Newborn Resuscitation

Newborn resuscitation is defined as a set of interventions done at the time of birth to support the establishment of breathing and circulation.

Introduction

Newborn resuscitation is a critical intervention performed in the immediate postnatal period to assist infants who fail to establish adequate breathing and circulation. This process, involving a sequence of evidence-based steps, is essential for reducing neonatal morbidity and mortality worldwide. According to the World Health Organization (WHO), approximately 10% of newborns require some assistance to begin breathing at birth, while about 1% need extensive resuscitative measures. In India and across the globe, effective newborn resuscitation is a cornerstone of perinatal care, significantly influencing short- and long-term neonatal outcomes.

The significance of timely and efficient resuscitation cannot be overstated. Delays or inadequacies can lead to hypoxic-ischemic encephalopathy, multi-organ dysfunction, or even death.

Purpose

• To ensure there is adequate circulation of oxygenated blood
• To ensure clear and open airway
• To ensure there is spontaneous or assisted breathing

Indications for Newborn Resuscitation

Not all newborns require resuscitation. Identifying infants at risk is crucial for timely intervention. Indications for resuscitation include:

• Absent or inadequate respiratory effort immediately after birth
• Heart rate less than 100 beats per minute (bpm)
• Poor muscle tone or limpness
• Cyanosis or pallor despite initial stabilisation
• History of high-risk perinatal events such as meconium-stained amniotic fluid, preterm delivery, or maternal complications (e.g., diabetes, hypertension)

Early recognition of these risk factors, both antenatally and during labour, enables the resuscitation team to anticipate and prepare for potential interventions.

Preparation

Team Briefing

Effective newborn resuscitation relies on a well-coordinated team. A pre-delivery briefing ensures clarity about individual roles and responsibilities, anticipated risks, and contingency plans. The team typically includes a team leader (usually a paediatrician or neonatologist), airway manager, person responsible for chest compressions, medication administrator, and a recorder.

Equipment Checklist

All necessary equipment should be checked and arranged prior to delivery. Common items include:

• Radiant warmer or heat source
• Resuscitation table or trolley
• Self-inflating bag and mask (appropriate neonatal sizes)
• T-piece resuscitator (if available)
• Suction device with appropriately sized catheters
• Laryngoscope with straight blades (sizes 0 and 1)
• Endotracheal tubes (sizes 2.5, 3.0, 3.5 mm internal diameter)
• Oxygen and air supply with blender
• Pulse oximeter with neonatal probe
• Stethoscope
• Pre-warmed towels and hats
• Medications: adrenaline (epinephrine), volume expanders, normal saline, sodium bicarbonate (if indicated)
• Umbilical venous catheter kit
• Clock or timer
• Documentation forms

Environment Setup

The resuscitation area must be warm, well-lit, and free from draughts. Ensure adequate space for the team to function efficiently. All equipment should be within arm’s reach, and backup supplies must be accessible.

Initial Assessment

APGAR Score

Developed by Dr Virginia Apgar in 1952, the APGAR score is a rapid method to assess a newborn’s condition at 1 and 5 minutes after birth. It evaluates five parameters: Appearance (colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. Each component is scored 0–2, with a maximum total of 10.

An APGAR score below 7 at 1 or 5 minutes warrants close monitoring and possible resuscitative intervention. However, clinical decision-making should not rely solely on APGAR; direct assessment of breathing, heart rate, and tone is crucial.

Rapid Evaluation and Initial Steps

Immediately after birth, the following rapid evaluation should be performed:

1. Is the baby term?
2. Is the baby breathing or crying?
3. Does the baby have good muscle tone?

If the answers are ‘yes’ to all, routine care is provided. If any answer is ‘no’, resuscitation steps commence.

Airway Management

Positioning

Proper positioning is foundational. Place the newborn supine with the neck in a neutral ‘sniffing’ position, using a shoulder roll if necessary. Hyperextension or flexion may obstruct the airway.

Suctioning

Routine suctioning of the mouth and nose is not recommended unless there is apparent obstruction or secretions compromising breathing. In cases of meconium-stained amniotic fluid and poor tone or absent breathing, gentle suctioning under direct vision is indicated.

Airway Adjuncts

If airway patency cannot be maintained with positioning and suctioning, consider an oropharyngeal airway or endotracheal intubation, especially if bag-mask ventilation is ineffective or prolonged.

Breathing Support

Positive Pressure Ventilation (PPV)

PPV is the most critical step in newborn resuscitation. Indications include apnea, gasping, or heart rate <100 bpm after initial steps. Use a self-inflating bag, flow-inflating bag, or T-piece resuscitator with an appropriately sized mask.

1. Ensure a good seal with the mask over the mouth and nose.
2. Deliver breaths at a rate of 40–60 per minute.
3. Observe for chest rise; if absent, reposition, recheck the mask seal, clear the airway, and consider increasing pressure.

Oxygen Delivery

Initiate ventilation with room air (21% oxygen) in term infants. If preterm (<35 weeks gestation), consider starting with 21–30% oxygen. Adjust FiO2 based on pulse oximetry, targeting preductal saturations appropriate for age in minutes after birth.

Monitoring

Continuous monitoring of heart rate (via stethoscope or ECG leads) and oxygen saturation (pulse oximetry) is essential. The heart rate is the most reliable indicator of effective ventilation.

Circulation Support

Indications

If, after 30 seconds of effective PPV, the heart rate remains <60 bpm, commence chest compressions coordinated with ventilation.

Technique

1. Place the thumbs on the lower third of the sternum, with fingers encircling the chest.
2. Compress the chest by one-third of its anteroposterior diameter.
3. Perform compressions at a ratio of 3:1 (three compressions to one breath), achieving 90 compressions and 30 breaths per minute (total 120 events/min).
4. Reassess heart rate after 60 seconds of coordinated compressions and ventilation.

