 INTRODUCTION

 HIGHLIGHTS OF NRP 7TH EDITION

 LESSON 1: FOUNDATIONS OF NEONATAL RESUSCITATION

 LESSON 2: PERFORMACE CHECKLIST-Preparing for

resuscitation

 LESSON 3: INITIAL STEPS OF RESUSCITATION

 LESSON 4: POSITIVE- PRESSURE VENTILATION

 LESSON 5: ENDOTRACHEAL INTUBATION

 LESSON 6: CHEST COMPRESSIONS

 LESSON 7: MEDICATIONS

 LESSON 8: POST RESUSCITATION CARE

 LESSON 9: RESUSCITATION OF BABIES BORN PRETERM

 LESSON 10: SPECIAL CONSIDERATIONS

 LESSON 11: ETHICS AND CARE AT THE END OF LIFE

 SUMMARY OF THE REVISED NEONATAL RESUSCITATION

GUIDELINES – NRP 7TH EDITION

 CONCLUSION

 REFERENCES

RESTRICTED 2
 The 7th edition of the Neonatal Resuscitation Program®
was released in July 2016.

 The Neonatal Resuscitation Program® (NRP®) was

developed by the American Heart Association and the
American Academy of Pediatrics to teach an evidence-
based approach to newborn care. It facilitates e​ffective
team-based care for healthcare professionals who care
for newborns at the time of delivery.

 NRP utilizes a blended learning approach, which

includes online testing, online case-based simulations,
and hands-on case-based simulation/debriefing that
focus on critical leadership, communication, and team-
work skills.​​

RESTRICTED 4
 Since 1999, revised NRP science has come from the work of the
International Liaison Committee on Resuscitation (ILCOR), a
multinational group that provides a coordinated forum for
researching, reporting, and developing an international consensus
supported by scientific data.

 Every 5 years, ILCOR coordinates an in-depth international review,

debates the science, and determines new international
resuscitation treatment recommendations for newborns, children,
and adults

 Based upon the consensus of the assembled international experts,

treatment recommendations are generated.
RESTRICTED 5
 The document, known as the International Consensus on Science
With Treatment Recommendations (CoSTR) is the international
consensus on resuscitation science for newborns, children, and
adults.

 Each resuscitation council that makes up ILCOR then uses the

CoSTR document to develop resuscitation guidelines applicable to
their country/region.
 The American Heart Association and American Academy of
Pediatrics wrote the neonatal guidelines for resuscitation and
released these in October 2015. The NRP Steering Committee
uses the guidelines as the foundation for NRP 7th edition materials.

 The NRP is the education program that translates the

guidelines into practice. A summary of the biggest changes in
neonatal resuscitation science are listed here.

RESTRICTED 6
To Interpret the 2015 American Heart
Association Guidelines for neonatal
resuscitation and apply them to clinical
practice.

RESTRICTED 7
RESTRICTED 9
 Increased Emphasis on
› Teamwork
› Preparation before resuscitation – Structured check of
equipment and supplies – Identifying roles
› Accurate documentation

RESTRICTED 10
 Determine the leader, clarify roles and responsibilities,
delegate tasks
 Perform a standardized Equipment Check
 Introduce yourself and discuss the plan of care with the
parent(s) if not already done
 Ask the OB provider the plan for delayed cord clamping

RESTRICTED 11
RESTRICTED 12
 A. Initial steps in stabilization
› Provide warmth by placing the baby under a radiant heay source
› Position head and neck in “sniffing” position to open airway
› Suction if needed. Clear the airway with a bulb syringe or suction catheyer
› Dry (or cover in plastic) the baby
› Stimulate breathing
 B. Ventilation
ASSESS BREATHING If breathing, assess heart rate If apneic, START
Positive Pressure Ventilation
 Routine tracheal suction no longer recommended for NON-
VIGOROUS babies with meconium stained fluid
› MSAF is a risk factor that requires at least 2 people at the birth and
› Someone with intubation skills IMMEDIATELY available
› If there are additional risk factors, someone with full resuscitation skills
should be present at the birth

RESTRICTED 13
 Start free-flow oxygen at 30%
 Liter flow is 10 L/min
 Initial FiO2 for PPV
› >OR = 35 weeks’ GA = 21%
› < 35 weeks’ GA = 21-30%
 Always use pulse oximetry to guide oxygen
concentration
 Use 100% oxygen during compressions
 Babies Less Than 32 Weeks’ Gestation
› Consider CPAP if baby is breathing immediately after birth as an
alternative to routine intubation and surfactant administration
› 5 cm H20 PEEP is recommended

RESTRICTED 14
 Rapid assessment of the following 4 characteristics:
› Was the baby born after a full-term gestation?
› Is the amniotic fluid clear of meconium and evidence
of infection?
› Is the baby breathing or crying?
› Does the baby have good muscle tone?

