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Newborn life support [advanced]

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Produced using UK Resuscitation Council ‘Newborn life support’ 2021

Preparation

  • Before birth – gather equipment, confirm gestation, foetal distress, meconium
  • Cord should be clamped after at least 1 minute if possible/immediate resuscitation not required (if not possible, cord milking is an option in babies >28 weeks gestation)
  • Keep baby warm (maintain temperature between 36.5-37.5°C)
    • >32 weeks: dry baby; cover head and body with warm towel; use radiant warmer if baby needs support or when resuscitation (if not, skin-to-skin with mother)
    • ≤ 32 weeks: completely cover with polyethylene wrapping (apart from face) without drying; use radiant warmer
  • Start timer

Initial assessment

  • Tone and colour (muscle tone, pallor)
  • Breathing (established/crying, pattern, gasping/grunting)
  • Heart rate (>100bpm satisfactory; <60bpm critical) – key observation (assess using oximeter on right hand/wrist)

Procedure

If heart rate <100bpm or breathing abnormal:

  • Establish and maintain open airway
  • Give 5 inflation breaths via bag and mask, maintaining the inflation pressure for 2-3 seconds (watch for adequate chest expansion)
  • Oxygenation
    • ≥32 weeks gestation - 21% oxygen (air)
    • 28-32 weeks – 21-30% oxygen
    • <28 weeks – 30% oxygen

NB. if <32 weeks, titrate oxygen to aim sats >80% at 5 mins.

  • If chest not expanding adequately:
    • Try jaw-thrust (2-person technique preferred) ± Oropharyngeal airway and suction
    • Check mask size, position and seal
    • Give 5 further inflation breaths
    • If still not expanding adequately, check for obstructing foreign matter; consider tracheal intubation or laryngeal mask

When 5 inflation breaths performed with adequate chest expansion:

  • Re-assess (tone and colour; breathing; heart rate)

↘ If heart rate <60bpm or absent:

  • Get help
  • Start chest compressions (3:1 compressions:breaths at about 15 cycles every 30 seconds)
  • 100% inspired oxygen initially then titrate
  • Re-evaluate the response every 30 seconds
  • If heart rate still <60bpm or absent
    • Continue compressions
    • Ensure airway is secure
    • Consider drugs below

↘ If heart rate >60bpm:

  • Breathing not established →
    • Continue ventilations until breathing established, at around 30 breaths/min with an inflation time of around 1 second
    • Re-assess every 30 seconds
  • Breathing established → hand back to mother but monitor closely

Ventilation technique (after 5 inflation breaths)

  • Ensure head is in neutral position
  • Inflation time of around 1 second
  • Ventilation rate of around 30 breaths/min
  • Watch for chest movement
  • Tracheal intubation may be required for prolonged resuscitation, severe meconium aspiration or diaphragmatic hernia
  • If no chest movement
    • Try jaw-thrust or Guedel airway
    • Look for airway obstruction – consider suction
    • May need higher positive pressure (e.g. if lung hypoplasia, diaphragmatic hernia)
    • If intubated – consider position of tracheal tube
  • Target saturations (attach monitor to right hand/wrist)
    • 1-5minutes: 70-80%
    • 5-10 minutes: 80-85%
    • >10 minutes: 85-95%

If low, increase oxygen in increments of 20%.

Compression technique

  • Technique
    • From caudal end, grasp both your hands around their chest
    • Place one thumb on top of the other over the sternum just below imaginary line between nipples
    • Compress the chest diameter by one third
  • 3:1 compression:breaths ratio at around 15 cycles every 30 seconds
  • Another person should perform ventilations – if you are alone, use 2 fingers to perform compressions and hold the mask in place with your other hand
  • Re-assess every 30 seconds

Drugs

Should be given via umbilical venous access (usually), intravenously, or intraosseously. Estimate birth weight to calculate doses. In usual order:

  • Adrenaline 1:10,000 0.2ml/kg (20micrograms/kg) IV, can be repeated every 3-5 minutes if heart rate remains <60bpm
  • Glucose 10% 2.5ml/kg IV in prolonged resuscitation
  • Sodium bicarbonate 4.2% 2-4ml/kg IV in prolonged unresponsive resuscitation
  • 10ml/kg fluid bolus (0.9% saline) IV or O Rh-negative blood if suspected blood loss or shock unresponsive to other resuscitative measures
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