Submitted to: Dr.

Agnes Swamy
Designation: Asso. Professor, TGINE
Submitted by: Ms. Amruta Gade
Class: First Year M.Sc. Nursing
Submitted on:
INTRODUCTION
Approximately 10% of newborns require some assistance to begin breathing at birth. Less than
1% require extensive resuscitation measures. The National Resuscitation Program was developed
by American Academy of Pediatrics (AAP) in conjunction with American Heart Association
(AHA) following the neonate resuscitation guidelines. According to the National Resuscitation
Program, those newborns that do not require resuscitation can generally be identified by a rapid
assessment of following 3 characteristics -
• Term Gestation?
• Crying or Breathing?
• Good muscles tone?
If answer to all these questions is "Yes", the baby does not need resuscitation. The baby should
be dried and placed in skin-to-skin contact with the mother. Apgar scoring should be done
simultaneously.
If answer to above three questions is "No", the infant requires resuscitation.
DEFINITION
Measures taken to revive newborns who have difficulty in establishing respiration at birth and
includes suctioning. Positive pressure ventilation, external cardiac massage, intubation and
medications as necessitated by the neonate's condition at one minute after birth.
PHYSIOLOGY, PATHOPHYSIOLOGY OF NEONATAL ASPHYXIA:

Oxygen is needed for survival both during fetal life and after birth. Before birth the oxygen to the
fetus is supplied by diffusion across the placental membranes from maternal blood. Most of the
oxygenated blood enters the right side of the fetal heart and flows through the low resistance
ductus arteriosus into the aorta. This is because the blood vessels in the fetal lungs are
constricted and offer high resistance to the blood flow. The fetal lungs even though expanded are
filled with fluid and do not play a major role in fetal oxygenation. After birth, the placenta no
longer supplies oxygen to the baby. The baby now depends on its lungs for supply of oxygen.
This transition occurs within seconds. The major changes during this transition are:
  Absorption of fetal alveolar fluid:
The initial breaths of baby result in the absorption of fetal lung fluid into the pulmonary
lymphatics. Air now replaces the lung fluid. Since this inspired air contains 21% oxygen,
this diffuses into the blood vessels surrounding the alveoli.
 Closure of the umbilical vessels:
The clamping or the cord removes the low resistance placental circuit and increases
baby's systemic blood pressure
 Decreased Pulmonary resistance:
As air fills the alveoli, the increased oxygen levels in alveoli decrease the resistance of
the pulmonary blood vessels this increases the blood flow into the lungs. The increase in
systemic blood pressure results in decreased blood flow through the ductus arteriosus,
contributing further towards increasing the pulmonary blood flow. The increase in
oxygen levels also results in constriction of ductus arteriosus Baby's initial breaths fill the
lungs with air and initiate the oxygenation by lungs 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 RISK FACTORS

Antepartum Risk Factors

Maternal Hypertension Multiple gestation
Diabetes in mother Premature rupture of membranes
Ante-partum bleed (2~ or 3" trimester) Post-term gestation
Maternal infections Intra-uterine growth restriction
Maternal medical problems (cardiac, Malformations in fetus
pulmonary, renal, thyroid, etc.)
Poly-hydramnios Mothers <18 yrs or older than 35 yrs
Oligo-hydramnios
 Intrapartum Risk Factors
Abnormal fetal heart rate patterns (late and Emergency cesarean section
variable decelerations)
Meconium stained amniotic fluid General anesthesia to mother
Significant intra-partum hemorrhage Premature labor
(Abruptio placentae, placenta previa)
No-vertex presentation Chorioamnionitis
Force/vacuum deliveries Prolonged labor (> 24 hrs)
Cord prolapse
Macrosomic (Large) fetus

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

 Poor muscle tone due to insufficient oxygen delivery to the brain, muscles and other Organs
 Poor respiratory drive due to in sufficient oxygen supply to the brain.
 Bradycardia due to insufficient oxygen supply to the heart muscle or brain stem.
 Low blood pressure from insufficient oxygen to the near 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

