Neonatal Resuscitation Program

Lesson 1: Overview and Principles of Resuscitation

1. 90% of babies are born and make the transition to extrauterine life with no
problem.
2. 10% of newborns require resuscitation, and 1% require extensive measures to
survive. It is for this reason that the NRP program was created
3. The ABCs of neonatal resuscitation are the same as for adults:
A. Airway: Make sure airway is open and clear.
B. Breathing: Respiration are needed to draw in oxygen
C. Circulation: Making sure blood is oxygenated
D. Drugs: Mainly epinepherine
4. The purpose of this course is to keep all this information fresh in your minds in
the rare case that you do need to use it, so you are proficient in it’s use, and to
make the experience less stressful.
5. Before birth all oxygen comes from placenta, and most oxygenated blood takes
the path of least resistance across the ductus arteriosis. Resistance is high in lungs
due to constricted arterioles and fluid filled alveoli.
6. After birth there are three major changes:
a. cord is clamped systemic blood pressure increases
b. Fluid leaves alveoli and replaced by 21% oxygen
c. Pulmonary vessels relax

Changes after birth:

1. Cord is clamped constricting the cord vessels
2. Systemic blood pressure increases
3. Baby forced to take a breath to get oxygen
4. In matter of seconds after oxygen enters lungs pulmonary vessels relax
5. and the Ductus Arteriosis constricts
6. This makes the lungs route of least resistance for blood from right side of
heart
7. Freshly oxygenated blood then leaves lungs to left side of heart
8. Oxygenated blood is sent to the system
9. Fluid in lungs is absorbed by body and gradually replaced by oxygen
7. 90% of time, baby makes vigorous effort to inhale air. Usually the 21% oxygen
breathed in is enough to relax the pulmonary vessels, cause baby to breathe,
baby’s skin color improves from gray to pink.
8. May take up to 10 minutes to get sat of 90%. That’s why most studies now
Recommend NOT shocking baby with 90-100% oxygen at birth.

9. What can go wrong? Sometimes problems occur before birth, but most often
problems arise during birth
a. Not ventilating effectively to remove fluid from lungs, or
meconium prevents lungs from filling with air
b. Excessive blood loss due to poor cardiac contractility results in
no increase in systemic blood pressure
c. No oxygen to lungs results in pulmonary arterioles don’t
constrict
d. Persistent Pulmonary Hypertension: (PPHN) Failure of
pulmonary arteriols to relax despite presence of oxygen.
10. The first sign of low oxygen to system is decreased respiratory drive – apnea
11. If body not getting enough oxygen, arterioles to bowels, kidney, muscles, and skin
constrict to increase oxygen to heart and brain.
12. If oxygen deprivation continues, heart and cardiac output deteriorate, BP falls,
oxygen to organs falls. This results in brain damage and death.
13. Compromised baby:
a. Poor muscle tone (decrease oxygen to brain)
b. Decreased respiratory drive (decrease oxygen to brain)
c. Bradycardia (decrease oxygen to heart)
d. Decreased blood pressure (decreased O2 to heart or brainstem)
e. Tachpnea or fast HR (Fetal fluid still in lungs
f. Cyanosis: Insufficient oxygen

14. Other causes of compromised baby:

a. hypoglycemia
b. medicines to mom (anesthetics during pregnancy, narcotics)

15. Apnea: You will have intervene to help baby take its first breath. What you will
do depends on whether baby is in primary or secondary apnea
a. Primary Apnea: Baby responds to tactile stimulation. You wrap the baby in a
warm blanket and that’s all the stimulation normally needed.
b. Secondary Apnea: Baby does not respond to tactile stimulation, you will have
to use PPV. (PPV a must)

Since you don’t know whether baby is in primary or secondary apnea, it is

important to dry, suction, and warm up every baby in a warm blanket. If the
baby is in primary it will respond to this stimilation, and you can give it to the
mother. If baby is in secondary apnea, no amount of stimulation will work, you
will have to do PPV. Make decision in 5 seconds while drying and suctioning.
16. If no response
a. tap heal of foot
b. rub back
17. 90% respond fine to PPV and need no further intervention
18. If HR <100 always assume baby is in secondary apnea and start PPV
19. The best sign of effective PPV is an increase in heart rate
20. Block A: Do anything you can to create an airway
a. Dry (wet, cold baby less likely to take in deep breath)
b. suction (clear obstruction from airway)
c. stimulate (get patient to take in that first breath)
d. reposition (create an easy path for air to come in)

21. Block B: Do whatever it takes to get the patient breathing

a. HR < 100 you must start PPV
b. If cyanotic you must start blowby oxygen

22. Block C: Do whatever it takes to get blood circulating

a. HR <60 you must start chest compressions

23. Block D: If after 30 seconds of PPV & 30 seconds of chest compressions baby
still not breathing, you must give epinephrine

You will have 30 seconds between each block. If the baby has a HR <60
after 90 seconds you MUST insert a UVC and give the baby epinephrine.
You cannot wait until you have a doctor present. Saying that you waited
until a doctor arrived before giving epinephrine will not hold up in a court of
law.