RESTRICTED 15
RESTRICTED 16
 NRP helps learn cognitive, technical and team work
skills to resuscitate and stabilize newborns
 Most newly born babies transit without intervention
 4 -10% of term and late preterm newborns require PPV,
1 – 3 per 1000 require major resuscitation measures
(chest compressions, and/or medications) to survive
 The need for resuscitation cannot always be predicted,
teams must always be prepared to provide these life
saving interventions quickly and efficiently
 Practicing together as a team helps build proficiency
and speed
RESTRICTED 18
 Adult cardiac arrest often results from arrythmias due to existing cardiac
disease or trauma
 Poor circulation results in reduced blood flow to the brain causing loss of
consciousness and then ceasation of breathing
 At the time of arrest, O2 and CO2 content of blood are usually normal
hence chest compressions are used to maintain circulation till electrical
defibrillation is available
 Most newborns needing resuscitation however have healthy hearts
 The need for resuscitation is usually caused by inadequate gas
exchange before or after birth
 If the fetus is born in early phase of respiratory failure, stimulation may
be sufficient to initiate spontaneous respiration
 If the newborn is born during later phase of respiratory failure, assisted
ventilation will be required or chest compressions in severe cases
RESTRICTED 19
 The first breath a newborn takes at birth inflates the lungs and
dramatically alters the circulatory system, closing the three shunts
that directed oxygenated blood away from the lungs and liver
during fetal life.
 Clamping and cutting the umbilical cord collapses the three
umbilical blood vessels. The proximal umbilical arteries remain a
part of the circulatory system, whereas the distal umbilical arteries
and the umbilical vein become fibrotic.
 The newborn keeps warm by breaking down brown adipose tissue
in the process of nonshivering thermogenesis.
 The first consumption of breast milk or formula floods the
newborn’s sterile gastrointestinal tract with beneficial bacteria that
eventually establish themselves as the bacterial flora, which aid in
digestion.
RESTRICTED 20
The fetal circulatory system includes three shunts to divert blood from undeveloped and partially
functioning organs, as well as blood supply to and from the placenta.
foramen ovale in the heart
ductus arteriosus in the great vessels
ductus venosus in the great vessels

RESTRICTED 21
At birth, when the infant breathes for the first time, there is a decrease in the resistance in the pulmonary
vasculature, which causes the pressure in the left atrium to increase relative to the pressure in the right atrium. This
leads to the closure of the foramen ovale, which is then referred to as the fossa ovalis. Additionally, the increase in
the concentration of oxygen in the blood leads to a decrease in prostaglandins, causing closure of the ductus
arteriosus. These closures prevent blood from bypassing pulmonary circulation, and therefore allow the neonate's
blood to become oxygenated in the newly operational lungs.

RESTRICTED 22
A newborn’s circulatory system reconfigures immediately after birth. The three fetal
shunts have been closed permanently, facilitating blood flow to the liver and lungs.

RESTRICTED 23
NRP Equipment Poster

RESTRICTED 25
 ♦Timer  ♠Thermal Mattress
 ♦Pulse Oximeter (and Pre-ductal SpO²  ♠Bulb Syringe
Target Chart)  ♠Warm and Dry Linen/Towel(2)
 ♦ECG MONITOR  ♠Suction Catheter
 ♦OXYGEN BLENDER & FLOW METER  ♠Meconium Aspirator
 ♦MANOMETER  ♠Stethoscope
 ♦RADIANT WARMER  ♠Pulse Oximeter Sensor
 ♦WALL SUCTION  ♠Self Inflating Bag
 ♠T-piece Resuscitator
 ♠Temperature
 ♠ECG Leads
 ♠Intubation Supplies – Laryngoscope
 ♠Laryngeal Mask
 ♠Flow-inflating Bag
 ♠Free-flow O² tube
 ♠Feeding Tube
 ♠Umbilical Catheter
 ♠Epinephrine♠Normal Saline

