Table of Contents
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
