1. Newborn resuscitation programme(NRP)
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. The Golden minute The “first minute after birth”
Anxiety for parents, health providers
Period of transition from intrauterine to extra uterine life
Major: No/minimal assistance
10%: assistance to begin breathing at birth
1%: extensive resuscitative measures
First Golden Minute Project: skill based training

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

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

7. Sniffing position
Extension of neck with help shoulder roll:: to open the airway

8. Newly born infant Specifically the Infant at time of birth
(A)Do not require resuscitation
(B)Require resuscitation
Rapid assessment of 3 characters
Term gestation?
Crying or breathing?
Good muscle tone?

9. Newly born infant YES :Do not require resuscitation Term gestation?
Crying or breathing?
Good muscle tone?
YES :Do not require resuscitation
Dry
Skin to skin contact
Covered with dry linen to maintain temperature
Ongoing observation: breathing, color, activity

10. Newly born infant
Term gestation?
Crying or breathing?
Good muscle tone?
NO :require resuscitation; One/more of the following actions in sequence
Initial steps in stabilization(warmth, clear airway, dry, stimulate)
Ventilation
Chest compressions
Administration of epinephrine& /or volume expansion

11. AAP Algorithm

12. IAP Algorithm

13. 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)

14. <60 seconds of birth If gasping/apnea
If heart rate<100 beats per minute
PPV( positive pressure ventilation)
Spo2 monitoring by pulse oximeter
Simultaneous evaluation of 3 vitals
Heart Rate,
Respiration,
oxygenation status

15. 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%

16. Increase in heart rate is the most sensitive indicator of a successful response to each step practiced

17. 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)

18. Bag & mask ventilation

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

20. Endotracheal tube

21. LMA(Laryngeal mask airway)
Fits over laryngeal inlet
Done when BMV is unsuccessful
When tracheal intubation is unsuccessful or not feasible

22. LMA(Laryngeal mask airway)

23. 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]

24. Chest compressions

25. 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

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

27. Volume expansion Suspected or known blood loss
Isotonic crystalloid solution
Blood
Dose calculation: 10 ml/kg

28. 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

29. Post resuscitation care
Needed for those who required PPV
At risk of deterioration
Need monitoring ,evaluation
NICU may be necessary

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

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

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

33. Discontinuing resuscitative efforts
Newly born baby with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes

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

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

36. MCQ2
Following are true in relation to initial steps of neonatal resuscitation except
Provide warmth
Tactile stimulation
Clear airway and intubation
Drying the baby

37. MCQ2
Following are true in relation to initial steps of neonatal resuscitation except
Provide warmth
Tactile stimulation
Clear airway and intubation
Drying the baby

38. MCQ3 The following is the primary measure of adequate ventilation
Chest wall movement
Improvement in heart rate
Pink extremities
Spo2 of 80%

39. MCQ3 The following is the primary measure of adequate ventilation
Chest wall movement
Improvement in heart rate
Pink extremities
Spo2 of 80%

40. MCQ4
Endotracheal intubation may be indicated at several points during neonatal resuscitation except
If BMV is ineffective
When chest compressions are performed
Endotracheal suctioning of vigorous meconium stained newborns
For special resuscitation circumstances like extremely LBW

41. MCQ4
Endotracheal intubation may be indicated at several points during neonatal resuscitation except
If BMV is ineffective
When chest compressions are performed
Endotracheal suctioning of vigorous meconium stained newborns
For special resuscitation circumstances like extremely LBW

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

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

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

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

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

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