RESTRICTED 26
Non-vigorous infants delivered through meconium stained
amniotic fluid (MSAF) do not routinely require intubation and
tracheal suction

MSAF (Meconium-Stained Amniotic Fluid) remains a risk factor

for abnormal transition, and teams must ensure a member with
advanced airway and resuscitation skills is in attendance

The Neonatal Resuscitation Program (NRP) protocol for

delivery room management no longer recommends tracheal
suctioning for vigorous infants . Approximately 20-30% of
infants born through MSAF are depressed at birth with an Apgar
score of 6 or less at 1 minute of age. Babies exposed to MSAF
who have respiratory depression at birth have a higher incidence
of MAS. If a baby is born through MSAF, has depressed
respirations, decreased muscle tone, and/or a heart rate below
100/min, intubation and direct suctioning of the trachea soon
after delivery is indicated before breaths have occurred.
RESTRICTED 28
Randomized controlled trials (RCT) with large numbers of mothers and
neonates (n – shown in parentheses for each study in a red box) do not
support amnioinfusion or oropharyngeal suction following delivery of the
head or tracheal suction in the vigorous newborns delivered through
meconium-stained amniotic fluid (MSAF). The current guidelines
recommend tracheal suctioning only for neonates that are not vigorous
and born through MSAF. Copyright Satyan Lakshminrusimha.

RESTRICTED 29
 Initial assessment: term, tone and breathing/crying?

 Warmth and position airway

 Suction if necessary

 Dry and stimulate

RESTRICTED 30
 Temperature should be maintained between 36.5 and 37.5 Celsius

 For preterm infants, combination of interventions

- Plastic wrap or bag
- Thermal mattress
- Hat

 Focus on thermoregulation throughout resuscitation

 In stable infants, delayed cord clamping should be performed for at least 30

seconds. Insufficient evidence to recommend approach in those requiring
resuscitation

 Starting resuscitation gas for term infant should be 21%

 In infants <35 weeks, starting gas should be 21-30%. Specific starting

concentration of oxygen should be incorporated into local-agreed guidelines

 Continue to target saturations using preductal saturation monitor

RESTRICTED 31
An intact umbilical cord allows continuous umbilical venous flow to the ventricles. With the concomitant
initiation of breathing through crying or PPV, PVR decreases allowing increased blood flow to the lungs
(decreased right to left shunt through the DA) as well as increased venous return to the LV. The
unclamped UA prevents a sudden increase in afterload. This results in improved cardiac output (A).
Conversely, immediate cord clamping restricts flow to the ventricles. With failure to establish ventilation,
PVR remains high and compromises pulmonary blood flow (increased right to left DA shunt) and venous
return to the left ventricle. Thus, decreased filling of the left ventricle (preload) and increased afterload
(due to removal of low-resistance placenta) compromise cardiac output (B). DA ductus arteriosus, PPV
positive pressure ventilation, LA left atrium, RA right atrium, LV left ventricle, UA umbilical artery, UV
umbilical vein. Copyright Satyan Lakshminrusimha.

RESTRICTED 32
 Peak Inspiratory Pressure (PIP): Highest
pressure delivered with each breath at the end of
the squeeze

 Positive End-Expiratory Pressure (PEEP): Gas

pressure in the lung sduring relaxation, before the
next squeeze (during assisted ventilation)

 Continuous Positive Airway Pressure (CPAP):

Same as PEEP, but the baby is breathing
spontaneously

 Rate: Number of assisted breaths per minute

RESTRICTED 34
 Positive pressure ventilation (PPV) if HR <100 bpm or
ineffective respirations. Initial PIP 20-25 cm H20

 When resuscitation of preterm baby is required, PEEP

is recommended (starting PEEP 5 cm H20)

 Consider electronic cardiac monitor when resuscitation

required

 After PPV started, reassess in 15 seconds. If no

response, MR SOPA corrective measures should be
incorporated. If no response to MR SOPA, consider
obstruction and suction through ETT or with meconium
aspirator

