thumb technique preferred over 2-finger technique:
– Generates higher blood pressures and coronary
perfusion pressure
– Less rescuer fatigue

CHEST COMPRESSIONS
• Always keep your thumbs on the chest even during relaxation when allowing the
chest to re-expand fully
• 3:1 ratio of compressions to ventilation (90 compressions and 30 breaths in one
minute)
• May use higher ratios (15:2) if the arrest is believed to be of cardiac origin
• Avoid frequent interruptions
• Highly suggested not to use of any single feedback device such as ETCO2
monitors or pulse oximeters for detection of return of spontaneous circulation in
asystolic/bradycardic neonates

CHEST COMPRESSIONS
• The Neonatal Guidelines Writing Group supports
increasing the oxygen concentration to 100% whenever
chest compressions are provided
• Lack of clinical studies regarding oxygen use in neonatal
CPR
• Animal evidence shows no advantage to 100% oxygen
during CPR
• As the heart rate recovers, the supplementary oxygen
should be weaned

MEDICATIONS
• 2010 dosing remained unchanged
• Intravenous administration of epinephrine may be considered at a dose
of 0.01 to 0.03 mg/kg of 1:10 000 epinephrine.
• For endotracheal administration higher dosing at 0.05 to 0.1 mg/kg
• Recommended to be administered intravenously

VOLUME EXPANSION
• Suspected blood loss :
– pale skin
– poor perfusion
– weak pulse
– heart rate not responding adequately to other resuscitative measures
• An isotonic crystalloid solution or blood may be useful for volume expansion,
the recommended dose is 10 mL/kg
• Rapid infusions of large volumes have been associated with IVH

POSTRESUSCITATION CARE
• Once effective ventilation and/or the circulation has been established, transfer
to the NICU
• Intravenous glucose infusion should be given as needed in avoiding
hypoglycemia

INDUCED THERAPEUTIC
HYPOTHERMIA
• 2010 recommendations:
Its recommended that infants born >36 weeks of gestation
with evolving moderate-to-severe hypoxic-ischemic
encephalopathy should be offered therapeutic
hypothermia under clearly defined protocols similar to
those used in published clinical trials and in facilities with
the capabilities for multidisciplinary care and longitudinal
follow-up
• 2015: This recommendation goes for both resource-
abundant and resource-limited areas

WITHHOLDING AND
DISCONTINUING
• There should be a consistent and coordinated approach to individual cases by the
obstetric and neonatal teams and the parents
• Clinicians should not hesitate to withdraw support when functional survival is
highly unlikely

WITHHOLDING AND
DISCONTINUING
• It is reasonable to stop assisted ventilation if APGAR score is 0 after 10mins of
resuscitation with undetectable heart rate
• Variables to be taken into account:
– whether the resuscitation was considered optimal
– availability of advanced neonatal care (ex. therapeutic hypothermia)
– family expressed wishes

WITHHOLDING AND
DISCONTINUING
• Resuscitation is not indicated when the gestation, birth weight, or congenital
anomalies are associated with early death
• Variables to take into consideration when counseling a family and making a prognosis
for survival at gestations <25 weeks:
– accuracy of gestational age assignment
– the presence/absence of chorioamnionitis
– level of care available
• Decisions about appropriateness of resuscitation <25 weekers will be influenced by
region-specific guidelines

BRIEFING/DEBRIEFING
• Briefings or debriefings of resuscitation team performance have been shown
to improve knowledge and skills

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