If the heart rate improves to >60 bpm, discontinue compressions but continue ventilation as needed.

Medications

Common Medications

• Adrenaline (Epinephrine): Indicated if heart rate remains <60 bpm despite adequate ventilation and compressions. Dose: 0.01–0.03 mg/kg (0.1–0.3 ml/kg of 1:10,000 solution) IV or intraosseous; endotracheal route is less effective.
• Volume Expanders: (e.g., normal saline) indicated if hypovolemia is suspected or there is evidence of blood loss. Dose: 10 ml/kg IV over 5–10 minutes.
• Sodium Bicarbonate: Rarely indicated, reserved for prolonged resuscitation with documented metabolic acidosis.

Administration Routes

Preferred routes include the umbilical venous catheter (UVC) or intraosseous access. Peripheral IV access may be used if available. Endotracheal administration of adrenaline is less reliable and should only be used if vascular access is delayed.

Team Roles

Team Structure

A typical resuscitation team comprises:

• Team Leader: Directs the resuscitation, makes decisions, and ensures adherence to protocols.
• Airway Manager: Maintains airway, delivers ventilation.
• Compressor: Performs chest compressions when indicated.
• Medication Administrator: Prepares and administers drugs, establishes vascular access.
• Recorder: Documents interventions, times, and responses.

Communication

Effective communication is vital. Use closed-loop communication (repeat-back), clear instructions, and regular status updates. The team leader should encourage input and maintain situational awareness.

Complications

Common Complications

• Airway trauma or malposition
• Pneumothorax due to excessive ventilation pressure
• Gastric distension
• Bradycardia or arrhythmias due to hypoxia or medication error
• Hypothermia
• Medication extravasation
• Infection due to invasive procedures

Troubleshooting

If the baby is not responding to resuscitation:

1. Reassess airway patency and mask seal.
2. Check for chest rise with ventilation.
3. Ensure correct compression technique and depth.
4. Verify oxygen supply and equipment function.
5. Consider reversible causes: hypovolemia, pneumothorax, congenital anomalies.

Prevention

Prevent complications through meticulous preparation, correct technique, and ongoing training. Use simulation-based drills to maintain team readiness.

Post-Resuscitation Care

Monitoring and Stabilisation

Following successful resuscitation, continuous monitoring is essential. Key aspects include:

• Temperature regulation (use of radiant warmer, pre-warmed linens)
• Cardiorespiratory monitoring (heart rate, respiratory rate, oxygen saturation)
• Blood glucose monitoring
• Neurological assessment for encephalopathy or seizures
• Assessment for organ dysfunction (renal, hepatic, haematological)

Transfer and Handover

If the newborn requires ongoing intensive care, arrange safe transfer to a neonatal intensive care unit (NICU). Use a structured handover tool (e.g., SBAR: Situation, Background, Assessment, Recommendation) to ensure continuity of care.

Documentation

Accurate documentation of events, interventions, timings, and responses is crucial for clinical, legal, and quality improvement purposes.

Recent Guidelines and Updates

Recent updates from global authorities such as the WHO, AAP, and NRP include:

• Initial use of room air for term infants, with oxygen titration based on oximetry
• Emphasis on effective ventilation as the highest priority
• Delayed cord clamping (30–60 seconds) for most newborns not requiring immediate resuscitation
• Minimising endotracheal suctioning in meconium-stained infants unless non-vigorous
• Structured team training and regular simulation exercises
• Integration of family-centred care and parental involvement post-resuscitation

It is essential to remain updated with national and institutional protocols, as recommendations may evolve with emerging evidence.

Case Studies

Case 1: Term Infant with Meconium-Stained Liquor

A 38-week male infant is born through thick meconium-stained amniotic fluid. At birth, he is limp and apnoeic. The team initiates resuscitation with airway positioning, gentle suctioning under direct vision, and positive pressure ventilation. The heart rate improves from 50 bpm to 120 bpm after 60 seconds of ventilation. The baby is stabilised and transferred to the NICU for observation. Lesson: Airway management and timely ventilation are critical; routine deep suctioning is not warranted unless the infant is non-vigorous.

Case 2: Preterm Birth at 30 Weeks

A preterm infant (1.3 kg) is delivered at 30 weeks gestation. She is hypotonic, gasping, and cyanosed. Resuscitation is commenced with 30% oxygen, PPV, and temperature maintenance using a plastic wrap and radiant warmer. The team uses a T-piece resuscitator for controlled pressures. After stabilisation, she is transferred to the NICU. Lesson: Preterm infants need careful oxygen titration, temperature control, and gentle ventilation to prevent complications such as retinopathy and lung injury.

Case 3: Delayed Response to Resuscitation

A term newborn fails to respond to initial PPV. The team re-evaluates the airway, finds a poor mask seal, and corrects it. Effective chest rise is achieved, and the heart rate increases. Lesson: Continuous reassessment and troubleshooting are essential; most failures result from inadequate ventilation technique.

Special Considerations

• Primary issue is respiratory, not cardiac: Most newborns needing resuscitation require ventilation, not chest compressions.
• Bradycardia is often due to hypoxia, so effective ventilation is the first priority.
• Preterm infants: Require extra thermal protection, gentle ventilation, and careful oxygen titration.
• Meconium-stained amniotic fluid: Routine intubation for suctioning is no longer recommended unless the baby is non-vigorous.
• Congenital anomalies: Anticipate airway or cardiac challenges (e.g., diaphragmatic hernia, CHD).

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
6. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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