PURPOSES
1. To establish and maintain a clear airway
2. To ensure effective circulation.
3. To correct any acidosis present.
4. To prevent hypothermia, hypoglycemia and hemorrhage.
INDICATION
 High risk delivery
 Maternal condition
Advanced maternal age ,DM, HT, stillbirth, fetal loss, early neonatal death
 Fetal condition
Prematurity, post maturity, congenital anomalies, multiple gestations
 Ante partum complications:
APH, oligo /polyhydramnios
 Delivery complications
Malpresentation, MSAF, instrumental delivery, antenatal asphyxia with abnormal FHR

PRINCIPAL OF NEONATAL RESUSCITATION

TABC of Resuscitation
T- Maintenance of Temperature
• Dry the baby quickly.
• Remove wet linen.
• Place the baby under radiant warmer.
A- Establish an open airway
• Position the infant.
• Suction mouth and nose [in few cases also trachea].
• ET intubation, if needed to ensure open airway.
Head position for clearing the airway
B - Initiate Breathing
• Tactile stimulation to initiate respiration.
• PPV (Positive pressure ventilation) when necessary, using either Bag and mask or Bag
and ET tube.
C -Circulation
• Chest compression
• Medications (if needed)
NEONATAL RESUSCITATION SUPPLIES AND EQUIPMENTS/ ARTICALS
Suction Equipment’s
• Mucus aspirator
• Meconium aspirator
• Mechanical suction
• Suction catheters, 10F or 12F
• Feeding tube 6F and 20 ml syringe
Bag Mask Equipment
 Neonate resuscitation bag
 Face masks, newborn and premature sizes
 Oxygen with flow meter and tubing
Intubation equipment
• Laryngoscope with straight blades, No. 0 (preterm) and No.1 (term)
• Extra bulbs and batteries for laryngoscope
 • Endotracheal tubes: 2.5, 3.0, 3.5, 4.0 mm ID
• Stylet
• Scissors
Medications
• Epinephrine
• Naloxone hydrochloride
• Sodium bicarbonate
• Normal Saline
• Sterile water
PROCEDURE
INITIAL STEPS
Nursing action Rationale

1. Assess the Apgar score. Helps to know if resuscitation measures are

to be instituted.
2. Place infant under warmer, quickly dry off Prevents heat loss.
amniotic fluid, replace wet sheets with a dry one.
3. Place the baby on his back with slightly head Straightens the trachea and opens the airway.
down 15 degree tilt, neck slightly extended. Hyper-extension may cause airway
obstruction.
4. Suction the mouth first and then nose. Clears the airway passage. Infants often gasp
when the nose is suctioned and may aspirate
secretion from the mouth into lungs.
5. Give tactile stimulation if infant does not Tactile stimulation may bring spontaneous
breathe (Flick or tap the sole of foot twice or respiration.
rub the back). Do not slap
6. Check the vital signs, and color of the newborn. Helps in determining further need for
resuscitation.
Evaluation should be done on respiration, heart rate and color. If the baby is apneic, heart rate is
less than 100 bpm and central cyanosis is present, proceed for bag and mask ventilation or
positive pressure ventilation.
BAG AND MASK VENTILATION/POSITIVE PRESSURE VENTILATION
INDICATIONS
 Apnea
 Heart rate less than 100 bpm
PROCEDURE
Nursing action Rationale
1. Place the newborn on his back with head Helps in opening airway. Hyperextension may
slightly extended. cause airway obstruction.
2. A tight seal is to be formed over the infant's Prevents leakage of oxygen from the sides of
mouth and nose with the face mask. the mask.
3. Ventilate at a rate of 40-50 per minute.
4. Ventilate for 15-30 seconds and evaluate Spontaneous respiration may be initiated with
initial attempts to ventilate.
5. Have an assistant to evaluate, listen to the heart
rate for 6 seconds and multiply by 10.

