NRP Book 27 12 2022

NEONATAL
RESUSCITATION
NEONATAL
RESUSCITATION
CONTENTS
1. Resuscitation Overview 1
2. Initial Steps in Resuscitation 14
3. Positive Pressure Ventilation 26
4. Chest Compression 38
5. Endotracheal intubation 47
6. Medication 69
Appendix: Pre/Post test 81

LESSON 1:
Resuscitation: Overview
About 10% of neonates require some assistance at birth to breathe and about 20% of all neonatal
deaths are due to birth asphyxia. This neonatal resuscitation training will help you learn how to
resuscitate newborns. Reading this book and practicing the skills during the training course will
help you acquire the skills needed.
Learning Objectives
After reading this chapter you will learn

• The physiological changes that occur at birth
• The sequence of steps to be followed during resuscitation
• Risk factors that could predict which babies may need resuscitation
• Equipment and personnel needed for neonatal resuscitation
Table 1.1: Transitional changes at birth

Intra uterine Extra uterine
Temperature regulation Maternal Self
Oxygen status Low oxygen High oxygen
Gas Exchange Placenta Lung alveoli
Lungs Fluid filled Air filled
Pulmonary vessels Constricted Dilated
Pulmonary vascular resistance High Low
Pulmonary blood flow Low Increased
Alveolar type ll cells Chloride secretion and lung liquid Sodium reabsorption and lung liquid
formation, synthesize surfactant clearance, increased surfactant
release
Foramen ovale Open, right to left shunt from right Closed due to increased left
atrium to left atrium atrial pressure
Ductus arteriosus Patent, right to left shunt from Closed due to increase in oxygen and
pulmonary artery to aorta to bypass decrease in prostaglandins
the lungs and reach placenta
Ductus venosus Carries oxygenated blood from the Constricted due to reduction in
placenta to the right atrium umbilical venous flow
NEONATAL RESUSCITATION 1
What are the transitional changes at birth which help the lungs to supply oxygen
to the baby?
Oxygen is needed for survival both, during fetal life and after birth. Before birth the oxygen to
the fetus is supplied by diffusion of oxygen across the placental membranes from the mother’s
blood supply. Most of the oxygenated blood from the placenta which enters the right side of the
fetal heart flows through the low resistance ductus arteriosus into the aorta (Fig 1.1). This is
because the constricted blood vessels in the fetal lungs offer increased resistance to blood flow.
The fetal lungs are expanded and filled with fluid, not air, and do not play a major role in fetal
oxygenation.
After birth, the placenta can no longer be a source of oxygen supply and the baby will have to
depend on its lungs for oxygen supply. This transition has to happen within seconds. The major
changes during this transition are:
1. Absorption of fetal alveolar fluid into pulmonary venous and lymphatic system and its
replacement with air by the baby’s initial breaths. Since air contains 21% oxygen, filling the
alveoli with air provides oxygen that can diffuse into the blood vessels surrounding the
alveoli.
2. Closure of the umbilical vessels by clamping the cord, removes the low resistance placental
circuit and increases baby’s systemic blood pressure.
3. As air fills the alveoli, the increased oxygen levels in alveoli decreases the resistance in the
blood vessels of the lungs. This increases the blood flow into the lungs. The increase in
systemic blood pressure results in decrease blood flow through the ductus arteriosus which
also increases the blood flow into the lungs. The increase in oxygen levels also results in
constriction of ductus arteriosus (Fig.1.2).
Fig. 1.1 : Normal Fetal Circulation Fig. 1.2 : Change in ductus arteriosus
2 NEONATAL RESUSCITATION
Baby’s initial breaths help to fill the lungs with air and allow the process of gas exchange to begin
which is needed for survival. Although most of the transition takes place within a few minutes
after birth, the process may take several hours for its completion. Studies have shown that it may
take up to 10 minutes for babies to achieve oxygen saturation of 90% or more; functional closure
of the ductus arteriosus may not occur up to 24 hours and complete relaxation of the lung blood
vessels may take up to several months.
What can go wrong during transition at birth?
The baby may encounter difficulties either before labor, during labor or after birth. Problems
before and during labor reflect compromised placental blood flow. Difficulties after birth usually
reflect problems with baby’s airway and/or lungs. Normal transition may be disrupted by the
following problems:
 Lungs do not fill with air because either the baby does not initiate breathing or has
inadequate spontaneous breaths, hence oxygen may not reach the baby’s blood.
 The expected increase in systemic blood pressure may fail to occur either because of
excessive blood loss or neonatal hypoxia; this may cause poor cardiac contractibility or
bradycardia and result in hypotension.
 Pulmonary arterioles may remain constricted because of inadequate gaseous distention

of the lungs or lack of oxygen. This results in decreased blood flow into the lungs and thus
reduced oxygen supply to the tissues.
How does the fetus/newborn respond to interruption in transition?

When the normal transition is interrupted, the oxygen supply to tissues is decreased, and the
baby may exhibit one or more of the following clinical signs:
• Poor muscle tone due to insufficient oxygen delivery to the brain, muscles and other organs
• Poor respiratory drive due to insufficient oxygen supply to the brain
• Bradycardia due to insufficient oxygen supply to the heart muscle or brainstem
• Low blood pressure from insufficient oxygen to the heart muscle or blood loss
• Tachypnea (fast breathing) due to failure to absorb fetal lung fluid
• Persistent cyanosis or low oxygen saturation on pulse oximeter, due to insufficient oxygen
in blood
Which babies require resuscitation?
Approximately 10% of newborns need some assistance at birth to begin breathing and about 1%
need intensive resuscitative measures (intubation, chest compressions and/or medications). The
presence of risk factors can help identify those who may need resuscitation, but you must always
be prepared to resuscitate, as even with no risk factors, some babies will require resuscitation.
Every birth should be attended by someone who is trained in initiating neonatal resuscitation.
Additional personnel should be available when intensive resuscitation is required. The diagram
below (Fig.1.3.) illustrates the relationship between resuscitation steps and the proportion of
newborns that need them. At the top are the resuscitative steps needed by majority of neonates
who do not cry soon after birth while the steps at the bottom are needed by very few neonates.
Fig.1.3: Resuscitation steps and proportion of neonates needing them
The resuscitation flow diagram (Fig.1.4.)

The flow diagram describes the Neonatal Resuscitation Program-India (NRP-India). The diamonds
indicate assessment and the rectangles show the actions that may be required based on the
assessment. The flow diagram begins with the birth of the baby. As you read the description of
each step, study the flow diagram too. You can use the flow diagram to help you remember the
steps involved in resuscitation.
Initial assessment. Deliver the baby onto the mother’s abdomen and then assess if the baby is
breathing/crying? If “Yes”, then the baby should stay with the mother and provided routine care.
If the answer is “No”, you should proceed to initial steps immediately after clamping and cutting
the cord.
Section A (Airway) These are the initial steps that you should take to establish an Airway and
begin resuscitating a newborn.
Provide warmth by placing the baby under a radiant warmer
Position the head to open the airway; clear airway as necessary
Dry the baby: remove wet linen
Stimulate the baby to breathe (if required)
Reposition the head to maintain an open airway
Evaluation of the effect of Section A. You should evaluate the newborn’s respiration and heart
rate simultaneously after these first interventions. If the baby is not breathing (is gasping or has
apnea) or has a heart rate below 100 beats per minute (bpm), you should immediately proceed
to Section B (left side). If the baby’s respiration appears labored or is persistently cyanotic
proceed to Section B (right side).
Section B (Breathing) If the baby has apnea or is gasping or has a heart rate below 100 bpm, you
should assist the baby’s breathing by providing positive pressure ventilation (PPV) with room air
for babies who are ≥ 32 weeks and with 21-30% for babies who are < 32weeks.
If the baby is breathing, but has persistent respiratory distress (labored breathing), attach a pulse
oximeter (if available) to consider need for supplemental oxygen. If the baby is preterm with
labored respiration, consider administering continuous positive airway pressure (CPAP) by face
mask (if facilities available). If pulse oximeter and/or CPAP are not available, initiate supplemental
oxygen and shift baby to SNCU/NICU.
Evaluation of the effect of Section B. After 30 seconds of effective PPV, CPAP and/or
supplemental oxygen, evaluate the newborn again to ensure that ventilation is adequate before
moving to the next step. With appropriate ventilation, in almost all cases, the heart rate would
rise to above 100 bpm. If the heart rate is below 60 bpm, you should proceed to Section C.
Section C (Circulation). You support Circulation by starting chest compressions while continuing
PPV. At this stage, it is strongly recommended to perform endotracheal intubation (if skilled), if
not done earlier. This is for more effective coordination of chest compressions and PPV.
Evaluation of the effect of Section C. After 60 seconds of coordinated chest compressions and
PPV, evaluate the newborn again. If the heart rate is still below 60 bpm, proceed to Section D.
Section D (Drug). You administer epinephrine as you continue PPV and chest compressions.
Evaluation of the effect of Section D. If the heart rate remains below 60 bpm, the actions of
Section C (circulation) are continued and D repeated every 3-5 minutes (lower curved arrow).
When the heart rate rises above 60 bpm, chest compressions are stopped. PPV is continued until
the heart rate is above 100 bpm and the baby is breathing well.
Evaluation occurs after initiation of each action and is based on the following 2 signs:
Respiration
Heart rate
Oxygen saturation can be assessed with a pulse oximeter.

This process of evaluation, decision and action is repeated frequently throughout resuscitation.
Note the following important points about the flow diagram:
• There are 2 heart rates to remember: 60 bpm and 100 bpm. A heart rate below 60 bpm
indicates that additional resuscitation steps are needed. A heart rate above 100 bpm
usually indicates that resuscitation procedures beyond those in Section A can be stopped,
unless the patient is apneic or has persistently low oxygen saturation levels.
• The primary actions in neonatal resuscitation are aimed at ventilating the baby’s lungs
(Sections A and B). Once this has been accomplished, heart rate, blood pressure and
pulmonary blood flow will improve spontaneously. But, if blood and tissue oxygen levels
are low, cardiac output may have to be assisted by chest compressions and epinephrine
(Sections C and D) for blood to reach the lungs and to provide oxygenation.
• As soon as the baby is delivered on to the mother’s abdomen or handed over to you
(Cesarean section), ask the initial question, (baby breathing or crying). In case the baby is
not breathing at birth perform initial steps. The first one minute is called the “Golden
Minute”, therefore it must be ensured that the baby is either breathing spontaneously or
is being assisted to breathe by 60 seconds of birth. First golden minute includes assessment
at birth, initial steps, reassessment and initiation of PPV.
What Risk factors may be associated with the need for resuscitation at birth?
Table 1.2 below lists some of the risk factors that may be associated with the need for neonatal
resuscitation in the delivery room.
Table 1.2: Resuscitation at birth: Risk factors
Risk Factors
Maternal Risk Factors Fetal Risk Factors
Mother’s age < 18/ >35 years Preterm/Post-term
Inadequate Antenatal care Previous fetal or neonatal deaths
Significant intra-partum hemorrhage (Abruptio placentae, Fetal anemia
placenta previa) Fetal hydrops
Preeclampsia or eclampsia Intrauterine growth restriction
Maternal Hypertension Significant malformations or anomalies in fetus
Maternal medical problems (cardiac, pulmonary, renal, Fetal macrosomia
thyroid, anemia, etc.)
Intrauterine infection
Maternal pyrexia, Infection, Chorioamnionitis
Reduced fetal movements before onset of labor
Polyhydramnios, Oligo-hydramnios
Intrapartum Risk Factors

Abnormal fetal heart rate patterns (late and variable Emergency cesarean section
decelerations; Category II and III Fetal heart rate) Maternal magnesium therapy
Meconium stained amniotic fluid Chorioamnionitis
Reduced fetal movements Shoulder dystocia
Precipitate labor Cord prolapse
Prolonged labor Narcotics administered to mother within 4 hours of
Breech or other non-vertex presentation delivery
Forceps/vacuum deliveries Maternal general anesthesia/sedation
Fig. 1.4: Resuscitation Flow Diagram (NRP-India)
Equipment Checklist for resuscitation
All equipment necessary for complete neonatal resuscitation should be available in the delivery
room and should be fully functional. A complete list of neonatal resuscitation equipment is given
in Table 1.3
What equipment should be available?