RESTRICTED 35
 Apnea/gasping
 Heart rate less than 100 beats per minute (bpm)
even if breathing
 Persistent cyanosis despite free-flow oxygen
 Consider if oxygen saturation less than target
range on free flow oxygen or CPAP even if
breathing and HR >100/min
 It must be commenced within 1minute of birth

 Ventilation of the lungs is the single most important and

most effective step in cardiopulmonary resuscitation of
the compromised infant

RESTRICTED 36
 Self-inflating bag
 Flow-inflating bag
 T-piece resuscitator

RESTRICTED 37
Advantages:
 Always refills after being squeezed
 Inflates without a compressed gas source
 Pressure release (pop-off) valve makes
over-inflation less likely

Disadvantages:
 Requires tight face-mask seal to inflate
the lungs
 Requires oxygen reservoir to provide high concentration of
oxygen
 Cannot give free-flow oxygen through
the mask
 Cannot be used for CPAP. No PEEP without
special valve
RESTRICTED 38
 Pressure-release valve (pop-off valve)
set at 30-40 cm H2O
 Pressure gauge or manometer

RESTRICTED 39
 Appropriate-sized mask
 Variable oxygen capability from 21% to 100% (oxygen
blender recommended)
 Control of peak pressure, end-expiratory pressure, and
inspiratory time
 Appropriate-sized bag (200-750 mL)
 Safety features

RESTRICTED 40
 The most important indicator of successful PPV
(Positive Pressure Ventilation) is rising heart rate.
Also…
• Improving color
• Spontaneous breathing
• Improving muscle tone

RESTRICTED 41
RESTRICTED 42
M – Adjust Mask in the face
R – Reposition the head to open airway
S – Suction mouth then nose
O – Open mouth and lift jaw forward
› Re-attempt to ventilate if not effective then
P – Gradually increase Pressure every few breaths until visible chest rise is noted
› Maximum Peak Inspiratory Pressure (PIP) is 40 cm H20
› If still not effective then…
A – Use of Artificial Airway – Endotracheal Tube (ETT) or LMA

RESTRICTED 43
(1) Recommendation of 21% oxygen for initial resuscitation of term infants and use of a blender
to titrate inspired oxygen based on target preductal (right upper extremity pulse oximeter
values – table)
(2) Use of PEEP/CPAP preferably with a T-piece resuscitator;
(3) Corrective steps to improve PPV by mask using the acronym “MR SOPA” – M – mask
adjustment and R – reposition airway should be addressed first, then the next two steps (S –
suction mouth and nose and O – open mouth). Then if there is not adequate chest
movement, move to P – pressure increase and A – airway alternative with endotracheal
intubation or laryngeal mask airway); (4) Use of two-thumb technique for chest compressions
from the head-end of the bed to provide room for umbilical vein catheterization; and (5) early
use of intravenous epinephrine. Copyright Satyan Lakshminrusimha.

RESTRICTED 44
RESTRICTED 45
 To improve efficacy of ventilation when bag-and-mask
ventilation does not result in clinical improvement
 When PPV lasts more than a few minutes
 To facilitate coordination of chest compressions and
ventilation
 To administer epinephrine while IV access is being
established
 Special circumstances like stabilisation in suspected
congenital diaphragmatic hernia
 For surfactant administration
 For direct tracheal suction if airway is obstructed by thick
secretions

RESTRICTED 47
 Sterile, disposable
 Uniform diameter (not tapered)
 Centimeter marks and vocal cord guides are helpful
 Uncuffed
 Consider using stylet (optional)

RESTRICTED 48
 Select preferred tube size
 Consider cutting tube to a shorter length
 Consider using a stylet (optional)

Weight Gestational Age Tube Size (mm)

(grams) (weeks) (inside diameter)
 Below 1,000 Below 28 2.5
 1,000-2,000 28-34 3.0
 2,000-3,000 34-38 3.5
 Above 3,000 Above 38 3.5-4.0

RESTRICTED 49
RESTRICTED 50
 HR <60 bpm in spite of 30 seconds of effective PPV.
Oxygen should be increased to 100%

 2-thumb technique is still recommended. Once airway

secured, switch to head of bed

 Electronic cardiac monitor preferred for assessment of

heart rate

 Continue chest compressions for 60 seconds before

rechecking
RESTRICTED 52
 Ventilation of the lungs is a critical component of neonatal
resuscitation.