Fig. Mask position

 Fig. Manual ventilation

EVALUATION
• If heart rate is above 100 bpm and spontaneous respirations are present, discontinue
bagging.
• If heart rate is 60-100 bpm and increasing, continue ventilation, check whether chest
is moving adequately.
• If heart rate is below 80 bpm, start chest compression.
• If heart rate is below 60 bpm, in addition to bagging and chest compressions, consider
intubation and initiate medications.
• Signs of improvement:
• Increasing heart rate
• Spontaneous respirations
• Improving color.
Continues to provide free flow oxygen by face mask after respirations are established If the baby
deteriorates, check the following:
• Placement of face mask for tight seal.
• Head position and presence of secretions.
• Presence of air in the stomach preventing chest expansion.
• Oxygen being delivered (100% or not).
CHEST COMPRESSIONS
Chest compressions consist of rhythmic compressions of the sternum that compresses the heart
against the spine, increases the intrathoracic pressure and circulates blood to the vital organs.
Chest compressions must always be accompanied by ventilation with 100% oxygen to assure
that the circulating blood is well oxygenated.
INDICATIONS
1. Heart rate less than 60 bpm after bagging with 100% oxygen for 15-30 seconds
2. Heart rate 60-80 bpm and not increasing after bagging with 100% oxygen for 15-30 seconds
PROCEDURE
Nursing action Rationale
Compress the chest by placing the hands around the Correct hand position compresses the heart and
newborn's chest with the fingers under the back to avoids injury to the liver, spleen, fracture, of the
provide support and the injury to the liver, spleen, ribs and pneumothorax.
fracture of the ribs and thumbs over the lower third
of the sternum just above the pneumothorax.
Xiphoid process).
Or
Use two fingers of one hand to compress the chest
and place the other hand under the back to provide
support.

Compress the sternum to a depth of approximately The size of the newborn determines the depth of
one third of the anteroposterior diameter of the compression to avoid injury.
chest and with sufficient force to cause a palpable
pulse. The fingers should remain in contact with the
chest between compressions.
Use three compressions followed by one ventilation Simultaneous compression and ventilation may
for a combined rate of compressions and interfere with adequate ventilation.
ventilations of 120 each minute. This provides 90
compressions and 30 ventilations each minute.
 Pause for ½ second after every third compression
for ventilation

Check the heart rate after 30 seconds. If it is 60 Periodic evaluation is necessary to ensure that
bpm or more, discontinue compressions but treatment is appropriate
continue ventilation until the heart rate is more than
100 bpm and spontaneous breathing begins.

Fig. Chest Compression

POST-RESUSCITATION CARE

Post-resuscitation care encompasses three levels they are following:

Routine care:

When baby is vigorous and may stay with mother. Provide warmth, clear airway, dry and
assess baby’s color.

Observational care:

When baby requires initial steps under the radiant warmer due to depressed breathing or
activity, meconium-stained amniotic fluid or cyanosis. Manage with frequent evaluation
and perhaps admission to a transitional nursery.
Post-resuscitation care:

• When baby receives positive pressure ventilation or more extensive resuscitation and is at
high risk for recurrent deterioration or subsequent complications. Manage where ongoing
evaluation and monitoring are available. Neonatal intensive care may be necessary.
• Observations and monitoring required by a newborn infant following resuscitation at
birth
• Review the screening and management of blood glucose levels to prevent and/or treat
hypoglycemia
• Discuss the management of fluids and electrolytes in the infant who has required
resuscitation
• Discuss the criteria for initiating therapeutic hypothermia for the infant with hypoxic
ischemic encephalopathy (HIE)
• List the circumstances in which discontinuation of resuscitation and/or withdrawal of
care should be considered
• Identify the psychosocial needs of the parents whose newborn infant has required
resuscitation and may require transfer to a higher level of care
CONCLUSION:
Neonatal resuscitation is defined as the set of interventions at the time of birth to support the
establishment of breathing and circulation. Neonatal resuscitation, also known as newborn
resuscitation, is an emergency procedure focused on supporting approximately 10% of newborn
children who do not readily begin breathing, putting them at risk of irreversible organ injury
and death. Through positive airway pressure, and in severe cases chest compressions, medical
personnel certified in neonatal resuscitation can often stimulate neonates to begin breathing on
their own, with attendant normalization of heart rate.
In this assignment I learned about Indication, contraindication, guideline of resuscitation, chest
compression, bag and mask ventilation, emergency drug and care of neonate.
Fig. Newborn resuscitation algorithm
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 Meharban Singh, Care of the Newborn, six edition, Sagar Publication New Delhi, 2004,
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 Rimple Sharma, Essential of Pediatric Nursing, First edition, JAYPEE Brother Medical
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