Table 1.3: Equipment needed for neonatal resuscitation in delivery room
Temperature  Radiant warmer
 Clean prewarmed sheets - 2/3
 Room thermometer
 Digital thermometer
 Plastic wrap (For <32 weeks gestation)
 Cap
Airway  Suction device
 Suction catheters (Size F 5, 6, 8, 10, 12, 14)
 Oxygen source
 Oxygen tubing
 Minute specific oxygen saturation chart
 Compressed air source*
 Air-oxygen blender*
Breathing  Self-inflating bag (240/500 ml)
 Face mask (size 0, 1)
 Feeding tube (size 6, 7, 8)
 Pulse oximeter
 Neonatal pulse oximeter probe
 Laryngoscope with batteries and straight blade (size 0,1)
 ET tubes (size 2.5, 3, 3.5mm)
 Scissors
 Oxygen Reservoir
 T-piece resuscitator*
Circulation  Syringes (1 cc, 2 cc, 5 cc, 10 cc, 20 cc)
 Umbilical catheterization set (umbilical catheters 3.5, 4.0 and 5.0, sterile blade,
gloves, alcohol swabs, cord ties, mosquito forceps, povidone iodine swabs)
 3 way stopcock
 Adhesive tape
 Sterile gauze
 Needles 25, 21, and 18-gauge
Drugs  Epinephrine (1: 10,000)
 Normal saline (0.9%)
Miscellaneous  Gloves
 Timer
 Extra laryngoscope bulb
 Extra laryngoscope batteries
 Scissors
 Stethoscope
 Cord clamp, Cord tie
 Measuring tape
 Transport incubator*
*Desirable
Response to resuscitation:
The APGAR score (Table 1.4) is widely used to assess the cardio-respiratory status of the newborn
in the delivery room. The 5 components of the APGAR score are- (1) color (2) heart rate
(3) irritability (4) muscle tone; and (5) breathing. These are indicators of different physiologic
responses. Of these, heart rate and breathing are the most important components. The score is
reported at 1 minute and 5 minutes after birth for all infants and at 5-minute intervals thereafter
until 20 minutes for infants with a score less than 7.
The APGAR score alone is not to be used to diagnose asphyxia. APGAR scores do not predict
individual mortality or adverse neurologic outcome.
Table 1.4: APGAR score
Sign Score Minutes

0 1 2 1 5 10 15 20
Color Blue, pale Pink body, Blue All pink
extremities
Heart Rate Absent < 100 bpm >100 bpm
Breathing Absent Slow, Irregular Good Crying
Irritability No response Grimace Cough, Sneeze
Muscle tone Limp Some flexion of Active motion

extremities
What do you do after resuscitation?

Routine care: Almost 90% of newborns are vigorous at birth with no risk factors. They do not
need to be separated from their mothers at birth. All vaginally delivered babies should be
delivered prone onto mother’s abdomen and assessed for breathing/crying. If the baby is
breathing or crying provide Routine Care by continuing skin to skin contact, turn head to one
side, clear the upper airway as necessary by wiping the baby's mouth and nose. Dry the baby with
prewarmed linen & discard the wet linen. Cover the mother & baby dyad with clean, dry linen
while continuing skin to skin contact. Cord should be clamped after at least one minute, baby is
placed between the mother’s breasts and breastfeeding is initiated. The baby may also crawl
towards the mother’s breast. Assess breathing, color and activity periodically. (Fig 1.5).
Fig. 1.5: Baby on mother’s abdomen for routine care
Delayed cord clamping

Clamping of the cord should be delayed as much as possible, preferably not earlier than one
minute after birth and the newborn should be continued to be nursed in prone position over
mother’s abdomen. Delayed cord clamping should be routinely done for all newborns – term and
preterm- who breathe spontaneously at birth.
Delayed cord clamping is not recommended for babies who are depressed at birth and need
resuscitation.
Table 1.5: Delayed Cord Clamping

DCC (Delayed Cord Clamping)
Benefits Decreased PVH/IVH, improved cardiovascular stability (higher blood pressure and
blood volume, less need for transfusion) and less NEC
Risk Higher chance of hyperbilirubinemia but not requiring phototherapy
Contraindication Newborn requiring resuscitation, placenta previa, vasa previa, Cord avulsion
Observational care: Babies who have received initial steps and PPV for < 1 minute to help them
initiate breathing can also be cared with their mothers. Monitor breathing, activity and color of
these babies at least once every 30 minutes during the first 2 hours after birth, along with
temperature and initiate breast feeding.
Post Resuscitation Care: Babies who have received PPV for more than 1 minute or more intensive
resuscitation are at high risk of further deterioration. These babies should be managed in a
Special Newborn Care Unit (SNCU) or Neonatal Intensive Care Unit (NICU) for post resuscitation
care. Neonates with respiratory distress after birth or preterms in whom CPAP has been initiated
in the delivery room also need to be shifted to SNCU/NICU.
Key to Successful Resuscitation

• Anticipation
• Preparation
• Call for help
• Able to work in coordination
• Communicate effectively
• Be gentle but quick
• Provide warmth, maintain hygiene, documentation/record keeping
Summary: Lesson 1
1. Most newborn babies are vigorous at birth. Only about 10% require some resuscitative
assistance and about 1% need advanced resuscitative measures (intubation, chest
compressions and/or medications) at birth.
2. The most important and effective action in neonatal resuscitation is to ventilate the baby’s
lungs.
3. Lack of ventilation of newborn lungs results in sustained constriction of pulmonary
arterioles preventing oxygenation. Lack of perfusion and oxygenation to the baby’s organs
can lead to damage to the brain, other organs or death.
4. All delivery points should have a checklist of equipment. All equipment should be
functional.
5. Many, but not all babies, who will need resuscitation at birth, can be identified by the
presence of antepartum or intrapartum risk factors.
6. All newborns at birth need to be initially assessed to determine if they need resuscitation.
7. Every birth should be attended by at least 1 person who is capable of initiating
resuscitation. When resuscitation is anticipated, additional personnel should be present in
the delivery room to assist the resuscitation procedures.
8. Resuscitation should proceed rapidly as it is time bound and requires coordinated
teamwork with a great degree of adaptability and good communication.
9. Evaluation and decision making are based primarily on respiration, heart rate and oxygen
saturation.
10. The steps of neonatal resuscitation are as follows:
A. Receive baby in prewarmed linen, cut the cord immediately and start with initial
steps
 Provide warmth by placing under the radiant warmer
 Position head and clear airway as necessary
 Dry baby and discard wet linen
 Stimulate to breathe and reposition
 Evaluate respiration, heart rate and oxygenation
B. Provide positive pressure ventilation
C. Provide chest compressions and continue ventilation
D. Administer epinephrine as you continue chest compressions and assisted ventilation.
LESSON 2:
Initial Steps in Resuscitation
Learning Objectives:
In this lesson you will learn how to:
• Determine if a newborn needs resuscitation
• Perform initial steps
• Provide free flow oxygen
The following scenarios will help you understand the initial steps of evaluation and resuscitation.
You are requested to imagine yourself as a part of the resuscitation team as you read through
the scenarios.
Case Scenario 1:
A 28-year-old primigravida is admitted to the labor room in active labor. Her membranes
ruptured on the way to the hospital, 2 hours back. The female attendant with the woman says
that the amniotic fluid was clear. In the labor room the obstetrician notices that the cervix is
dilating progressively and after 4 hours a baby girl is born vaginally by vertex presentation.
As soon as the baby is delivered, the “time of birth” is noted and the baby is placed prone on the
mother’s abdomen. On assessing, the baby is active and crying. Skin to skin care is continued.
The face is turned to one side and no secretions are noted. The baby is dried, wet linen is
discarded and the mother and baby are covered with prewarmed linen. The cord is cut after 1
minute of birth. The baby is allowed to continue transition as the color becomes increasingly
pink. (Fig 2.1)
Fig. 2.1: Routine care
Case Scenario 2:
A 34 year old multi-parous woman is admitted to the labor room in early labor. After some time,
the membranes rupture to reveal meconium stained amniotic fluid. The obstetrician looks at the
fetal heart rate. She decides to allow a vaginal delivery.
As soon as the baby is born, the time of birth is noted and the baby is placed prone on the
mother’s abdomen. On assessing the breathing, the baby is observed to have minimal breathing
efforts and poor tone. The cord of the baby is cut and the baby is taken under a preheated
warmer. His oropharynx is cleared with a large bore suction catheter of size 14F. The baby is still
having very poor respiratory efforts.
The baby is dried with a warm towel and stimulated to breathe by rubbing the back twice and
the baby is repositioned to open his airway. He immediately begins to breathe more effectively.
The heart rate is evaluated to be more than 120 beats per minute. The baby is placed on the
mother’s chest and covered with warm linen, breastfeeding is initiated and the baby is monitored
for breathing, heart rate, temperature and color. (Fig 2.2)
Fig. 2.2: Initial Steps
Determining if a baby needs resuscitation

The need for resuscitation in a baby is determined by looking at the breathing efforts of the baby.
Breathing is evident by watching the baby’s chest. Breathing is indicated if a baby is vigorously
crying or has good rhythmic chest movements. One should not be misled by a baby who is
gasping. Gasping baby takes a series of deep, irregular inspirations. Such breathing occurs when
the baby is hypoxic and is indicative of severe neurologic and respiratory depression.
What are the initial steps and how are they administered?
Once it is decided that a baby needs resuscitation, the Initial steps should be initiated
immediately. These are performed in a particular order. These steps should be applied
throughout the resuscitation process wherever required.
Provision of warmth:
The cord of the baby needing the initial steps should be cut (without delay) and the baby should
be placed under the radiant warmer (Fig. 2.3). In all deliveries the warmer should be pre warmed
prior to the delivery for at least 20 minutes in the manual mode. In this way the resuscitation
team will have access to the baby and the heat loss is prevented by the radiant warmer. At this
stage full visualization of the baby is needed and the baby should not be covered. In case of
suspicion of severe birth asphyxia, due care should be taken not to overheat the baby. The
resuscitator should stand at the head end of the baby.
Fig. 2.3: A baby placed in the radiant warmer for provision of warmth during Initial Steps
For Preterm babies less than 32 weeks gestation:

Wrap the baby in a polythene plastic bag or wrap (Fig 2.4). Instead of drying the baby with towels,
very premature newborns should be covered or wrapped up to their neck in polythene plastic
bag or wrap immediately after birth. Drying the body is not necessary. You may use a food grade
plastic bag, wrap or sheets of commercially available polythene plastic. If using a plastic sheet or
food wrap, you may either wrap the baby in a single sheet or use 2 sheets and place the baby
between the sheets.
Fig. 2.4: Wrapping the baby in polythene plastic bag

Position
The baby should be positioned on the back with the neck slightly extended in the “sniffing”
position. Care should be taken to prevent hyper extension or flexion of the neck, since either
may restrict air entry. To attain a correct posture, a rolled piece of cloth/gauze piece (shoulder
roll) may be placed under the shoulder of the baby (Fig. 2.5). This is particularly useful when there
is a large occiput (back of head) resulting from molding or edema.
An appropriate position as described facilitates an unrestricted air entry by bringing the posterior
pharynx, larynx and trachea in line. This alignment in the supine position is also the best position
for assisted ventilation with mask or for the placement of an endotracheal tube.
Fig. 2.5: Positioning of the baby with shoulder roll in place
Clearing the Airway

After the baby is positioned well, the presence of secretions may prevent entry of air into the
lungs. Hence, clearing of the airway, if required, should immediately follow once the newborn
has been positioned. However, suction should not be done as a ‘routine ritual’ in all cases.
Secretions may be removed from the airway with an oral mucous extractor or a suction catheter
attached to a mechanical suction device. Before suctioning, set the suction pressure to 80-100
mm of Hg and turn the head of the baby to one side. Mouth should be suctioned before nose
(Figure 2.6).
Fig. 2.6: Sequence of suction; mouth ‘M’ followed by nose ‘N’
Table 2.1: Indications and procedure of suctioning
Indication Visible secretions
Need for PPV and secretions are blocking the airway
No chest rise during ventilation
To visualize vocal cords
Device Mucous extractor, Suction catheter attached to machine or wall mounted suction
Size 10, 12(14G- for meconium or thick secretions)
Technique Suction should be gentle and brief
Turn head to one side
Suction mouth before nose
Apply suction while withdrawing catheter
Maximum suction pressure 80-100 mm of Hg
Risk Hypoxia, apnea, mucosal injury, cyanosis
Drying: Drying is essential to prevent heat loss. It should be performed quickly starting from the
head, upper extremity, torso, back and the lower extremity. The wet cloth should then be
discarded.
Stimulation: Drying and suctioning stimulate a baby to breathe. For many newborns, these are
sufficient to initiate respiration. If a baby does not have vigorous breathing, additional tactile
stimulation may be required.
Stimulation may be useful not only to induce and begin breathing during the initial steps of
resuscitation but also may be used to stimulate continued breathing after positive pressure
ventilation (PPV).
The only safe and appropriate method of providing tactile stimulation is gently rubbing the back
of the baby twice.
If a baby is in primary apnea, any form of stimulation will initiate breathing. Therefore, gently
rubbing the back twice is sufficient.
Vigorous and prolonged stimulation is not helpful and can cause serious injury. Shaking the
baby and holding the baby upside down should be strictly avoided.
If a baby remains apneic despite tactile stimulation, positive pressure ventilation should be
immediately initiated (discussed in Lesson 3).
Fig. 2.7: Appropriate method of tactile stimulation
After initial steps, what do you do next?
Evaluate the baby (Table 2.2)

The next step is to evaluate the baby and assess if further resuscitation is required. The vital signs
to be evaluated are ‘Respiration’ and ‘Heart rate’. If the baby is apneic or has gasping respiration
or the heart rate is less than 100 bpm, initiate positive pressure ventilation within 60 sec of birth.
Respiration
The baby is assessed for chest movements. Baby is said to have good respiration if, normal chest
movement is present. The rate and depth of respiration should increase after few seconds of
tactile stimulation.
In some babies especially preterm neonates, respiration may be labored. Such breathing should
also be noted. These babies may require additional respiratory support and monitoring.
Heart Rate
The best way to rapidly determine the heart rate is by using a stethoscope. Tapping the table
with each beat of the heart rate will assist other members of the team to know the heart rate.
Count the heart rate for 6 seconds (multiply the number of beats in 6 seconds by 10 to provide a
quick estimate of the beats per minute). The heart rate should be more than 100 bpm.
What do you do if the Heart Rate or Respiration are abnormal?

