Nrp

1. NEONATAL RESUSCITATION
PROGMAN

3. CONTENTS
• LESSON 1: FOUNDATIONS OF NEONATAL RESUSCITATION
• LESSON 2: ANTICIPATING AND PREPARING FOR
RESUSCITATION
• LESSON 3: INITIAL STEPS OF NEWBORN CARE
• LESSON 4: POSITIVE-PRESSURE VENTILATION

4. CONTINUE CONTENTS…
• LESSON 5: ENDOTRACHEAL INTUBATION
• LESSON 6: CHEST COMPRESSIONS
• LESSON 7: MEDICATIONS
• LESSON 8: RESUSCITATION AND STABILIZATION OF
BABIES BORN PRETERM

5. • MOST NEWBORNS MAKE THE TRANSITION TO EXTRAUTERINE LIFE WITHOUT
INTERVENTION.
• WITHIN 30 SECONDS AFTER BIRTH, APPROXIMATELY 85% OF TERM NEWBORNS
WILL BEGIN BREATHING.
• AN ADDITIONAL 10% WILL BEGIN BREATHING IN RESPONSE TO DRYING AND
STIMULATION.

6. • FIVE PERCENT OF TERM NEWBORNS WILL RECEIVE POSITIVE-PRESSURE
VENTILATION (PPV).
• TWO PERCENT OF TERM NEWBORNS WILL BE INTUBATED.
• ONE TO 3 BABIES PER 1,000 BIRTHS WILL RECEIVE CHEST COMPRESSIONS OR
EMERGENCY MEDICATIONS.

7. WHY DO NEWBORNS REQUIRE A DIFFERENT APPROACH TO
RESUSCITATION THAN ADULTS?
• MOST OFTEN, ADULT CARDIAC ARREST IS A COMPLICATION OF CORONARY
ARTERY DISEASE THAT PREVENTS THE HEART FROM EFFECTIVELY CIRCULATING
BLOOD TO THE BRAIN.
• IN CONTRAST, MOST NEWBORNS REQUIRING RESUSCITATION HAVE A HEALTHY
HEART. WHEN A NEWBORN REQUIRES RESUSCITATION, IT IS USUALLY BECAUSE
RESPIRATORY FAILURE INTERFERES WITH OXYGEN AND C0 2 EXCHANGE.

8. VENTILATION OF THE NEWBORN'S LUNGS
IS THE SINGLE MOST IMPORTANT
AND EFFECTIVE STEP IN NEONATAL
RESUSCITATION.

9. WHAT HAPPENS DURING THE TRANSITION
FROM FETAL TO NEONATAL CIRCULATION?
• UNDERSTANDING THE BASIC PHYSIOLOGY OF THE CARDIORESPIRATORY
TRANSITION FROM INTRAUTERINE TO EXTRAUTERINE LIFE WILL HELP YOU
UNDERSTAND THE STEPS OF NEONATAL RESUSCITATION.

12. • IT MAY TAKE UP TO 10 MINUTES FOR A HEALTHY TERM NEWBORN TO ACHIEVE
AN OXYGEN SATURATION GREATER THAN 90%.

13. HOW DOES A NEWBORN RESPOND TO AN
INTERRUPTION IN NORMAL TRANSITION?

15. ANTICIPATING AND PREPARING FOR
RESUSCITATION
• IDENTIFY RISK FACTORS BY ASKING THE OBSTETRIC PROVIDER THESE 4 QUESTIONS
BEFORE BIRTH:
( 1) WHAT IS THE EXPECTED GESTATIONAL AGE ?
(2) IS THE AMNIOTIC FLUID CLEAR?
(3) ARE THERE ANY ADDITIONAL RISK FACTORS?
(4) WHAT IS OUR UMBILICAL CORD MANAGEMENT PLAN?
• SOME NEWBORNS WITHOUT ANY APPARENT RISK FACTORS WILL REQUIRE
RESUSCITATION.

16. • EVERY BIRTH SHOULD BE ATTENDED BY AT LEAST 1 QUALIFIED INDIVIDUAL,
SKILLED IN THE INITIAL STEPS OF NEWBORN CARE AND POSITIVE-PRESSURE
VENTILATION (PPV), WHOSE ONLY RESPONSIBILITY IS MANAGEMENT OF THE
NEWLY BORN BABY.
• IF RISK FACTORS ARE PRESENT, AT LEAST 2 QUALIFIED INDIVIDUALS SHOULD BE
PRESENT SOLELY TO MANAGE THE BABY.

17. • IT IS IMPORTANT FOR THE TEAM LEADER TO
REMAIN AWARE OF THE ENTIRE CLINICAL
SITUATION, MAINTAIN A VIEW OF THE "BIG
PICTURE;' AND NOT BECOME DISTRACTED BY A
SINGLE ACTIVITY.

18. WHAT SUPPLIES AND EQUIPMENT SHOULD BE
AVAILABLE?
• ALL SUPPLIES AND EQUIPMENT NECESSARY FOR A COMPLETE RESUSCITATION
MUST BE READILY AVAILABLE AND FUNCTIONAL FOR EVERY BIRTH.

