Resuscitation of the newborn

Last Updated on by FRCEM Intermediate

Clamp the cord securely

  • For uncompromised term and preterm infants, a delay in cord clamping of at least one minute from the complete delivery of the infant.
  • For infants requiring resuscitation, resuscitative intervention remains the immediate priority.

Maintain a normal body temperature

  • The temperature of newly born infants is actively maintained between 36.5°C and 37.5°C after birth
  • Dry the baby, remove the wet towels and wrap the baby in dry towels.
  • Preterm infants are best placed, without drying, into polyethylene wrapping under a radiant heater

Assessing the infant’s condition

  • Assess colour, tone, breathing by chest movement, and heart rate regularly every 30 s
  • An Apgar score (ranging from 0–10, based upon an assessment of heart rate, respiration, muscle tone, reflex irritability, and colour) at 1 and 5min is calculated and used to assess newborn babies.

Airway

  • Place the infant on his back with the head in the neutral position

Breathing

  • If the baby is gasping or not breathing adequately by 90sec, open the airway, give 5 inflation breaths (pressures of 30cm water for 2–3sec), preferably using air
  • Begin with lower pressures (20–25 cm H2O) in preterm infants
  • Use positive end-expiratory pressure (PEEP) of 4–5 cm H2O if possible
  • Consider Monitoring Spo2 +/- ECG
  • If the heart rate increases, this indicates successful ventilation of the lungs
  • If the heart rate increases but the infant does not start breathing for himself(apnoeic), then continue ventilations at a rate of about 30–40 min-1 until the infant starts to breathe on his own.

Re-assess

  • If the heart rate does not increase, then the most likely cause is that the lungs have not been inflated- look for chest movement during inflation

If chest not moving:

  • Recheck head position
  • Consider 2-person airway control and other airway maneuvers
  • If the airway is obstructed, consider an oropharyngeal airway, laryngoscopy, and suction.
  • Repeat inflation breaths

Airway Manoeuvres:

  • Jaw thrust ( 2 person technique)
  • Direct Inspection of Oropharynx and Airway Suction
  • Guedel Airway
  • Intubation

Tracheal intubation

  • Treat continuing apnoea with tracheal intubation using a 3mm tube (2.5mm in premature babies). Precede intubation by pre-oxygenation with bag valve mask ventilation for 30sec.

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  • Checking again that the infant’s head is in the neutral position?
  • Is there a problem with face mask leak?
  • Do you need jaw thrust or a two-person approach to mask inflation?
  • Do you need a longer inflation time? – were the inspiratory phases of your inflation breaths really of 2–3 s duration?
  • Is there an obstruction in the oropharynx (laryngoscope and suction)?
  • Will an oropharyngeal (Guedel) airway assist?
  • Is there a tracheal obstruction?

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  • If no increase in heart rate (less than 60 min-1) – look for chest movement
  • When the chest is moving but the heart remains slow (less than 60 min-1) or absent after 5 effective inflation breaths and 30 seconds of effective ventilation, start chest compressions.

Chest compression

  • The ratio of compressions to inflations in newborn resuscitation is 3:1.
  • Re-assess infant after every 30 secs (15 cycles)
  • Rate approx 100/mins, using two thumbs technique-lower third of the sternum

Drugs

  • If heart rate is not detectable or slow (<60 min –1) consider umbilical venous catheter (UVC) or IO and drugs(ETT-adrenaline can be considered).Remember B.A.D – Bicarbonate/Adrenaline/Dextrose 10%)
  • Give adrenaline 10mcg/kg (0.1mL/kg of 1 in 10 000 if there is no initial response. If this is ineffective the dose may be increased to 30 mcg/kg (0.3mL/kg of 1 in 10 000). The tracheal dose is thought to be between 50–100 microgram kg-1
  • Give sodium bicarbonate 1–2mmol/kg (2–4mL of 4.2 % solution/kg) when there is no cardiac output despite all resuscitative efforts or in profound or unresponsive bradycardia.
  • Hypoglycemia is a potential problem for all newborns and BMG is unreliable when reading <5mmol/L. Take a blood sample to confirm and treat immediately with a bolus of 2.5mL/kg of 10 % glucose.
  • In the presence of hypovolaemia, a bolus of 10 mL kg-1 of 0.9% sodium chloride

When to stop resuscitation

  • In a newly-born infant with no detectable cardiac activity, and with the cardiac activity that remains undetectable for 10 min, it is appropriate to consider stopping resuscitation.

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