On evaluation of the breathing and the heart rate after initial steps, if the baby is apneic or has
gasping respirations, or the heart rate is less than 100, one should proceed immediately to
provide positive pressure ventilation (PPV).
Continuing to provide tactile stimulation or administering free flow oxygen to a non-breathing
baby or a baby with a heart rate below 100 bpm, is harmful and delays appropriate
management. The appropriate management is described in detail in Lesson 3.
Table 2.2: Evaluation and Action
Breathing Heart rate Action
Regular >100 bpm Routine Care
Labored breathing >100 bpm Open airway, Suction if required, Place pulse oximeter
Consider CPAP in preterm
Dusky or Cyanotic >100 bpm Assess SpO2, Provide oxygen if required
Apnea, Gasping <100 bpm Initiate positive pressure ventilation
If a baby is breathing well and heart rate is above 100 bpm BUT breathing is
labored OR you think that the baby is persistently cyanotic:
On evaluation after initial steps, if the baby is breathing spontaneously and has a heart rate of
more than 100 bpm, but has labored breathing or central cyanosis, additional respiratory support
needs to be considered (especially if preterm) and tailored optimal oxygen delivery may be
required. CPAP machine for respiratory support and a blender with pulse oximeter for
optimization of the oxygen delivery will be needed, but may not be available in the delivery room.
In such circumstances these babies are started on supplemental oxygen and immediately shifted
to the SNCU/NICU.
SPO2 monitoring and Optimal Oxygen Delivery

The state of oxygenation of the baby can be suggested by the baby’s skin color. Cyanosis, caused
by low oxygen in blood, will appear as blue color over lips, tongue and trunk. Acrocyanosis (blue
hue of the hands and feet) is often due to the decreased circulation of the extremities and is not,
by itself, an indication of decreased blood oxygen levels.
• Studies have now shown that clinical assessment of skin color is not reliable, and may vary
with the skin pigmentation.
• A baby who is undergoing a normal transition to extra uterine life, may take several minutes
after birth to increase blood oxygen saturation from approximately 60% (normal in
intrauterine state) to more than 90%, which is the normal for a healthy newborn.
Hence, if central cyanosis persists, it would be ideal to attach a pulse oximeter probe to
determine if the baby’s oxygenation is in the abnormal range. If the levels are below the
saturation targets established for a normal baby during transition (Table 2.3) and are not
increasing, one may need to provide supplemental oxygen.
Table 2.3 provides an easy to remember, accepted range of the pre-ductal (right hand or wrist)
pulse oximetry oxygen saturation values, during the first 10 minutes, following birth of
uncomplicated babies born at term.
Table 2.3: Targeted saturation after birth
Administration of supplemental oxygen:

How?
Free flow oxygen can be given to a spontaneously breathing baby by using one of the following
methods (Fig. 2.8):
• Oxygen tubing held close to the baby’s nose and mouth
• Oxygen Mask
• T piece Resuscitator
Free flow oxygen cannot be given reliably by a mask attached to the self–inflating bag.
However, free flow oxygen may be administered through the open reservoir (‘tail’) attached to
some self-inflating bags.
When unregulated oxygen is administered to a baby who is cyanosed or when the oximeter
readings are lower than the expected range, the oxygen levels may increase very quickly to levels
that may be toxic to the baby at that time. The likelihood of this situation increases when the
baby is preterm.
Thus, it is best to use an oxygen concentration ranging from 21% to 100% depending on the
desired saturation. This will be possible only with the availability of a compressed air source and
an oxygen blender.
Fig. 2.8: Methods by which free flow oxygen can be administered to a baby – oxygen tubing, face mask
and T piece resuscitator
How Much?
The normal intra-uterine saturation is 60%, which increases gradually to 90% only by about 10
minutes of birth. Because of this normal transition pattern and the possibility of oxygen toxicity
there is an ongoing controversy as to how much oxygen is safe during resuscitation. It is best to
give oxygen to maintain the saturation of the baby in the acceptable range. This will require the
use of a blender and a compressed gas source for graded delivery of oxygen and, a good pulse
oximeter for optimal monitoring of saturation in the earliest minutes of life. If these are not
available in the delivery room, it is best to shift these babies to a SNCU/NICU for further
management.
How Long?
The oxygen saturation of the baby should be used to decide the duration of oxygen delivery. In
case oxygen is to be given for a longer time, it should be heated and humidified.
When central cyanosis improves and the oxygen saturation of the baby is above 90%,
supplemental oxygen is gradually decreased. If the cyanosis or low oxygen saturation (less than
90%) persists in spite of giving free flow oxygen, the baby may have significant lung disease, and
a trial of positive pressure ventilation (PPV) is justified. However, if ventilation is adequate and
the baby still remains cyanotic, then a diagnosis of congenital cyanotic heart disease or persistent
pulmonary hypertension of the newborn should be strongly considered.
Observational care: Babies who have received initial steps to help them initiate breathing, can
also be cared with their mothers. The baby should be placed prone on the mother’s chest and
breast feeds should be initiated. Besides thermal control and breast feeding (as in routine care),
breathing, activity and color of these babies should also be monitored at least once every 30
minutes during the first 2 hours after birth.
Observational care with Mother

 Warmth (skin to skin care)
 Initiate breastfeeding
 Monitor neonate (Temperature, heart rate,
breathing and color every 30 min for 2hr)
Summary: Lesson 2
1. Babies who do not cry/breathe well at birth should receive initial steps.
2. If the baby did not breathe or cry after birth then
a) The cord should be clamped and cut immediately and the baby should be placed
under a preheated radiant warmer
b) Open the airway by positioning the newborn in the “sniffing” position
c) Dry the baby immediately. Appropriate tactile stimulus involves gently rubbing the
back of the baby twice
d) Reposition the baby and then reassess
3. Continued use of tactile stimulation in an apneic baby wastes valuable time. For persistent
apnea start positive pressure ventilation within 60 seconds of birth.
4. Acceptable methods for administering free flow oxygen are
- Oxygen Mask
- Oxygen tubing held close to the baby’s nose and mouth
- T piece Resuscitator
5. Free flow oxygen cannot be given reliably by a mask attached to a self- inflating bag.
6. Decisions and actions during newborn resuscitation are based on newborn’s
(a) Respiration (b) Heart rate (c) Oxygen saturation (by pulse oximeter)
7. If the baby is breathing well spontaneously and heart rate is above 100 bpm the baby
should receive observational care with the mother.
LESSON 3:
Positive Pressure Ventilation (PPV)
In this lesson you will learn:

• When to initiate positive pressure ventilation (PPV)
• What are the devices used for PPV
• How to check the PPV device for functionality
• How to select appropriate size bag and mask
• What is the technique for providing PPV and the expected response
• What to do if there is no desired response following PPV
The following case scenario will illustrate how positive pressure ventilation (PPV) is provided
during resuscitation. Imagine yourself as a part of the team as you read through the case.
Case Scenario 3:
A 25 years old primigravida with non-progress of labor delivers a male baby at term gestation. As
soon as the baby is delivered, the “time of birth” is noted and the baby is placed prone on the
mother’s abdomen. On assessing breathing, it is observed that the baby is not breathing and is
limp and has a large caput.
The cord is clamped and cut immediately and the baby is placed under a radiant warmer. The
baby is placed in sniffing position to keep the airway open. A quick suction is done of the mouth
followed by suction of the nose. The nurse then dries the baby with pre-warmed sheets and then
removes the wet linen. A brief stimulation is done by rubbing the back of the baby. The head is
repositioned.
The baby is still not breathing after these initial steps. The resuscitation team takes a decision to
initiate positive pressure ventilation. A team member initiates positive pressure ventilation (PPV)
with a bag and mask using 21% oxygen (room air) and calls for help. After 5 breaths, a second
team member auscultates and reports heart rate as 70/min. The team member providing PPV
takes ventilation corrective steps by reapplying the mask to the face and repositioning the baby’s
head to open the airway. Reassessment after 5 breaths shows that the chest is rising and the
heart rate is increasing, hence, PPV is continued for 30 seconds. At the end of 30 seconds of
positive pressure ventilation the baby still does not have spontaneous breathing, and the
assistant reports that the heart rate has risen to 110/min. Ventilation is continued further,
ensuring adequate chest rise with each breath for another 30 seconds. The baby is about 2
minutes old; has some spontaneous breaths, a heart rate of 140/min and is pink. PPV is continued
and soon the baby starts crying. PPV is then gradually discontinued.
The baby’s cord is tied and the baby is shown to the mother. The baby is then shifted to the
SNCU for post- resuscitation care.
In the previous lesson (Lesson 2) you learnt how to determine whether the baby needs some
form of resuscitation and how to perform the initial steps of resuscitation. In this lesson you will
learn what to do next if the baby is not breathing effectively (apnea or gasping) or is bradycardic
(HR <100 bpm) after initial steps of resuscitation.
When should you provide positive pressure ventilation?

PPV should be initiated if after providing initial steps of resuscitation-
• The infant is apneic or gasping or
• The heart rate is less than 100 bpm
What is the equipment available for PPV in newborns?

The types of equipment available for providing PPV in the newborn are:
• The Self inflating bag
• The T- piece resuscitator
The Self-inflating bag (240-500ml) is presently the most commonly used ventilation device (Fig.
3.1). The bag inflates following compression due to elastic recoil and does not need a compressed
gas source to keep it inflated. It has a pressure limiting valve (pop off valve) regulated to limit
inflation pressure to around 30-40 cm of water. The bag can be used with or without an attached
manometer and/or oxygen reservoir (Fig.3.2). When squeezed, a self-inflating bag delivers a
breath.
Table 3.1: Advantages and disadvantages of a self- inflating bag
Self-inflating bag
Advantages  Will always refill after being squeezed, does not require compressed gas
source
 Pressure limiting valve reduces risk of over-inflation
Disadvantages  Will inflate even if there is no seal between mask and patient’s face
 Requires oxygen reservoir to provide high oxygen concentration
 Cannot deliver free flow oxygen through face mask
 Cannot be used to deliver continuous positive airway pressure (CPAP); can
only deliver CPAP if positive end-expiratory pressure (PEEP) valve and
pressurized gas is used.
Fig. 3.1: Self inflating bag
Fig. 3.2: Self inflating bag with oxygen tubing and reservoir
T-piece resuscitator is a flow-controlled pressure limited ventilator device (Fig.3.3). Piped

compressed gas is delivered at one port of the T Piece. A preset peak inspiratory pressure (PIP),
positive end expiratory pressure (PEEP), and maximum circuit pressure is set. With a T-piece
device, gas flows into a face mask or endotracheal tube through a ‘patient supply line’. Inflation
is achieved by interrupting the escape of gas through an outlet hole on the T-piece using a thumb
so that the pressure rises and is displayed by a manometer. Adjusting the PEEP valve varies
positive end expiratory pressure (PEEP). Varying the duration of occlusion of the outlet hole alters
the inflation time. The newborn is ventilated by placing a finger over the outlet aperture (hole in
the PEEP valve) and removing it periodically at about 40-60 times a minute. The inspiratory and
expiratory pressure settings can be altered upwards or downwards as needed during use,
depending on the infant’s response.
Fig. 3.3: T piece resuscitator
Table 3.2: Advantages and disadvantages of a T piece resuscitator

T piece resuscitator
Advantages Consistent delivery of PIP and PEEP
Can be used to provide free flow oxygen reliably – 21-100 % (with blender)
Provider does not get tired while providing ventilation
Disadvantages Needs compressed gas with a blender
Requires pressures to be set prior to use
Changing inflation pressure during resuscitation is more difficult
Risk of prolonged inspiratory time
A self-inflating bag should always be available as a back-up to flow-dependent devices in case of

failure of compressed gas supply.
What are the important features of resuscitation equipment used in newborns?