 However, in the presence of extreme bradycardia or cardiac

arrest, pulmonary blood flow cannot be sustained and gas
exchange does not occur with ventilation alone

 Although a combination of PPV and CCs are required for

effective resuscitation, the optimal CV ratio remains to be
determined.

 The current 3:1 CV ratio recommended by NRP is an expert

consensus, attempting to match the heart and respiratory
rates of the newborn.

RESTRICTED 53
During CCs, the extrinsic pressure on the
sternum squeezes the heart against the
spine leading to antegrade blood flow
(cardiac pump theory).

During ventilation, generation of increased

thoracic pressure results in arterial blood
flow from the thorax because intrathoracic
pressure exceeds extrathoracic vascular
pressure (thoracic pump theory).
Flow is restricted to the arterial-to-venous
direction because of collapse of veins at
the thoracic inlet and venous valves that
prevent retrograde flow.

Coronary perfusion pressure (CPP) is a

key determinant in return of spontaneous
resuscitation and is dependent on aortic
diastolic and right atrial pressure.
In the presence of a PDA, CCs may be
less effective as aortic diastolic pressure
may be decreased with blood shunting
from the aorta into the pulmonary artery,
thus decreasing CPP.

RESTRICTED 54
 Indicated if HR remains <60 bpm after at least 30 secs
of effective PPV and another 60 seconds of chest
compressions using 100% oxygen

 One dose may be given through ETT. If no response,

give intravenous dose via emergency UVC or IO access

RESTRICTED 56
 Ringer’s Lactate no longer recommended for
management of hypovolaemic shock

 UVC preferred route of emergency vascular access, but

IO can be used as alternative

 “No evidence to support the routine practice” of

NaHCO3 to correct metabolic acidosis

 “Insufficient evidence to evaluate safety and efficacy” of

Naloxone and risks of complications
RESTRICTED 57
 The physiology of transition to extrauterine life
continues for several hours after birth
 Babies who have required resuscitation may still have
problems making this transition after the have
resumed spontaneous respiration
 They may have consequencies due to the period of
depression
 There are 2 broad categories of postnatal care,
babies who require routine care only and those
requiring post resuscitation care
 The intensity of monitoring and interventions differ
across these 2 groups

RESTRICTED 59
Almost 90% of deliveries are vigorous term babies
Such babies should remain with their mothers skin to skin to
promote bonding and initiate breastfeeding
Term babies with some prenatal and intrapartum risk factors
who respond well to initial steps (warmth, airway* and
drying/stimulation) should have close observation but not
separated from their mothers
Ongoing observation in routine care include; observation of
breathing, thermoregulation, feeding and activity
This helps determine the need for further intervention, E.g
fast breathing or low or high temperatue

RESTRICTED 60
Babies who required oxygen supplementation or PPV
after delivery need closer assessment
They may develop problems associated with abnormal
transition
They often require ongoing respiratory support
(supplemental O2, CPAP or mechanical ventilation)
Many will require admission into the nursery or NICU for
adequate cardiorespiratory monitoring
The duration of admission will depend on the clinical
condition, progress toward normal transition and the
identified risk factors
Parents must be encouraged to see and touch their
babies assoon as feasible

RESTRICTED 61
 A baby who required resuscitation must have close
monitoring of clinical and lab parameters
 Avoid overheating during and after resuscitation
 If indicated, therapeutic hypothermia must be initiated
promptly
 Sodium bicarbonate has not been shown to be beneficial
during and immediately after resuscitation. It has potential
of causing harm
 Though PPHN responds to oxygen therapy, the need for
oxygen therapy should only be guided by pulse oximetry
and not routine administration

RESTRICTED 62
 Temperature control
- Room temperature 23-25 degrees Celsius
- Plastic wrap or bag
- Thermal mattress and hat

 3-lead EKG monitor for rapid and reliable HR

assessment

 If resuscitation required, PEEP recommended; no

particular device recommended

 CPAP can be used if stable but increased work of

breathing (PEEP 5-8 cmH20 suggested )

RESTRICTED 64
RESTRICTED 65
RESTRICTED 66
The 7th edition NRP Flow Diagram is similar to the 6th edition
diagram. Revisions include:
 Begin the resuscitation with antenatal counseling (when
appropriate) and a team briefing and equipment check
 Maintain the newborn’s normal body temperature during
resuscitation
 Consider using a cardiac monitor when PPV begins.
 Ensure ventilation that inflates and moves the chest
 Recommendation to intubate prior to beginning chest
compressions
 Recommendation to use cardiac monitoring to accurately
assess heart rate during chest compressions
 End the resuscitation with team debriefing.

