1. Neonatal resuscitation (NNR)
Dr. Renu Singh

2. Burden of the problem Birth asphyxia
23% of the 1 million neonatal deaths in India
Long term neurological complications
Death
NNR (Neonatal resuscitation) :simple, inexpensive, cost effective method
Problem: NNR often not initiated, incorrect use of methods

3. Successful NNR: factors
Anticipation: call a skilled personnel
Adequate preparation
Accurate evaluation, algorithm based
Prompt initiation of support

4. 1.Anticipation: High risk delivery
Maternal condition
Advanced maternal age ,DM, HT, stillbirth, fetal loss, early neonatal death
Fetal condition
Prematurity, post maturity, congenital anomalies, multiple gestations
Ante partum complications:
APH, oligo /polyhydramnios
Delivery complications
Malpresentation, MSAF, instrumental delivery, antenatal asphyxia with abnormal FHR

5. 2. Adequate preparation Radiant warmer is turned on,& is heating
Oxygen source is open with adequate flow through the tubing
Suction apparatus tested, functioning properly
Laryngoscope is functional with bright light
Resuscitation bag & mask demonstrates an adequate seal & generation of pressure

6. Radiant warmer

11. Successful NNR: factors
Anticipation: call a skilled personnel
Adequate preparation
Accurate evaluation, algorithm based
Prompt initiation of support

12. Evaluation, algorithm based
Rapid assessment of neonate clinical status
Is the infant full term?
Is the infant breathing or crying?
Does the infant has good muscle tone?
Yes: no resuscitation, routine neonatal care
No: needs resuscitation

14. Approach to resuscitation 2010 AHA, AAP
A: initial steps(provide warmth, clear airway if necessary, dry, stimulate)
B: breathing(ventilation)
C: chest compressions (circulation)
D: administration of drugs &/or volume expansion

15. Resuscitation: initial steps
Provide warmth
Head position “ sniffing position”
Clearing the airway, if necessary
Drying the baby
Tactile stimulation for breathing

17. AAP Algorithm

18. AAP Algorithm

20. PPV: Positive pressure ventilation
Form of assisted ventilation
Needed when there is no improvement in HR
Also assess chest wall movements
Should be delivered at rate of breaths /min, maintain HR>100 /min
Devices: BMV, ET (endotracheal tube),LMA(laryngeal mask airway)

22. Bag & mask ventilation

24. Endotracheal tube If BMV is ineffective/prolonged
When chest compressions are performed
Initial endotracheal suctioning of non vigorous meconium stained newborn

25. Endotracheal tube

27. LMA(Laryngeal mask airway)
Soft mask, fits over laryngeal inlet when inflated, occludes the oesophageal opening
Done when BMV is unsuccessful & tracheal intubation is unsuccessful or not feasible

28. LMA(Laryngeal mask airway)

29. Targeted SPO2 after birth
1 minute
60-65%
2 minutes
65-70%
3 minutes
70-75%
4 minutes
75-80%
5 minutes
80-85%
10 minutes
85-90%

30. Initial steps in resuscitation
PPV

31. AAP Algorithm

32. Chest compressions
Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec
Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest
2 techniques:
2 thumb-encircling hands technique
Compression with 2 fingers ,second hand supporting the back
3:1 ratio::[ 90 comp:30 ventilations]

35. Initial steps of resuscitation
PPV(ET)
CHEST COMPRESSIONS

37. AAP Algorithm

38. Medications Rarely indicated
Most important step to treat bradycardia is establishing adequate ventilation
HR remains <60bpm,despite adequate ventilation(ET) with 100% Oxygen & chest compressions
Epinephrine or volume expansion or both

39. Epinephrine Route of administration: intravenous(IV),ideal
Recommended dose: mg/kg per dose
Desired concentration: 1:10,000
0.1 mg/ml

40. Volume expansion Suspected or known blood loss
Isotonic crystalloid solution ; normal saline
Blood
Dose calculation: 10 ml/kg

41. Give oxygen as necessary Positive pressure ventilation
Asses if resuscitation is needed, keep warm, position, clear, dry, stimulation
Give oxygen as necessary
Positive pressure ventilation
Endotracheal intubation
Chest compression
drugs

42. The golden minute <30 seconds: complete initial steps
Warmth
Drying
Clear airway if necessary
Stimulate
30-60 seconds: assess 2 vital characteristics
Respiration (apnea/gasping/labored/unlabored)
Heart rate (<100/>100bpm)
Golden Minute Project: skill based training

44. AAP Algorithm

45. Post resuscitation care
Needed for those who required PPV
At risk of deterioration
Hypo/hyperthermia ,hypoglycemia, CNS complications(apnea, HIE), pulmonary complications(TTN, Pneumonia), hypotension
Need monitoring ,evaluation
NICU may be necessary

46. NNR : not indicated Conditions with certainly early death
Extreme prematurity(GA<23 weeks)
Birth weight<400g
Anencephaly
Chromosomal abnormality: Trisomy 13

47. NNR: nearly always indicated
High rate of survival
Acceptable morbidity
GA≥ 25 weeks
Those with most congenital malformations

48. NNR? Conditions associated with uncertain prognosis
Survival borderline
Parental desires concerning initiation of resuscitation should be supported

49. Discontinuing resuscitative efforts
Newborn with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes

50. Summary Most infants transfer from intrauterine to extra uterine life
10% need some intervention,1% need extensive resuscitation
Anticipate the need for NNR
Adequate preparation for NNR
Evaluate the newborn as per AHA/AAP guidelines & follow the recommended protocol

51. MCQ1
For successful neonatal resuscitation following is/are needed except:
Anticipation
Adequate preparation
Skilled personnel
Delayed initiation of support

52. MCQ1
For successful neonatal resuscitation following is/are needed except:
Anticipation
Adequate preparation
Skilled personnel
Delayed initiation of support

53. MCQ2
Following are true in relation to initial steps of neonatal resuscitation except
Provide warmth
Tactile stimulation
Endotracheal intubation
Drying the baby

54. MCQ2
Following are true in relation to initial steps of neonatal resuscitation except
Provide warmth
Tactile stimulation
Endotracheal intubation
Drying the baby

55. MCQ3 The following is the primary measure of adequate ventilation
Chest wall movement
Improvement in heart rate
Pink extremities
Spo2 of 100%

56. MCQ3 The following is the primary measure of adequate ventilation
Chest wall movement
Improvement in heart rate
Pink extremities
Spo2 of 100%

57. MCQ4
Endotracheal intubation may be indicated at several points during neonatal resuscitation except
Ineffective BMV
During chest compressions
Vigorous meconium stained newborn
Non vigorous meconium stained newborn

58. MCQ4
Endotracheal intubation may be indicated at several points during neonatal resuscitation except
Ineffective BMV
During chest compressions
Vigorous meconium stained newborn
Non vigorous meconium stained newborn

59. MCQ5
The recommended compression to ventilation ratio in neonatal resuscitation is
2:1
3:1
4:1
5:1

60. MCQ5
The recommended compression to ventilation ratio in neonatal resuscitation is
2:1
3:1
4:1
5:1

61. MCQ6
The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation
,IV
,IM
,1V
,IV

62. MCQ6
The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation is
,IV
,IM
,1V
,IV

63. MCQ7
Recommended method/clinical indicator of confirming ET placement is
Condensation in ET
Chest movement
Equal breath sounds on auscultation
Exhaled C Detection

64. MCQ7
Recommended method/clinical indicator of confirming ET placement is
Condensation in ET
Chest movement
Equal breath sounds on auscultation
Exhaled C Detection