The equipment should be designed for use in newborns and the following features must be given
consideration:
Appropriate size face mask (Fig. 3.4a and b)
Masks come in a variety of shapes, sizes, and materials. An appropriate size face mask must seal
around the mouth and nose but not cover the eyes or overlap the chin. It can be difficult to
establish and maintain a good seal between the mask and the infant’s face and it should not be
assumed that just because the mask is on the face, there is a good seal. Masks with a cushioned
rim and round shape are preferable. An ideal mask should extend from bridge of nose to tip of
chin covering the nose without covering the eyes.
Fig. 3.4a: Two sizes of face masks (1 and 0) used in Fig. 3.4b: Appropriate size face mask
newborns
Appropriate size bag

Bags used for newborn resuscitation should have a volume between 240-500 ml. Term newborns
require about 10-25 ml with each breath (4-6 mL/kg). Bags larger than 500 ml cannot deliver such
small volumes and bags smaller than 240ml will not adequately re-inflate between breaths, when
40-60 breaths/min are given.
Safety features in PPV devices

Self-inflating bags should have a pressure relief valve (commonly known as a pop off valve) (Fig.
3.1) which is usually set at 30-40 cm H2O by the manufacturer. If peak inspiratory pressure
exceeds this limit, the valve opens limiting the pressure transmitted to the newborn lungs. Many
self-inflating bags are equipped with a pressure manometer. This manometer helps to adjust
pressure delivered.
A T-piece resuscitator has 2 controls. The inspiratory pressure control sets the amount of
pressure delivered during a normal assisted breath. The maximum pressure relief control is a
safety feature that prevents the pressure from exceeding a preset value (usually 40 cm H2O, but
is adjustable).
How to check functionality of self-inflating bag?

Assemble the device correctly.
a. Occlude the face mask of the self-inflating bag against the palm.
b. Look for following features as you squeeze the bag:
 You should feel pressure against the palm. (Fig 3.5)
 The pop off valve should make a hissing sound or move up and down.
 The bag should reinflate instantly when pressure is released.
Absence of any of the above features suggest malfunction.
Fig. 3.5: Checking for pressure against palm
Table 3.3: Steps of providing ventilation using self-inflating bag?

Step 1 Choose the correct size bag (240 -500ml)
Step 2 Choose the correct size mask
Step 3 Assemble the bag & mask and ensure valves are present and appropriately placed
Step 4 Test the functionality of bag and mask
Step 5 Create an airtight seal between the mask and infant’s face
Step 6 Assess for effective ventilation
How do you provide ventilation using self-inflating bag? (Table 3.4)
• Complete the initial steps (warm, position and clear the airway, if necessary, dry and
stimulate, reposition), re-evaluate the infant.
• Assess condition (heart rate [HR] and breathing) and begin positive pressure ventilation
(PPV) within first 60 seconds of birth, if the baby is apneic/gasping or HR is< 100bpm.
• Ensure the device is assembled correctly and is functional.
• Ensure oxygen source, oxygen tubing, reservoir and additional help is available.
• Call for HELP as you decide to provide PPV.
Positioning
• Place the baby on firm, flat and clean surface.
• Position the head of the baby in a neutral position to open the airway.
• The rescuer should stand at the head end of the baby.
• Use of shoulder roll may be required in presence of large caput or in preterm infants.
• Apply the face mask firmly and gently covering the chin, mouth and nose to achieve an air
tight seal.
Applying face mask (Fig 3.6, 3.7 3.8)

• The mask usually is held on the face with the thumb, index, and/or middle finger encircling
much of the rim of the mask using the non-dominant hand.
• Ensure that the mask does not extend on the eyes or beyond the chin.
Fig. 3.6: Applying face mask
Fig. 3.7: Applying face mask Fig. 3.8: Applying face mask
Providing Ventilation (Fig. 3.9)

• Squeeze the bag between thumb and two fingers using the dominant hand.
• Deliver at a rate of 40-60 breaths per minute – call loudly “squeeze, two, three”. Deliver a
breath when you call squeeze and allow the bag to recoil during calling “two-three”.
• Apply gentle pressure to achieve chest rise.
• Provide five breaths and look for increase in heart rate. If there is no increase in HR, look
for chest rise.
• Ventilate uninterruptedly for 30 seconds from the time you get chest rise.
• Ensure gentle chest rise.
• Reassess HR at the end of 30 seconds of effective PPV.
Fig. 3.9: Delivering 40-60 breaths using self-inflating bag. If one is using a T-piece resuscitator, occlude the PEEP
valve when saying “squeeze” and release it while saying “two, three”.
Oxygen delivery with self-inflating bag

• For babies born ≥ 35 weeks gestation, it is best to begin resuscitation with room air rather
than 100% oxygen. In babies < 35 weeks gestation, start resuscitation with 21-30% oxygen.
Begin with room air if blender is not available.
Assessing effectiveness of ventilation
• Provide 5 manual breaths and watch for chest rise with each breath.
• Ask assistant to check for heart rate.
If there is no chest rise or there is no rise in heart rate take ventilation corrective measures.
(Table 3.4)
Table 3.4: Techniques to improve PPV using bag and mask (Ventilation corrective steps-
MRSOPA)
Problem Remedial step
M Inadequate seal Mask adjusted to ensure airtight seal
R Inappropriate Reposition the head in sniffing position
position
Try PPV and Reassess Chest Movement*
S Blocked airway Suction the airway
O Open baby’s mouth and ventilate

P Inadequate pressure Increase Pressure by squeezing the bag with more pressure
till a chest rise is visible
A No improvement Consider Alternative airway (endotracheal intubation
with above steps laryngeal mask airway, if expertise present)
Remember to follow the corrective steps in the sequence indicated in the table
* At any stage of re-assessment, if the chest rise is visible, no further corrective steps are
required and PPV is given for 30 seconds beginning from this point.
• Provide un-interrupted effective ventilation for 30 seconds and assess for spontaneous
breathing. If spontaneous breathing is present, gradually discontinue PPV.
What is effective ventilation?

• Prompt increase in heart rate with chest rise is the best indicator of adequacy of ventilation.
• Additional signs of effective ventilation include appearance of spontaneous breathing,
improving saturation and muscle tone.
What to do if baby is not improving?
You have so far done the following:
• Initiated PPV at a rate of 40-60 breaths/minute
• Called for assistance
• If chest rise or rise in heart rate was not evident after 5 breaths, you had initiated
ventilation corrective steps and provided effective ventilation for 30 seconds.
Now evaluate heart rate:
 If the heart rate is more than 60 bpm but less than 100 bpm, continue PPV. Ensure effective
ventilation.
 Reassess respiratory effort, heart rate every 30 secs (oxygen saturation may be monitored
continuously if pulse oximeter is available).
 If PPV is prolonged over several minutes place an orogastric tube to prevent distention of
stomach with air which may interfere with ventilation.
If the baby's heart rate is below 60 bpm despite 30 seconds of effective PPV (chest rise
with ventilation), your next step will be to initiate chest compression (This will be described in
lesson 4).
Increase oxygen concentration to 100% when you initiate chest compressions.
When to stop PPV?

PPV can be discontinued when:
 When the heart rate is above 100 bpm
 Sustained spontaneous breathing is present

Newborn infants requiring PPV for less than 1 minute should be provided observational care with
the mother.

 Warmth (skin to skin care)
 Initiate breastfeeding
 Monitor neonate (Temperature, heart rate,
breathing and color every 30 min for 2hr)
Post Resuscitation care

Preterm infants with labored breathing should be shifted to SNCU/NICU for considering CPAP.
Newborns requiring PPV for more than 1 minute or needing intubation, chest compressions or
medications should be shifted to SNCU/NICU for post-resuscitation care.
Summary: Lesson 3
 Establishing effective ventilation is the key to nearly all successful neonatal resuscitation.
 Be very familiar with the type of resuscitation device(s) you are using.
 Ensure the ventilation device is in working order before every delivery.
 The primary measure of adequate ventilation is prompt improvement in heart rate. Chest
wall movement should be assessed if heart rate does not improve.
 Resuscitation should begin with room air for term babies and preterm babies ≥ 32 weeks.
For babies < 32 weeks, begin resuscitation at 21-30% FiO2.
 A common source of error is inadequate seal of mask with the face; hence always ensure
optimal seal.
 Perform ventilation correction steps (MRSOPA), if HR does not increase or there is no chest
rise after 5 breaths of initial PPV.
LESSON 4:
Chest Compressions
 When to start chest compressions
 How to perform chest compressions
 How to coordinate chest compression with positive pressure ventilation
 When to stop chest compressions
The following case scenario will illustrate how chest compressions are provided as a part of
advanced resuscitation. Imagine yourself as a member of the team as you read through the case.
The details of chest compressions will be described later in this lesson.
Case Scenario 4:
A primigravida woman with term pregnancy was admitted in labor with poor fetal movements.
The obstetric team notified the pediatric team to be available in the delivery room at the time of
delivery. The radiant warmer was turned on and resuscitation equipment is checked.
As soon as the baby is delivered, the “time of birth” is noted and the baby is placed prone on the
mother’s abdomen. On assessing breathing, it is observed that the baby is not breathing and is
limp. The cord was clamped and cut and the baby was immediately transferred by the
resuscitation team to the radiant warmer. The baby was properly positioned, suctioned, dried
and stimulated by rubbing the back. But the baby was still limp, apneic and cyanotic.
One member of the team initiated positive pressure ventilation with bag and mask using room
air. Another member checked the heart rate by a stethoscope. After 5 breaths the baby had a
heart rate below 60 bpm and there was no chest rise. The care provider performing PPV checked
the mask for its seal, repositioned the head and continued PPV. Now on reassessment, the chest
was rising with each breath.
After 30 seconds of effective ventilation the baby’s heart rate was below 60 bpm, so the baby
was intubated, 100% oxygen was added to PPV and the second team member begins chest
compressions coordinated with PPV using 3:1 ratio of compressions to ventilation. After another
60 seconds, the baby had gasping breathing efforts; the heart rate was more than 60 bpm but
less than 100 bpm.
The team stops chest compression but continues PPV for another 30 seconds. The baby now had
evidence of spontaneous breathing and the heart rate was now above 100 bpm. The rate of PPV
was gradually slowed down and on observation the baby was found to be breathing regularly,
the heart rate was 120 per minute, and was pink. The baby was then shifted to the SNCU for post-
resuscitation care.
Resuscitation Flow Diagram (NRP-India)
Why are chest compressions required?
Chest compressions are required to ensure that the heart is able to pump the blood being
oxygenated in the lung by mechanical ventilation, to the body. In babies with a heart rate below
60 bpm despite PPV, the oxygen level drops to cause acidosis and significant myocardial
dysfunction. Chest compressions are performed to supplement the mechanical ability of the
heart to maintain circulation till the time the myocardium is oxygenated to function adequately
and deliver oxygen to the brain. Bag and mask can be used to provide ventilation but to make it
more effective during chest compressions, endotracheal intubation should be performed.
What are chest compressions?

Chest compressions :
 Are rhythmic compressions of the sternum that compress the heart between the sternum
and spine
 Increase the intrathoracic pressure
 Pump blood into the circulatory system during compression and when pressure from the
sternum is released, blood enters the heart from the veins
When to initiate Chest compressions?

Chest compressions are initiated if after 30 seconds of effective PPV, the heart rate remains
below 60 bpm.
What should be done before starting chest compressions?

Call for help
Resuscitate with 100% oxygen
Endotracheal Intubation
Attach Pulse Oximeter if not done earlier
Technique of Chest Compressions:

The technique used for chest compressions is the thumb technique.
Thumb technique (Fig. 4.1): The two thumbs are used to depress the sternum while the hands
encircle the chest and fingers support the spine. The distal phalanx of the thumb should be at
right angle to the chest to achieve adequate pressure.
Fig. 4.1: Technique of chest compressions
The thumb technique provides:

 Constant pressure
 Better control of depth of compression
Site of compressions (Fig. 4.2)

The site of compression is the lower third of the sternum in the midline. The area lies between
xiphoid and a line drawn between nipples. This can also be located by running one’s fingers along
the costal margin and localizing the xiphoid and placing the thumbs above the xiphoid. The
thumbs should be alongside each other but can overlap if the baby is very small.
Fig. 4.2: Landmarks for chest compression
The provider stands at the foot end of the baby. Chest compressions can also be delivered from
head end to permit access to umbilical vessels (Fig. 4.3 A and B).
Fig. 4.3: Thumb technique of chest compressions administered from(A)foot end, from head end (B)
What is the pressure required for Compression?