24. The entire process should proceed rapidly. While you are wrapping blanket and
doing initial assessment you should be able to decide what needs to be done next.
Usually this should take less than 5 seconds.
25. After each block check HR, RR and color
26. What kind of care do you give each baby?
a. Routine care: 90% of babies are vigorous. Wrap these in a
warm blanket and hand to mom
b. Observational care: These are babies that have risk factors for
Complications: Meconium,Diabetic, cyanotic, etc. Evaluate
closely in a radiant warmer to be on safe side and monitor vitals.
c. Post rescusitation: Any baby that requires PPV there is an
increased risk for further problems

.
Lesson 2: Initial steps of rescusitation

1. Initial four questions:

a. Term Gestation: Premies are more likely to have problems
b. Clear amniotic fluid: Pea soup amniotic fluid may pose problems
c. Breathing or Crying: If not baby needs to be stimulated
d. Good muscle tone: If not, baby not getting oxygen
2. Initial Steps:
a. Provide warmth as necessary
b. Position w/ head extended
c. Clear airway (as necessary
3. After initial steps, you’ll want to evaluate for need for further rescusitation:
a. Heart rate: If < 100 start PPV
b. Respiratory Rate: If absent stimulate or start PPV
c. Color: If HR < 100 start PPV. IF HR > 100 provide supplemental O2
4. Central Cysnosis: This is the only cyanosis you need to treat with O2.
5. Happy Central Cyanosis: Leave then alone and call doctor. These kids are rare
and are likely to have cardiac diseases.
6. Free flow oxygen:
a. Mask
b. O2 tubing
c. T-piece rescusitator (NeoPuff)

7. If a baby continues to need supplemental oxygen, it should be heated and

humidified. Blowby oxygen can cool a baby.

8. If baby has prolonged central cyanosis despite supplemental oxygen, do PPV.

9. New studies show that 21% Fio2 may be equally as stimulating as 100%
10. NPR now recommends starting at an FiO2 of 40% and if a baby continues to have
a HR <100 after 90 seconds oxygen should be increased to 100%.
11. New studies show that babies in secondary apnea respond to PPV and not so
much the oxygen.

Butterworth’s Neonatologist strongly recommends starting at 40% FiO2. Butts

is currently doing a study on the effectiveness of resuscitating babies on 21%
FiO2.
12. Usually you can provide enough stimulation and warmth by placing baby in a
warm blanket and suctioning with a bulb syringe.

13. Before you even think about PPV, make sure you have an airway, have suctioned
to clear airway of secretions or meconium, wamed the baby, and checked your
equipment.
14. One of the best ways to position airway is to put a rolled blanket under shoulders.
15. Meconium: If you see meconium you need to know what to do
a. Vigorous: No intubation. Suction mouth and nose with bulb
Syringe
b. Not vigorous: Intubate and suction mouth and trachea

16. Vigorous: This is true if baby is breathing, has a HR >100, and good muscle tone.
17. Some doctors do deep tracheal suctioning on all babys, but this is not necessary.
Too vigorous suction can cause a vagal response and cause baby to stop breathing.
18. Years ago doctors and nurses were told to actually do things like hold the tongue
of the baby’s with meconium to prevent them from inhaling before suctioning was
done, but studies show there is no evidence this in any way improved outcomes.
If baby wants to be vigorous let it.
19. If Meconium baby not breathing, it is important to intubate and look beyond the
vocal cords to make sure there is no mec in lungs. Meconium in the lungs can
become an obstruction and causes air trapping you don’t want.
20. Connect suction tubing to meconium aspirator and connect aspirator to ETT and
suction while removing the ETT.
21. Suction should be set at 100 cwp
22. M before N: Suction the mouth before the nose to make sure secretions are
removed from mouth so baby doesn’t aspirate while suctioning the nose.
23. Suctioning supplies a degree of stimulation in itself.
Section 3: Positive Pressure Ventilation

1.

his causes the ductus arteriosis to stay open, systemic BP to stay

relatively low, and oxygenated blood continues to be shunted from
right to left side of heart, resulting in less oxygen to system.