RESTRICTED 68
 It is recommended that the temperature of newly born
non-asphyxiated infants be maintained between 36.5°C
and 37.5°C after birth through resuscitation or
stabilization.

RESTRICTED 69
 Non-vigorous newborns with meconium-stained fluid do
not require routine intubation and tracheal suctioning.
Initial steps may be performed at the radiant warmer.
Meconium-stained amniotic fluid is a perinatal risk factor
that requires the presence of one resuscitation team
member with full resuscitation skills, including
endotracheal intubation.

RESTRICTED 70
 Current evidence suggests that cord clamping should
be delayed for at least 30 to 60 seconds for most
vigorous term and preterm newborns. If the placental
circulation is not intact, such as after a placental
abruption, bleeding placenta previa, bleeding vasa
previa, or cord avulsion, the cord should be clamped
immediately after birth. There is insufficient evidence to
recommend an approach to cord clamping for newborns
who require resuscitation at birth.

RESTRICTED 71
 Your initial assessment of the heart rate will be made using a
stethoscope. Auscultation along the left side of the chest is the
most accurate physical examination method of determining a
newborn’s heart rate. Although pulsations may be felt at the
umbilical cord base, palpation is less accurate and may
underestimate the true heart rate. If you cannot determine the heart
rate by auscultating and the baby is not vigorous, quickly connect a
pulse oximetry sensor or ECG leads and use a pulse oximeter or
cardiac monitor to assess the heart rate.
› • When PPV begins, consider using a cardiac monitor for
accurate assessment of the heart rate.
› • An electronic cardiac monitor is the preferred method for
assessing heart rate during chest compressions.

RESTRICTED 72
 Resuscitation (positive-pressure ventilation) of
newborns greater than or equal to 35 weeks’ gestation
begins with 21% oxygen (room air). Positive-pressure
ventilation of newborns less than 35 weeks’ gestation
begins with 21-30% oxygen. Free-flow oxygen
administration may begin at 30%. Using the blender,
adjust the oxygen concentration as needed to achieve
the oxygen saturation target by pulse oximetry. If the
newborn has labored breathing or oxygen saturation
cannot be maintained with the target range despite
100% free flow oxygen, consider a trial of CPAP.

RESTRICTED 73
 If PPV is required for resuscitation of a preterm newborn, it is preferable to
use a device that can provide positive end expiratory pressure (PEEP).
Using PEEP (5 cm H20) helps the baby’s lungs to remain inflated between
positive pressure breaths.
 When PPV begins, the assistant listens for increasing heart rate for the first
15 seconds of PPV
› • If the assistant announces “heart rate is increasing,” PPV continues
for another 15 seconds, then HR is re-assessed
› • If the assistant announces “heart rate is not increasing, chest is
moving,” PPV continues for another 15 seconds, then HR is re-
assessed
› • If the assistant announces “the heart rate is not increasing and the
chest is not moving,” ventilation corrective steps (MR. SOPA) are
administered until the chest moves with ventilation. The assistant
announces, “The chest is moving now. Ventilate for 30 seconds.”
Reassess the heart rate after 30 seconds of PPV that moves the chest.
RESTRICTED 74
 The second assessment of HR is performed after 30
seconds of PPV that moves the chest
 • If HR is at least 100 bpm: continue PPV 40-60
breaths/minute until spontaneous effort
 • If HR is 60-99 bpm: reassess ventilation. Perform
ventilation corrective steps if necessary
 • If HR is less than 60 bpm: reassess ventilation.
Perform ventilation corrective steps if necessary. Insert
an alternative airway (ET tube or laryngeal mask). If no
improvement in HR but chest is moving with PPV, begin
100% oxygen and chest compressions.
RESTRICTED 75
 Intubation is strongly recommended prior to beginning chest
compressions. If intubation is not successful or not feasible, a
laryngeal mask may be used. To determine tip-to-lip depth of the
endotracheal tube after insertion, use the endotracheal tube initial
insertion depth table or measure the nasal-tragus length (NTL)
› • Chest compressions are administered with the two-thumb
technique
› • Once the endotracheal tube or laryngeal mask is secured, the
compressor administers chest compressions from the head of
the newborn
› • Chest compressions continue for 60 seconds prior to checking
a heart rate.