The sternum should be depressed to a depth of approximately one third the anterior – posterior
diameter of the chest (Fig. 4.4).
Fig. 4.4: Compression depth should be approximately one-third of the antero -posterior diameter of the chest
Duration of downward stroke is shorter than the duration of release to permit the heart to fill.
On complete release, the thumbs should maintain contact with the chest to avoid relocating
compression area and loss of control over compression.
Table 4.1: Chest compressions- indications and technique
Indication HR less than 60 bpm despite effective ventilation
Rescuer position The person providing ventilation is at the head end of the baby. The chest
compression provider stands at the side or at the foot end of the baby. For ease
of vascular access, chest compression may be provided from head end and
ventilation from the side of the baby.
Site Lower 1/3 of the sternum

Depth 1/3 the AP diameter of the chest
Ratio 3 compressions to 1 ventilation

90 compressions to 30 breaths per minute
120 events per minute
Technique Two thumb technique
Rescuer’s hands (thumbs) should not leave contact with the chest
Avoid simultaneous compression with breath
Avoid interruptions
Ensure adequate ventilation
Counting One (Chest compression); and (release) Two (Chest compression); and (release)
Three (Chest compression); and (release) followed by Squeeze (Ventilation
breath)
Duration Un-interrupted for 60 sec
What are the dangers which may be associated with Chest Compressions?
Chest compressions can cause trauma to the baby. Improper placement of the thumbs
can cause:
 Damage to xiphoid
 Injury to internal organs like liver, spleen or lungs
 Fracture of ribs
What should be the rate of Compression and how is it coordinated with PPV?
Chest compressions should always be accompanied by positive pressure ventilation. Avoid giving
compressions and ventilation simultaneously, they need to be coordinated. For every 3
compressions 1 breath is delivered (hence in a minute, 90 compressions and 30 breaths are given)
(Fig. 4.5).
Fig. 4.5: Coordination of chest compression and ventilation
The person compressing should call out the counting sequence of "One and Two and Three and
Breathe and". The person ventilating squeezes the bag during “Breathe and” and releases during
“One and”.
Practicing rhythm of chest compression and ventilation

Imagine yourself as the person giving chest compressions. Repeat the sequence ‘One and Two
and Three and Breathe and" loudly and move your hands to compress at "One and“, “Two and”
and “Three and” but not at “Breathe and". Practice this several times so that you can do 5 cycles
in 10 seconds.
Since chest compression has to be coordinated with ventilation, now imagine yourself as the
person giving ventilation. Repeat the sequence ‘One and Two and Three and Breathe and" loudly
but do not move hands when you say "One and”, “Two and” and “Three and” but squeeze the
bag only when you say “Breathe and". Practice this several times so that you can do 5 cycles in
10 seconds.
When to stop chest compressions?

Reassess after 60 seconds of coordinated PPV and chest compression. The heart rate should be
above 60 bpm to stop chest compressions but the PPV is continued. After stopping the chest
compression, effective ventilation is delivered at 40-60 breaths/minute. Then ventilation is
gradually stopped after the heart rate goes above 100 bpm and the baby begins to breathe
spontaneously. The baby is then shifted to SNCU/NICU for post resuscitation care as described in
Lesson 3.
If the infant is not improving
Questions to be asked when heart rate is not improving with compressions and ventilation
(Mnemonic CARDIO)
l. Chest movement: Is the chest moving with each breath?
2. Airway: Is the airway secured with an endotracheal tube or laryngeal mask?
3. Rate: Are 3 compressions coordinated with 1 ventilation being delivered every 2 seconds?
4. Depth: Is the depth of compressions one-third of the AP diameter of the chest?
5. lnspired Oxygen: Is 100% oxygen being administered through the PPV device?
If you cannot intubate, make sure you call someone who is skilled in endotracheal intubation. In
the meantime, continue PPV with bag and mask. The technique of endotracheal intubation will
be described in lesson 5.
If the baby’s heart rate remains below 60 bpm after 60 seconds of coordinated PPV with
chest compressions, you should insert an umbilical catheter and give epinephrine (Described in
lesson 6).
Summary: Lesson 4
 The compression ventilation ratio is 3:1 and in a minute 90 compressions are delivered for
30 PPV.
 It is preferable to intubate the baby at this stage so as to provide effective ventilation.
 Ventilate with 100% oxygen while performing chest compressions
 Give coordinated PPV and Chest compression for 60 seconds and then reassess
 If the heart rate is above 60 bpm, stop chest compressions.
 Insert umbilical catheter if heart rate remains below 60 bpm after 60 seconds of
coordinated chest compressions and positive pressure ventilation and give epinephrine.
LESSON 5:
Endotracheal Intubation

 The indications for endotracheal intubation during resuscitation
 How to select and prepare the appropriate equipment for endotracheal intubation
 How to use the laryngoscope to insert an endotracheal tube
 How to determine if the endotracheal tube is in the trachea
 How to use the endotracheal tube to administer positive-pressure ventilation
When is endotracheal intubation required?

Endotracheal intubation may be performed at various points during a resuscitation as indicated
by the asterisks (*) in the resuscitation algorithm.
Indications for endotracheal intubation are:

 If positive-pressure ventilation is not resulting in adequate clinical improvement i.e., if the
heart rate is not increasing or if the chest rise is not good.
 If there is a need for positive-pressure ventilation for more than a few minutes.
 If chest compressions are required, endotracheal intubation may be performed to improve
the efficiency of positive pressure breaths.
 For special situations, such as giving endotracheal medications and in cases of suspected
or antenatally diagnosed diaphragmatic hernia.
What equipment and supplies are needed?
The supplies and equipment necessary to perform endotracheal intubation should be kept
together and should be readily available. Each delivery room should have at least one complete
set of the following items (Figure 5.1):
 Laryngoscope with an extra set of batteries and extra bulbs
 Blades: No. 1 (term newborn), No. 0 (preterm newborn), No. 00 (optional for extremely
preterm newborn). Straight rather than curved blades are preferred.
 Endotracheal tubes with inside diameters of 2.5, 3.0 & 3.5
 Suction apparatus with suction catheters 10F, 12F and 14F
 Stethoscope (neonatal head preferred)
 Self- inflating bag with oxygen reservoir
 Oxygen source and tubing
 Scissors and adhesive tape for fixing endotracheal tube
This equipment should be available at a specified place near the newborn care corner. It should
be so placed that it is readily accessible when required. Intubation is best performed as a clean
procedure. Use disposable endotracheal tubes. The laryngoscope blades and handles should be
cleaned after each use.
Fig. 5.1: Neonatal resuscitation equipment and supplies
What kind of endotracheal tubes are best to use?
Endotracheal tubes are supplied in sterile packages and should be handled with clean technique.
ET tubes with uniform diameter throughout the length of the tube should be used (Figure 5.2).
Most endotracheal tubes for newborns have a black line near the tip of the tube, which is called
a “vocal cord guide” (Figure 5.3). The vocal cord guide is placed at the level of the vocal cords.
This usually positions the tip of the tube above the bifurcation of the trachea (carina). One should
remember that the length of the trachea in a premature newborn is less than that in a term
newborn.
Use non cuffed ET tubes for neonatal resuscitation.
Most endotracheal tubes made for newborns come with centimeter markings along the tube,
identifying the distance from the tip of the tube is explained later in this chapter.
Fig. 5.2: Type of endotracheal tube preferred in neonates
Fig. 5.3: Endotracheal tube sizes with vocal cord guide
How do you prepare the endotracheal tube for insertion?
Select the appropriate-sized tube.
Table 5.1. Endotracheal tube sizes for babies of different weights/gestations
Weight (g) Gestational age (weeks) Tube size (mm) (Internal diameter)
Below 1000 Below 28 2.5
1000 - 2000 28 - 34 3.0
Above 2000 Greater than 34 3.5
Endotracheal tube size for babies of various weights and gestational ages should be available.
One should not waste time once the resuscitation is underway. Therefore, preparation of
equipment before a high-risk delivery is important. The approximate size of the endotracheal
tube is determined from the baby’s weight. Table 5.1 gives the tube size for various weight and
gestational age categories. It may be helpful to post the table in each delivery room near the
radiant warmer.
Consider cutting the tube to a shorter length

Many endotracheal tubes are much longer than necessary for orotracheal use. The extra length
increases the resistance to airflow. Some clinicians find it helpful to shorten the endotracheal
tube before insertion (Figure 5.4). The endotracheal tube may be shortened to 13 to 15 cm to
make it easier to handle during intubation and to reduce the chance of inserting the tube too far.
A 13-15 cm tube will provide enough tube length extending beyond the baby’s lips for adjusting
the depth of insertion if necessary and to properly secure the tube to the face. Remove the
connector and then cut the tube diagonally to make it easier to reinsert the connector back to
the tube. Replace the endotracheal tube connector. The fitting should be tight so that the
connector does not inadvertently separate during insertion or use. Ensure that the connector
and the tube are properly aligned so that kinking of the tube is avoided. Connectors are made to
fit a specific size tube. They cannot be interchanged between tubes of different sizes.
Some prefer to leave the tube long initially and cut it to the desired length after insertion.
Fig. 5.4: Where to cut endotracheal tube to shorten it
How do you prepare the laryngoscope and additional supplies?

Select the blade and attach it to the handle. First, select the appropriate-sized blade and attach
it to the laryngoscope handle.
No 00 for extremely preterm
No 0 for preterm newborn
No 1 for term newborn
Next, check working of the laryngoscope, turn on the light by clicking the blade into the “open”
position to determine that the batteries and bulb are working. Check to see that the bulb is
screwed tightly to ensure that it will not flicker or fall out during the procedure.
Prepare suction equipment. Suction equipment should be available and ready for use.
Adjust the suction pressure to 80- 100 mm Hg by increasing or decreasing the level of suction
while occluding the end of the suction tubing.
Connect a 10F (or larger 12-14 F for meconium) suction catheter to the suction tubing so that it
will be available to suction secretions from the mouth and nose.
Smaller suction catheters (5F, 6F, or 8F, depending on the size of the endotracheal tube)
should be available for suctioning the endotracheal tube, if required. Appropriate sizes are listed
in Table 5.2.
Table 5.2: Suction catheter sizes for various endotracheal tube sizes
Gestation Weight ETT size Internal diameter (mm) ETT suction catheter size (F)
< 28 weeks < 1 kg 2.5 5–6
28 – 34 weeks 1 – 2 kg 3.0
34 – 38 weeks 2 – 3 kg 3.5 6–8
> 38 weeks 3 – 4 kg 3.5
Tip :
 ETT internal diameter in millimeters can be calculated by gestational age in weeks divided by 10 and rounded
to the nearest tube size (in multiples of 0.5), e.g. 30 weeks gestation neonate will require ET tube of size 3
 Catheter size to be no more than twice the internal diameter of ETT
Preparing the device for administering positive-pressure ventilation

A resuscitation bag and mask capable of providing 90% to 100% oxygen should be available to
ventilate the baby between intubation attempts or if intubation is unsuccessful. The resuscitation
device without the mask will be required to ventilate the baby after intubation to initially check
correct tube placement and to provide continued ventilation if necessary. Check the operation
of the PPV device as described in Lesson 3.
Turn on oxygen. The oxygen tubing should be connected to an oxygen source and be available
to deliver up to 100% free- flow oxygen and should be connected to the resuscitation bag. The
oxygen flow should be turned on to 10 L/min.
A stethoscope will be required to check for air entry.
What anatomy do you need to know to insert the tube properly?

The anatomic landmarks that relate to intubation are labeled in Figures 5.5 and Figure 5.6. Study
the relative position of these landmarks using the figures, because each landmark is important
for better understanding of the intubation procedure.
Epiglottis – A lid like structure overhanging the entrance to the trachea.
Vallecula – A pouch formed by the base of the tongue and the epiglottis.
Esophagus – The food passageway extending from the throat to the stomach.
Cricoid – Cartilage of the larynx.
Glottis – The opening of the larynx leading to the trachea, flanked by the vocal cords.
Vocal cords – Mucous membrane covered ligaments on both sides of the glottis
Trachea – The windpipe, extending from the throat to the main bronchi.
Main bronchi – The two air passageways leading from the trachea to the lungs.
Carina – Where the trachea branches into the two main bronchi.
Fig. 5.5: Diagram of upper airway showing position of laryngoscope and endotracheal tube
Fig 5.6: Diagram showing the glottis and structures around it
How should you position the newborn to make intubation easiest?
The correct position of the newborn for intubation is the same as for bag and mask ventilation –
on a flat surface with the head in a midline position and the neck slightly extended. It may be
helpful to place a roll under the baby’s shoulders to maintain slight extension of the neck. This
“sniffing” position aligns the trachea for optimal viewing by allowing a straight line of sight into
the glottis once the laryngoscope has been properly placed. It is important not to hyperextend
the neck, because this will raise the glottis above your line of sight and narrow the trachea. If
there is too much flexion of the head towards the chest, you will be viewing the posterior pharynx
and may not be able to directly visualize the glottis.
How do you hold the laryngoscope?

Turn on the laryngoscope light and hold the laryngoscope in your left hand, between your thumb
and first two or three fingers, with the blade pointing away from you (Figure 5.7). One or 2 fingers
should be left free to rest on the baby’s face to provide stability. The laryngoscope is designed to
be held in the left hand – by both right-and left-handed persons. Turn on the light by clicking the
blade to an open position. You will hear a click as the blade gets locked with the handle.
Fig. 5.7: Correct method of holding a laryngoscope
How do you visualize the glottis and insert the tube?

The next few steps will describe the insertion of an endotracheal tube in detail. However, during
an actual resuscitation, they will need to be completed very quickly-within approximately 30
seconds. The baby will not be ventilated during this process, so quick action is essential.
Steps for Endotracheal intubation:
Firstly, stabilize the baby’s head with your right hand (Fig. 5.8). It may be helpful to have a second
person hold the head in the desired “sniffing” position. Free-flow oxygen should be delivered
throughout the procedure.
Note: The important consideration here is that the procedure should be accomplished as quickly
as possible (within 30 seconds). If the patient appears to be compromised, it is usually preferable
to stop, resume positive-pressure ventilation with a mask, and then try again.
Fig. 5.8: Stabilizing the neonate’s head prior to intubation
Secondly, slide the laryngoscope blade over the right side of the tongue, pushing the tongue to
the left side of the mouth and advance the blade until the tip lies in the vallecula, just beyond the
base of the tongue (Fig. 5.9). You may need to use your right index finger to open the baby’s
mouth to make it easier to insert the laryngoscope.
Note: Although this lesson describes placing the tip of the blade in the vallecula, some prefer to
place it directly on the epiglottis, gently compressing the epiglottis against the base of the tongue.
Third, lift the blade slightly, thus lifting the tongue out of the way to expose the pharyngeal area.
When lifting the blade, raise the entire blade by pulling up in the direction the handle is pointing
(Fig. 5.10).
Do not elevate the tip of the blade by using a rocking motion and pulling the handle towards you.
Rocking rather than elevating the tip of the blade will not produce the view of the glottis you
desire and will put excessive pressure on the alveolar ridge.
Fig. 5.9: Correct method of inserting the laryngoscope blade
Fig. 5.10: Correct (top) and Incorrect

(bottom) method for lifting
laryngoscope blade to expose the
larynx
Fourth, look for landmarks (Fig. 5.11). If the tip of the blade is correctly positioned in the vallecula,
you should see the epiglottis at the top, with the glottis opening below. You also should see the
vocal cords appearing as vertical stripes on each side of the glottis or as an inverted letter “V”
(Fig. 5.11). If these structures are not immediately visible, quickly adjust the blade until the
structures come into view. Applying downward pressure to the cricoid (the cartilage that covers
the larynx) may help bring the glottis into view (Fig. 5.12). The pressure may be applied with your
own little finger or by an assistant. Suctioning of secretions may also be helpful to improve your
view. Inadequate visualization of the glottis is the most common reason for unsuccessful
intubation.
Fig. 5.11: Visualization of anatomic landmarks before intubating the newborn
Fig. 5. 12: Improving visualization of larynx with pressure applied to cricoid
Next, insert the tube (Fig. 5.13). Holding the tube in your right hand, introduce it into the right
side of the baby’s mouth with the curve of the tube lying in the horizontal plane. This will prevent
the tube from blocking your view of the glottis. Keep the glottis in view and, when the vocal cords
are apart, insert the tip of the endotracheal tube until the vocal cord guide is at the level of the
cords.
If the cords are together, wait for them to open. Do not touch the closed cords with the tip of the
tube because it may cause spasm of the cords. Never try to force the tube between closed cords.
If the tube could not be inserted, abandon the procedure and continue to ventilate with a bag
and mask. After the heart rate and color have improved, you can then try again.
Be careful to insert the tube only so far as to place the vocal cord guide at the level of the vocal
cords. This positions the tube in the trachea approximately halfway between the vocal cords and
the carina. Note the markings on the tube that align with the baby’s lip.
Fig. 5.13: Inserting the endotracheal tube through the vocal cords
Stabilize the tube with one hand, and remove the laryngoscope with the other (Fig. 5.14). With
the right hand held against the face, hold the tube firmly at the lips and/or use a finger to hold
the tube against the baby’s hard palate. Use your left hand to carefully remove the laryngoscope
without displacing the tube.
Fig. 5.14: Stabilizing the endotracheal tube while laryngoscope is withdrawn
Although it is important to hold the tube firmly, be careful not to press the tube so tightly that
the tube gets compressed and obstructs the airflow. You are now ready to use the tube for the
reason you inserted it.
To ventilate the baby, quickly attach a self-inflating bag to the tube, take steps to ascertain that
the tube is in the trachea, fix the endotracheal tube (Figure 5.15 ABCD) while continuing to
provide positive pressure ventilation.
Fig. 5.15 (A, B, C, D): Fixing the Endotracheal Tube
How do you check to be sure that the tube is in the trachea?
Watching the tube pass between the cords, watching for chest movement following application
of positive pressure, listening for breath sounds are all helpful signs to suggest that the tube is in
trachea rather than esophagus. However, these signs can be misleading. An increasing heart rate
is the primary method for confirming endotracheal tube placement.
If the tube is positioned correctly, you should observe the following:

• Improvement in heart rate and color
• Breath sounds heard over both lung fields but decreased or absent sound over the stomach
• No gastric distention with ventilation
• Vapor condensing on the inside of the tube during exhalation
• Symmetrical movement of chest with each breath
When listening to breath sounds, be sure to use a small stethoscope and place it laterally and
high on the chest wall (in the axilla). A large stethoscope, or a stethoscope placed too central or
too low, may transmit sounds from the esophagus or stomach. Observe for absence of gastric
distension and movement of both sides of the chest with each ventilated breath. Listening for
bilateral breath sounds and observing symmetrical chest movement with positive-pressure
ventilation provide secondary confirmation of correct endotracheal tube placement in the airway
with tip of the tube positioned above the carina. A rapid increase in heart rate is indicative of
effective positive- pressure ventilation.
Be cautious when interpreting breath sounds in newborns. Since sounds are easily transmitted,
those heard over the anterior part of the chest may be coming from the stomach or esophagus.
Breath sounds can also be transmitted to the abdomen.
What do you do if you suspect that the tube may not be in the trachea?
Be certain that the tube is in the trachea. A misplaced tube is worse than having no tube at all.
The tube is not likely to be in the trachea if:
• The newborn remains bradycardic and cyanotic despite positive-pressure ventilation.

• No breath sounds are heard over the lungs.
• The abdomen appears to be distended.
• Air sounds are heard over the stomach.
• There is no mist in the tube.
• The chest is not moving symmetrically with each positive-pressure breath.
If you suspect the tube is not in the trachea, you should do the following:
Use your right hand to hold the tube in place while you use your left hand to reinsert the
laryngoscope so that you can visualize the glottis and see if the tube is passing between the vocal
cords.
And/or
Remove the tube, use a self-inflating bag and mask to stabilize the heart rate and color, and then
repeat the intubation procedure.
How do you know if the tip of the tube is in the right location within the trachea?
1. Tip-to-lip measurement: To estimate if the tube has been inserted to the correct distance
(Table 5.3). Adding 6 to the baby’s weight in kilograms will give you a rough estimate of the
correct distance from the tube tip to the vermillion border of the upper lip. (Note: This rule is
unreliable in those babies who have congenital anomalies of the neck and mandible (e.g. Pierre
Robin syndrome).
Table 5.3: Estimated depth of insertion of ET tube by tip to lip distance (Based on birth weight)
Weight (kg) Depth of insertion (cm) (tip to lip distance)
1 7
2 8
3 9
4 10
Nasal Tragus Length (NTL) measurement: The NTL is a method that has been validated in both
full- term and preterm newborns. It uses a calculation based on the distance (cm) from the baby’s
nasal septum (Fig.5.16 (a)) to the ear tragus (Fig.5.16 (b)). Use a measuring tape to measure the
NTL (Fig.5.16 (c)). The estimated insertion depth (cm) is NTL + 1 cm. Place the endotracheal tube
so that the marking in the tube corresponding to the estimated insertion depth is adjacent to the
baby’s lip.
Fig. 5.16: (a) Nasal septum (b) Tragus (c) Measuring NTL
3. Gestational Age: Recent studies have also shown that the gestational age is an accurate
predictor of the correct insertion depth and has the advantage of being known before birth.
Table 5.4: Depth of insertion of endotracheal tube according to gestational age

Gestation (weeks) Endotracheal tube insertion Baby’s Weight (grams)
depth at lips (cm)
23 – 24 5.5 500 – 600
25 – 26 6.0 700 – 800
27 – 29 6.5 900 – 1000
30 – 32 7.0 1100 – 1400
33 – 34 7.5 1500 – 1800
35 – 37 8.0 1900 – 2400
38 – 40 8.5 2500 – 3100
41 – 43 9.0 3200 – 4200
Adapted from Kempley ST, Momeira JW, Petrone FL. Endotracheal tube length for neonatal intubation.
Resuscitation. 2008+ 77(3):369-373
All these methods (Tip to Lip distance, NTL method and ET insertion based on gestational age)
are only an approximation of the correct distance at which the tube is inserted. You should listen
to the breath sounds over both axillae after positioning the endotracheal tube. If properly
positioned, you should be able to hear breath sounds over both axillae with equal intensity.
If the tube is inserted too far, you will hear breath sounds that are louder on one side than the
other (usually the right). If that is the case, pull back the tube very slowly while listening to the
left side of the chest. When the tip reaches the carina, you should hear equal breath sounds.
After you have ensured that the tube is in the correct position, take note of the centimeter
marking that appears at the upper lip. This can help you maintain the appropriate depth of
insertion.
How do you continue resuscitation while you intubate?
Ventilation must be discontinued while intubating because the bag and mask has to be removed
from the airway during the procedure. Chest compressions generally must be interrupted
because compressions cause movement and prevent you from seeing landmarks. Therefore, you
should make every effort to minimize the amount of hypoxia imposed during intubation.
The following steps will be helpful to prevent hypoxia during intubation:
Pre-oxygenate before attempting intubation

Oxygenate the baby appropriately with bag and mask before beginning intubation and between
repeated intubation attempts. This will not be possible when intubation is being performed to
improve ineffective positive-pressure ventilation.
Deliver free-flow oxygen during intubation. Hold free-flow oxygen by the baby’s face while the
health care provider is clearing the airway and trying to visualize the landmarks. This will provide
oxygen-enriched air for the baby to inhale in case he/she makes any spontaneous respiratory
efforts during the procedure.
Limit attempts to 30 seconds. Don’t try to intubate for longer than approximately 30 seconds. If
you are unable to visualize the glottis and insert the tube within 30 seconds, remove the
laryngoscope and attempt to oxygenate the baby with bag-and- mask. Ensure that the baby is
stable, then try again.
What can go wrong while you are trying to intubate?

Poor visualization of the glottis also may be caused by not elevating the tongue high enough to
bring the glottis into view. Sometimes, pressure applied to the cricoid, which is the cartilage
covering the larynx, will help to bring the glottis into view. This is accomplished by using the
fourth or fifth finger of the left hand or by asking an assistant to apply the pressure. Practice
intubating a manikin enough times so that you can find the correct landmarks quickly, thus
allowing you to insert the tube within 30 seconds.
You may inadvertently insert the tube into the esophagus instead of the trachea. An
endotracheal tube in the esophagus will be worse than having no tube at all, since the tube will
tend to obstruct the baby’s pharyngeal airway without providing an artificial airway. Therefore:
 Be certain that you visualize the glottis before inserting the tube.
 Watch the tube enter the glottis between the vocal cords.
 Look carefully for signs of esophageal intubation after the tube has been inserted.
 Check air entry over chest and epigastrium.
 If you have concerns that the tube may be in the esophagus, visualize the glottis and tube
with a laryngoscope and/or remove the tube, oxygenate the newborn with a bag and mask,
and reintroduce the tube.
Signs of endotracheal tube in the esophagus instead of the trachea:

 Poor response to intubation (bradycardia, cyanosis, etc.)
 No audible breath sounds
 Air heard entering the stomach
 Gastric distention may be seen
 No mist in tube
 Poor chest movement
You may inadvertently insert the tube too far into the trachea, down the right main bronchus.
If the tube is inserted too far, it usually will pass into the right main bronchus. When you insert
the tube, it is important to remember, to see the vocal cord guide on the tube and to stop
advancing the tube as soon as the vocal cord guide reaches the cords.
Signs of the tube being in the right main bronchus include:

 Baby’s heart rate or color shows no improvement
 Breath sounds heard over the right but not over the left side of the chest
 Breath sounds are louder on the right side of the chest than on the left side
 If you think the tube may be down the right main bronchus, first check the tip-to-lip
measurement or use NTL method to see if the number at the lip is higher than the
estimated measurement. Even if the measurement appears to be correct, if breath sounds
remains asymmetric, you should withdraw the tube slightly while you listen over the left
side of the chest to hear if the breath sounds improve.
Common complications associated with endotracheal intubation (Table 5.5): Some of the
common complications associated with endotracheal intubation, their possible causes and their
preventive/corrective actions are tabulated below:
Table 5.5: Common complications associated with endotracheal intubation
Complication Possible Causes Prevention or Corrective Action to be Considered
Hypoxia Taking too long to intubate Pre-oxygenate with bag and mask.
Provide free-flow oxygen during procedure.
Stop intubation attempt after 30 seconds.
Incorrect placement of tube Reposition the tube
Bradycardia/apnea Hypoxia Pre-oxygenate with bag and mask
Provide free-flow oxygen during procedure.
Oxygenate after intubation with bag and tube.
Vagal response from Be quick and gentle during the procedure.

laryngoscope or suction
catheter
Pneumothorax Overventilation of one lung Place the tube correctly.
due to tube in right main Use appropriate ventilating Pressures.
bronchus or excessive Consider transillumination or
ventilation pressures needle aspiration if pneumothorax is suspected
Contusions or Rough handling of Obtain additional practice/ skill
lacerations of tongue, laryngoscope or tube.
gums or airway Inappropriate “rocking”
rather than lifting of
laryngoscope
Laryngoscope blade too long Select appropriate equipment

or too short.
Perforation of trachea Too vigorous insertion of Handle tube gently
or esophagus tube
Obstructed Kink in tube or tube Try to suction the ET tube with an appropriate size
endotracheal obstructed suction catheter
tube
Infection Introduction of organisms via Pay careful attention to
hands or equipment clean/sterile technique
Summary: Lesson 5
 A person experienced in endotracheal intubation should be available to assist every
delivery.
 Indications for endotracheal intubation include the following:

- Ineffective ventilation
- Prolonged ventilation
- Better coordination between chest compressions and bag and mask ventilation
- To administer drugs
- To provide positive pressure ventilation in cases with suspected diaphragmatic hernia
 The laryngoscope is always held in the operator’s left hand.
 The correct-size laryngoscope blade for a term newborn is No. 1. The correct-size blade for
a preterm newborn is No. 0.
 Choice of proper endotracheal tube size is based on weight or gestational age.
 The intubation procedure ideally should be completed within 30 seconds. The steps for
intubating a newborn are as follows:
- Stabilize the newborn’s head in the “sniffing” position. Deliver free-flow oxygen
during procedure.
- Slide laryngoscope over the right side of the tongue, pushing the tongue to the left
side of the mouth, and advancing the blade until the tip lies just beyond the base of
the tongue.
- Lift the blade slightly. Raise the entire blade, not just the tip.
- Look for landmarks. Vocal cords should appear as vertical stripes on each side of the
glottis or as an inverted letter “V”. Suction, if necessary, for visualization.
- Insert the tube into the right side of the mouth with the curve of the tube lying in the
horizontal plane.
- If the cords are closed, wait for them to open. Insert the tip of the endotracheal tube
until the vocal cord guide is at the level of the cords.
- Hold the tube firmly against the baby’s palate while removing the laryngoscope.
 Correct placement of the endotracheal tube is indicated by:

- Improved vital signs (heart rate & color)
- Breath sounds heard over both lung fields but decreased or absent sound over the
stomach
- No gastric distention with ventilation
- Vapor seen in the tube during exhalation
- Chest movement is visible with each breath
- Measurement of depth of insertion includes :
▪ Tip-to-lip measurement (add 6 to newborn’s weight in kilograms) or use NTL length +1
or use the gestational age method
▪ Direct visualization of the tube passing between the vocal cords
LESSON 6:
Medications
 What medications to be given during resuscitation
 When to give medications during resuscitation
 How to give medications during resuscitation
 How to insert an umbilical venous catheter
 How to administer epinephrine
 When and how to administer fluids intravenously to expand blood volume during
resuscitation
The following case scenario will illustrate how medications may be used during resuscitation.
Imagine yourself as a part of the team as you read through the case. The details of how to
administer medications will be described later in this lesson.
Case Scenario 5:
A woman with term pregnancy was admitted to the delivery ward in early labor with profuse
vaginal bleeding. A diagnosis of placental abruption is made. Fetal heart rate tracings show late
deceleration. The obstetric team decides to deliver the fetus by emergency cesarean section and
notifies the pediatric team. The radiant warmer was turned on and resuscitation equipment
checked (including medications and umbilical vascular catheters) before the delivery. A limp and
apneic baby, weighing about 3 kg was delivered; the baby was immediately transferred by the
resuscitation team under the radiant warmer. The baby was positioned, suctioned, dried and
stimulated by rubbing the back. But, the baby was still limp, apneic and cyanotic. Positive
pressure ventilation with bag and mask using room air was initiated. Another member checked
the heart rate. After 5 breaths the baby had a heart rate below 60 bpm. The care provider
performing PPV checked the mask for its seal, ensured that the head is positioned properly, if the
airway was clear, and the chest was rising with each breath. Despite these steps after 30 seconds
of effective ventilation the baby’s heart rate was below 60 bpm, so 100% oxygen was added to
PPV and the second team member begins chest compressions coordinated with PPV using 3:1
ratio of compressions to ventilation. After another 60 seconds, the baby’s heart rate has not
increased. The baby is intubated and 1.5 mL of 1: 10,000 epinephrine is instilled into the
endotracheal tube while another member of the team prepares to insert an umbilical venous
line. Coordinated PPV and chest compressions are continued while monitoring the heart rate
every 60 seconds. At 5 minutes the umbilical venous catheter has been inserted and checked to
be in place by observing free flow of blood on aspiration. The heart rate is undetectable and the
baby is pale. A dose of 0.6 mL of 1: 10,000 epinephrine is given as a rapid bolus into the umbilical
catheter as PPV and chest compressions are continued. Heart sounds become audible, but the
HR is still below 60 bpm after 1 minute. Because of persistent bradycardia and possible blood
loss due to maternal bleeding, 30 mL of normal saline is given via the umbilical catheter. The
heart rate gradually increased. At 8 minutes the baby makes its initial gasp and the heart rate is
over 60 bpm. Chest compression is stopped but PPV is continued. The heart rate rises to over 100
bpm and color improves and the baby begins to breathe spontaneously. Now, the PPV is gradually
stopped. The baby was then shifted to the SNCU/NICU for post-resuscitation care.
When to give Medications during resuscitation?

Most newborns requiring resuscitation will improve without the need for medications if timely
and effective resuscitation steps are carried out. Fewer than 2 per 1000 births would need
medication during resuscitation. Before administering medications, one should check the
effectiveness of ventilation several times, ensuring good chest movement and audible bilateral
breath sounds with each breath, and providing 100% oxygen for positive-pressure ventilation.
Ideally an endotracheal tube should be put in place to ensure a good airway and effective
coordination of chest compressions and positive- pressure ventilation.
If the heart rate remains below 60 bpm despite administration of 60 seconds of coordinated
ventilation and chest compressions, one should ensure that ventilation and compressions are
being given optimally and 100% oxygen is being used. If still the heart rate is low, consider use of
medications.
How do you establish intravenous access during resuscitation of a newborn?
The umbilical vein is the quickest venous access for neonatal resuscitation. If the need for
epinephrine is anticipated you need an additional member in the resuscitation team, who is
competent to insert an umbilical venous catheter, while others continue with PPV and chest
compressions.
Steps of Umbilical venous catheterization

1. Clean the cord with an antiseptic solution. Place a loose tie of umbilical tape/sterile thread
around the base of the cord. This tie can be tightened if there is excessive bleeding after
you cut the cord.
2. Pre-fill a 3.5F or 5F umbilical catheter with normal saline using a 2 mL syringe connected to
a stopcock. The catheter should have a single end-hole. Close the stopcock to the catheter
to prevent fluid loss and air entry.
3. Using sterile technique cut the cord with a scalpel below the clamp and about 1 to 2 cm
from the skin line. Make the cut perpendicular rather than at an angle.
4. Locate the umbilical vein: It is seen as a large, thin-walled structure, usually at the 11 to 12
o’clock position. The 2 umbilical arteries have thicker walls and usually lie close together
somewhere at the 4 to 8 o’clock position. However, the arteries coil within the cord.
Therefore, longer the cord stump below your cut, the greater the likelihood that the vessels
will not lie in the position described.
5. Insert the catheter into the umbilical vein (Figure 6.1). The course of the vein will be up,
toward the heart, so this is the direction you should point the catheter. Continue inserting
the catheter 2 to 4 cm (less in preterm babies) until you get free flow of blood when you
open the stopcock attached to the syringe and gently aspirate. For emergency use during
resuscitation, the tip of the catheter should be located only a short distance into the vein
– only to the point at which the blood can be aspirated. If the catheter is inserted further,
there is a risk of infusing solution into the liver and possibly causing damage to the liver.
6. Inject the appropriate dose of epinephrine or volume expander followed by 3 mL of normal
saline flush to clear the drug from the catheter into the baby.
Once the baby has been fully resuscitated, either suture the catheter in place or remove the
catheter, tighten the cord tie, and complete the knot to prevent bleeding from the umbilical
stump. Do not advance the catheter once the sterile field has been violated.
Fig. 6.1: Correct (left) and incorrect (right) placement of umbilical venous catheter
What medication to use and why?

Epinephrine is the most effective medication used during resuscitation. Babies who have a heart
rate of less than 60 bpm despite adequate resuscitation with PPV and chest compressions for 60
seconds are likely to have low cardiac output. This is insufficient to meet the oxygen requirement
of vital organs. Epinephrine improves cardiac contractility, thus increasing cardiac output which
improves blood supply and oxygen to vital organs.
Epinephrine is not indicated before you have established adequate ventilation.

Epinephrine will increase workload and oxygen consumption of the heart muscle, which, in the
absence of available oxygen, may cause unnecessary myocardial damage.
Table 6.1: Drugs in newborn resuscitation

Epinephrine Normal Saline
When HR < 60 bpm despite ongoing chest No response to resuscitation, signs of

compressions with ventilation shock and h/s/o blood loss
Route IV, ET, IO IV, IO
Dose 0.2 ml/kg iv, 0.5 – 1 ml/kg ET, 1:10,000 10 ml/kg
Rate Quickly Over 5-10 min
How to prepare epinephrine?

Epinephrine is available as 1ml ampoule of 1:1,000 concentration, however for neonates, take
one ml of 1:1000 solution and add 9 ml of normal saline. This makes 10 ml of 1:10,000
concentration.
How to administer epinephrine?
Epinephrine should be given intravenously. If there is a delay in placement of intravenous access,
the endotracheal route may be used to administer the drug. But the endotracheal route results
in lower and unpredictable blood levels that may not be effective. Some clinicians may choose to
give a dose of endotracheal epinephrine while venous access is being established.
Table 6.2: Dose of Epinephrine
Approximate weight Epinephrine (1:10,000)
IV ET
1kg 0.2 ml 1 ml
2 kg 0.4 ml 2 ml
3 kg 0.6 ml 3 ml
4 kg 0.8 ml 4 ml
What is the dose of epinephrine during neonatal resuscitation?

The recommended intravenous dose in newborns (Table 6.2) is 0.2 mL/kg of a 1: 10,000 solution
(equal to 0.02 mg/kg). You will need to estimate the baby’s weight after birth. In the past, higher
intravenous doses had been suggested for adults and older children when they did not respond
to a lower dose. However, there is no evidence that this results in a better outcome and there is
some evidence that higher doses in babies may result in brain and heart damage.
Animal and adult human studies demonstrate that, when given via the trachea, significantly
higher doses of epinephrine than the intravenous doses are required to show a positive effect. If
you decide to give a dose endotracheally while intravenous access is being obtained, consider
giving a higher dose (0.5 to 1 mL/kg of 1:10,000 epinephrine) (Table 6.2) by endotracheal route.
However, the safety of these higher tracheal doses has not been studied. Do not give high doses
intravenously.
While giving epinephrine by endotracheal tube, be sure to give the drug directly into the tube,
be careful not to leave the drug deposited in the endotracheal tube connector or along the walls
of the tube. Some people prefer to use a catheter to give the drug deeply into the tube. Because
you will need to give a higher dose endotracheally, you will be giving a relatively large volume of
fluid into the endotracheal tube (upto 1mL/kg). You should follow the drug with several positive-
pressure breaths to distribute the drug throughout the lungs for absorption.
Table 6.3: Epinephrine Routes

IV ET
Choice Preferred If no vascular access
Concentration 1: 10,000 1: 10,000
Dose 0.2 mL/kg 0.5-1 mL/kg
Post dosing Flush with NS No flush
Repeat dose  Every 3-5 min Not recommended

 Immediately after iv access (not to wait for
3-5 min, if first dose is given by ET tube)
When the drug is given intravenously through a umbilical venous catheter, you should follow the
drug with a 3mL flush of normal saline to be sure that the drug has reached the blood.
How should you give epinephrine during neonatal resuscitation?

Administer epinephrine rapidly - as quickly as possible.
What is the expected response after giving Epinephrine?

Check the baby’s heart rate 60 seconds after administering epinephrine. As you continue
positive-pressure ventilation and chest compressions, the heart rate should increase to more
than 60 bpm within 60 seconds after you give epinephrine. If this does not happen, you can
repeat the dose every 3 to 5 minutes. However, any repeat doses should be given intravenously
if possible. In addition, ensure that:
 There is a good air exchange as evidenced by adequate chest movement and presence of
bilateral breath sounds.
 Chest compressions are given to a depth of one third the AP diameter of the chest and are
well coordinated with ventilation.
Strongly consider placement of an endotracheal tube, if not done earlier. Once in place, ensure
that the tube remains in the trachea during cardiopulmonary resuscitation activities. If the baby
is pale and there is evidence of blood loss, and there is a poor response to resuscitation, you
should consider the possibility of volume loss.
What should you do if the baby is in shock, there is evidence of blood loss, and
the baby is responding poorly to resuscitation?
Babies in shock appear pale, have delayed capillary refill and weak pulses. They may have a
persistently low heart rate, and circulatory status often does not improve in response to effective
ventilation, chest compressions, and epinephrine.
If the baby appears to be in shock and is not responding to resuscitation, administration of a

volume expander may be indicated.
What can you give to expand blood volume? How much and how to give it?
The recommended solution for treating hypovolemia is an isotonic crystalloid solution.
Acceptable solution is 0.9% NaCl (“Normal saline”).
O Rh-negative packed red blood cells should be considered as a part of volume replacement
when severe fetal anemia is documented or expected. If timely diagnosis permits, the donor unit
can be cross-matched with the mother who would be the source of any problematic antibody.
Otherwise, emergency-release of O-Rh negative packed cells may be necessary.
What is the dose of volume expander?