RESTRICTED 76
 The recommended solution for acutely treating
hypovolemia is 0.9% NaCl (normal saline) or type-O Rh-
negative blood. Ringer’s lactate is no longer
recommended for treating hypovolemia. All
medications and fluids that can be infused into a UVC
can be infused into an intraosseous needle in term and
preterm newborns.

RESTRICTED 77
In preparation for the birth of a preterm newborn, increase
the temperature in the room where the baby will receive
initial care to approximately 23-25° C (74-77° F). For
newborns less than 32 weeks’ gestation, it is
recommended that you:
 Cover the newborn in food-grade plastic wrap or bag
and use a hat and thermal mattress
 Use a 3-lead electronic cardiac monitor (ECG) with
chest leads or limb leads to provide a rapid and reliable
method of continuously displaying the baby’s heart rate
if the pulse oximeter has difficulty acquiring a stable
signal.
RESTRICTED 78
 • Consider using CPAP immediately after birth as an
alternative to routine intubation and prophylactic
surfactant administration. Many preterm babies can be
treated with early CPAP and avoid the risks of intubation
and mechanical ventilation. Criteria for CPAP usage and
the administration of prophylactic surfactant should be
developed in coordination with local experts.

RESTRICTED 79
 If the responsible physicians believe that there is no chance for
survival, initiation of resuscitation is not an ethical treatment option
and should not be offered. Examples include birth at a confirmed
gestational age of less than 22 weeks’ gestation and some
congenital malformations and chromosomal anomalies.
 In conditions associated with a high risk of mortality or significant
burden of morbidity for the baby, caregivers should discuss the
risks and benefits of life-sustaining treatment and allow the parents
to participate in the decision whether attempting resuscitation is in
their baby’s best interest. If there is agreement between the parents
and the caregivers that intensive medical care will not improve the
chances for the newborn’s survival or will pose an unacceptable
burden on the child, it is ethical to provide compassionate palliative
care and not initiate resuscitation.

RESTRICTED 80
 Over the past two decades, a tremendous amount of knowledge
has been gained in the field of neonatal resuscitation. We have
also identified gaps in knowledge on how to best approach and
treat newborns in need of aggressive resuscitation. The
emphasis should lie on optimizing ventilation, while
avoiding lung injury and hyperoxemia.
 Though sustained inflations may prove to be beneficial, the
means by which to best provide positive pressure ventilation to
establish and maintain a functional residual capacity, how to
best assess ventilation and how to decrease mask leak remains
to be determined.
 In the rare instance that chest compressions and medications
are needed to achieve effective return of spontaneous
circulation, the optimal compression to ventilation ratio, the
timing, route, dose and type of vasopressor still needs to be
studied. With the advancement of science and the development
of technology, it is expected that healthcare providers will have
more reliable tools to reduce the rates of newborn mortality.

RESTRICTED 82
 In addition to technological advances, the need for
further research evaluating strategies for education,
dissemination of knowledge and appropriate
interventions for resource-limited settings is
important.
 Simple interventions such as delayed/physiological
cord clamping, drying and stimulating newborns,
and bag-mask ventilation along with programs such
as ‘Helping Babies Breathe®’ will have a
significant impact on reducing mortality and
morbidity secondary to birth asphyxia worldwide.

RESTRICTED 83
 American Heart Association and the American Academy
of Pediatrics Guidelines for Cardio Pulmonary
Resuscitation & Emergency Cardiovascular Care.
https://www.aap.org/en-us/continuing-medical-
education/life-support/NRP/Pages/NRP.aspx

 Maternal Health, Neonatology and Perinatology 2015

Neonatal resuscitation: evolving strategies

RESTRICTED 84
RESTRICTED 85