The initial dose is 10 mL/kg. However, if the baby shows minimal improvement after the first
dose, you may need to give another dose of 10 mL/kg. In an unusual case of large blood loss
additional dose might be considered.
How to give volume expander?

A volume expander must be given into the vascular system. The umbilical vein is usually the most
accessible vein in a newborn, although other routes (intraosseous) can be used. If hypovolemia
is suspected, fill a large syringe with normal saline and give it via umbilical venous route while
the other members of the team continue resuscitation.
How rapidly to give volume expander?

Acute hypovolemia, resulting in a need for resuscitation should be corrected fairly quickly,
although some clinicians are concerned that rapid administration in a newborn may result in
intracranial hemorrhage, particularly in preterm infants. No clinical trials have been conducted
to define an optimum rate, but a steady infusion rate over 5 to 10 minutes is reasonable.
What should you do if there is still no improvement?
If the baby has been severely compromised and all resuscitation efforts have gone smoothly, you
should have reached the point of giving epinephrine relatively quickly. By this time, you have
performed these 4 steps in the following order:
 Assessment and initial steps
 Positive-pressure ventilation
 Positive-pressure ventilation and chest compressions
 Positive-pressure ventilation, chest compressions and epinephrine
Endotracheal intubation should preferably have been performed. You would have checked the
efficacy of each of the steps, and you would have considered the possibility of hypovolemia. If
the heart rate is detectable but remains below 60 beats per minute, it is still likely that the baby
will respond to resuscitation, unless the baby is either extremely immature or has a lethal
congenital malformation. If you are certain that effective ventilation, chest compressions, and
medications are being provided, you might then consider mechanical causes of poor response,
such as an airway malformation, pneumothorax, diaphragmatic hernia, or congenital heart
disease. If the heart rate is absent, or no progress is being made in certain conditions, such as
extreme prematurity, it may be appropriate to discontinue resuscitative efforts. You should be
confident that effective resuscitative measures have been provided for a minimum of 20 minutes
and there has been no response to resuscitation and the APGAR score remains 0 even at 20
minutes, before considering a decision to stop or withdraw the resuscitation process.
Summary: Lesson 6
 Epinephrine, a cardiac stimulant, is indicated when the heart rate remains below 60 beats
per minute, despite 60 seconds of coordinated chest compressions and ventilation.
 Recommended epinephrine concentration: 1:10,000 (0.1 mg/mL)
 Route: Intravenous or endotracheal.
Endotracheal administration may be considered while intravenous access is being
established. Dose: 0.2 mL/kg intravenously (consider higher dose, 0.5 to 1mL/kg, for
endotracheal route only).
 Preparation: 1:10,000 solution
 Rate: Rapidly-as quickly as possible
 Epinephrine should be given by umbilical vein. The endotracheal route is often faster and
more accessible than placing an umbilical catheter, but is associated with unreliable
absorption and may not be as effective as the intravenous route.
 Indications for volume expander include:
- Baby who is not responding to resuscitation
AND
Baby appears in shock (pale color, weak pulses, persistently low heart rate, no improvement in
circulatory status despite resuscitation efforts
AND
There is a history of a condition associated with fetal blood loss (e.g., extensive vaginal bleeding,
abruptio placentae, placenta previa, twin-to-twin transfusion, etc.).
 Recommended volume expander:
Solution: Normal saline, or O-Rh negative blood.
Dose: 10 mL/kg
Route: Umbilical vein
Preparation: Correct volume drawn into a large syringe
Rate: Over 5 to 10 minutes
Resuscitation of preterm baby
Birth of a preterm neonates poses additional challenges that makes the transition to extra-
uterine life more difficult. Generally, the degree of prematurity determines the extent of support
required to achieve this transition smoothly. Preterm neonates need additional resuscitative
measures due to the presence of large body surface area, immature organ system, fragile brain
capillaries, weak chest muscles coupled with immature lungs and a frail immune system. Special
skills including gentle handling are required to prevent neurologic injury and heat loss, optimize
oxygenation, provide respiratory support and prevent infection during resuscitation of these
vulnerable neonates.
Problems associated with a preterm neonate in the delivery room
Problem Contributing factors
Hypothermia Less subcutaneous brown fat, thin skin, large surface area relative to body mass,
limited thermal response
Asphyxia Poor respiratory drive, poor muscle tone, immature brain control
Breathing difficulty Immature & surfactant deficient lungs, weak breathing muscles, immature
respiratory drive
Hypovolemia Smaller blood volume loss can increase the risk of hypovolemia
Hypoglycemia Limited reserve and immature compensatory mechanism
Sepsis Immature immune system
Preterm specific resuscitation interventions
Step Intervention
Thermal Care  Ensure room is draft free and warm (26°C)
 Early skin to skin contact, if breathing well (≥32 weeks)
 Maintain temperature between 36.5°C and 37.5°C
 Record temperature at the end of resuscitation and on admission
 Avoid hyperthermia (>38°C)
 Use plastic wrap/food grade bag, if available for neonates <32 weeks
Delayed cord clamping  Perform cord clamping for all well preterm babies between 1-3 minutes to
facilitate placental transfusion
Initial steps  Place infant under pre heated warmer
 Cover the head with a cap
 Place the baby in plastic bag/wrap/food grade bag (< 32 weeks) immediately at
birth without drying
 In case a plastic bag/wrap is used, the entire resuscitation is done with the plastic
bag in situ
Respiratory Support  Avoid routine suction. Use gentle suction
 Place a roll below the shoulders to open the airway
 Consider delivery room CPAP (PEEP of 5-8) in spontaneously breathing baby with
respiratory distress
 If fails to initiate spontaneous breathing consider PPV via face mask (PIP of 20-25,
PEEP of 5 cm of H2O)
 Prefer T piece resuscitator over self-inflating bag to deliver adequate tidal volume
 Avoid high tidal volumes
 Look for visible chest rise
Oxygen  Ensure use of air oxygen blender and pulse oximeter
 Use room air for ≥ 32 weeks with PPV
 Use 21-30% for < 32 weeks with PPV
 Place the pulse oximetry probe on the right wrist to titrate oxygen delivery based
on targeted oxygen saturation
 If blended air and oxygen is not available commence resuscitation with room air in
preference to 100% oxygen
 Avoid hypoxia and hyperoxia
Chest compression  Consider use of ECG, if available
Drugs  Avoid rapid infusions of fluid
 Surfactant can be administered in the delivery room to those preterm neonates
who had severe RDS, such as severe chest retractions and high FiO2 requirement
Handling  Handle gently to prevent neurological injury
 Maintain head in neutral position
 Avoid head high or head low position
Transport  Transport incubator for providing warmth
 Blended oxygen and saturation monitoring by pulse oximeter should ideally be
provided during transport
APPENDIX
PRETEST /POST-TEST
Neonatal Resuscitation Time: 20 Minutes
Name: Date: _________________________
1. At birth, a baby's strong breathing efforts causes___________to be absorbed from the

lungs and replaced with___________. .
2. Mention the question of initial assessment which must be asked for all newborns.
________________________________________________________________________
3. What care should be provided to a baby who is breathing/crying at birth?

________________________________________________________________________
4. Which of the following are recommended ways of providing tactile stimulation in an

attempt to initiate respiration?
• Squeeze the ribcage
• Slapping or flicking the soles of feet
• Rubbing the back
• Force things on to abdomen
• Apply a cold compress
5. List the two indications for positive pressure ventilation

________________________________________________________________________
________________________________________________________________________
6. List in order, the three signs on which an infant' s condition is primarily evaluated
1.
2.
3.
7. When a suction catheter is used to clear the meconium from an oropharynx, the
appropriate size of the catheter to be used is _____ to ____ F.
8. By what time should you begin PPV in a baby who has not started breathing or crying after
initial steps? ____________________________
9. When selecting a face mask, make sure that the rim covers the tip of the __________,
the ___________and the __________but does not cover the eyes.
10. In a 34 week baby, who has not started breathing after initial steps, will you start PPV with
room air or with 21-30% oxygen?
________________________________________________________________________
11. What is the purpose of using an oxygen reservoir with a self-inflating bag?
_________________________________________________________________________
12. The rate at which a neonate should be ventilated using bag valve mask device
is_____________ per minute.
13. What is the maximum permissible suction pressure while suctioning the airway?
________________________________________________________________________
14. What type of care is provided to a baby who has received PPV for less than one minute and
is now breathing spontaneously? ____________________
15. You must hold the resuscitation bag so that you can see the newborn's _____________and
_____________.
16. At what pressure should the safety pop off valve give way in bag and mask ventilation?
________________________________________________________________________
17. After placing the mask in position and ventilating for 5 breaths, you do not observe any
appropriate rise of the chest. What could be the three reasons?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
18. The correct depth of chest compression is approximately ___________of the anterior-
posterior diameter of the chest.
19. The ratio of compression to ventilation is______to _______.
20. At what heart rate should chest compressions be discontinued?

___________per minute.
21. Chest compressions should be accompanied by___________________________.
22. The following is the 6 seconds count of heart rate obtained in an infant during resuscitation.
What is the Heart Rate per minute?
H.R.in 6 seconds H.R. per minute
6 ___________________
9 ___________________
12 ___________________
14 ___________________
23. Indicate the correct ET tube size for infants with the following weights.
Weight Tube size

800 gm ___________
3400gm _____________
1200gm _____________
2500gm _____________
24. If the baby is pale, there is evidence of blood loss and resuscitation is not resulting in
improvement, you should consider giving _________ml/kg of __________________
by___________________ route.
25. After one minute of well-coordinated chest compressions and ventilation, the baby's heart
rate is less than 60 beats per minute. You should now give ___________________ by the
most quickly accessible route while continuing chest compressions and ______________.
26. During endotracheal intubation what is the maximum permissible time for successfully
carrying out endotracheal intubation? _____________.
27. If you have not completed endotracheal intubation in the prescribed time limit, what
should you do? ________________________.
28. The blade of a laryngoscope for preterm newborn should be No.__________. The blade
for term newborns should be ____________.
29. During Positive Pressure Ventilation with chest compressions, the rate of 'events per
Minute’ should be _____________events per minute.
30. What concentration of epinephrine is recommended for neonatal resuscitation?

________________________________________________________________________.

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NEONATAL

2. Initial Steps in Resuscitation 14

3. Positive Pressure Ventilation 26

Appendix: Pre/Post test 81

After reading this chapter you will learn

Table 1.1: Transitional changes at birth

What can go wrong during transition at birth?

 Pulmonary arterioles may remain constricted because of inadequate gaseous distention

How does the fetus/newborn respond to interruption in transition?

• Poor respiratory drive due to insufficient oxygen supply to the brain

• Bradycardia due to insufficient oxygen supply to the heart muscle or brainstem

• Tachypnea (fast breathing) due to failure to absorb fetal lung fluid

Fig.1.3: Resuscitation steps and proportion of neonates needing them

The resuscitation flow diagram (Fig.1.4.)

Oxygen saturation can be assessed with a pulse oximeter.

Note the following important points about the flow diagram:

Table 1.2: Resuscitation at birth: Risk factors

Intrapartum Risk Factors

What equipment should be available?

Table 1.4: APGAR score

Sign Score Minutes

Heart Rate Absent < 100 bpm >100 bpm

Breathing Absent Slow, Irregular Good Crying

Irritability No response Grimace Cough, Sneeze

Muscle tone Limp Some flexion of Active motion

What do you do after resuscitation?

Delayed cord clamping

Table 1.5: Delayed Cord Clamping

Risk Higher chance of hyperbilirubinemia but not requiring phototherapy

Key to Successful Resuscitation

Determining if a baby needs resuscitation

For Preterm babies less than 32 weeks gestation:

Fig. 2.4: Wrapping the baby in polythene plastic bag

Fig. 2.5: Positioning of the baby with shoulder roll in place

Clearing the Airway

Fig. 2.6: Sequence of suction; mouth ‘M’ followed by nose ‘N’

After initial steps, what do you do next?

Evaluate the baby (Table 2.2)

What do you do if the Heart Rate or Respiration are abnormal?

Table 2.2: Evaluation and Action

Breathing Heart rate Action

Regular >100 bpm Routine Care

Apnea, Gasping <100 bpm Initiate positive pressure ventilation

SPO2 monitoring and Optimal Oxygen Delivery

Table 2.3: Targeted saturation after birth

Administration of supplemental oxygen:

Observational care with Mother

In this lesson you will learn:

When should you provide positive pressure ventilation?

• The infant is apneic or gasping or

• The heart rate is less than 100 bpm

What is the equipment available for PPV in newborns?

• The Self inflating bag

• The T- piece resuscitator

Fig. 3.1: Self inflating bag

T-piece resuscitator is a flow-controlled pressure limited ventilator device (Fig.3.3). Piped

Fig. 3.3: T piece resuscitator

Table 3.2: Advantages and disadvantages of a T piece resuscitator

A self-inflating bag should always be available as a back-up to flow-dependent devices in case of