21. INITIAL STEPS OF NEWBORN CARE

22. • FOR MOST VIGOROUS TERM AND PRETERM NEWBORNS, CLAMPING THE
UMBILICAL CORD SHOULD BE DELAYED FOR AT LEAST 30 TO 60 SECONDS.
• ALL NEWBORNS REQUIRE A RAPID EVALUATION. ASK IF THE BABY IS TERM, HAS
GOOD MUSCLE TONE, AND IS BREATHING OR CRYING. IF THE ANSWER IS "NO"
TO ANY OF THESE, THE NEWBORN SHOULD BE BROUGHT TO THE RADIANT
WARMER FOR THE INITIAL STEPS OF NEWBORN CARE.

23. • THE 5 INITIAL STEPS INCLUDE THE FOLLOWING: PROVIDE WARMTH, DRY,
STIMULATE, POSITION THE HEAD AND NECK TO OPEN THE AIRWAY, CLEAR
SECRETIONS FROM THE AIRWAY IF NEEDED.
• USE PULSE OXIMETRY AND THE TARGET OXYGEN SATURATION TABLE TO GUIDE
OXYGEN THERAPY.
• VISUAL ASSESSMENT OF CYANOSIS IS NOT A RELIABLE INDICATOR OF OXYGEN
SATURATION.

24. HOW DO YOU EVALUATE THE NEWBORN
IMMEDIATELY AFTER BIRTH (RAPID
EVALUATION)?
• THIS INITIAL EVALUATION MAY OCCUR DURING THE INTERVAL BETWEEN BIRTH
AND UMBILICAL CORD CLAMPING. YOU WILL RAPIDLY ASK 3 QUESTIONS: ( 1)
DOES THE BABY APPEAR TO BE TERM, (2) DOES THE BABY HAVE GOOD MUSCLE
TONE, AND (3) IS THE BABY BREATHING OR CRYING?
• BE CAREFUL NOT TO BE MISLED BETWEEN NORMAL BREATHING AND GASPING!

25. •TERM?
•TONE?
•BREATHING OR CRYING

27. WHAT ARE THE INITIAL STEPS OF NEWBORN
CARE?

28. • THESE STEPS MAY BE INITIATED DURING THE INTERVAL BETWEEN BIRTH AND
UMBILICAL CORD CLAMPING AND SHOULD BE COMPLETED WITHIN
APPROXIMATELY 30 SECONDS OF BIRTH.
• IF THE ANSWERS TO ALL 3 RAPID EVALUATION QUESTIONS ARE "YES," THE BABY
CAN REMAIN WITH THE MOTHER AND HAVE THE INITIAL STEPS PERFORMED ON
THE MOTHER'S CHEST OR ABDOMEN.

29. • AFTER THE INITIAL STEPS ARE COMPLETED, CONTINUE MONITORING THE
NEWBORN'S BREATHING, TONE, ACTIVITY, COLOR, AND TEMPERATURE TO
DETERMINE IF ADDITIONAL INTERVENTIONS ARE REQUIRED.

30. • IF THE ANSWER TO ANY OF THE INITIAL EVALUATION QUESTIONS IS "NO," BRING
THE BABY TO A RADIANT WARMER AND DO THE INITIAL STEPS:
• 1/ WARMING: APPLY A SERVO-CONTROLLED TEMPERATURE
SENSOR TO THE BABY'S SKIN TO MONITOR AND CONTROL
THE BABY’S BODY TEMPERATURE.
• THE BABY TEMP SHOULD BE MAINTAINED
BETWEEN 36.5º C AND 37.5º C.

31. • 2/ DRYING: TO AVOID EXCESSIVE HEAT LOSE. USE 2 WARM TOWELS.
• DRYING IS NOT NECESSARY FOR VERY PRETERM BABIES LESS THAN 32 WEEKS'
GESTATION BECAUSE THEY SHOULD BE COVERED IMMEDIATELY IN
POLYETHYLENE PLASTIC
• 3/ STIMULATE: GENTLY RUB THE NEWBORN'S BACK, TRUNK, OR EXTREMITIES
• NEVER SHAKE A BABY

32. • 4/ POSITIONING: POSITION THE BABY ON THE BACK ( SUPINE) WITH THE HEAD
AND NECK NEUTRAL OR SLIGHTLY EXTENDED. THIS POSITION OPENS THE
AIRWAY.

33. • YOU MAY PLACE A SMALL, ROLLED TOWEL UNDER THE BABY'S SHOULDERS
• AVOID HYP EREXTENSION OR FLEXION OF THE NECK

34. • 5/ CLEAR SECRETIONS:

35. • IF USING A SUCTION CATHETER, THE SUCTION CONTROL SHOULD BE SET SO
THAT THE NEGATIVE PRESSURE READS APPROXIMATELY 80 TO 100 MM HG
WHEN THE TUBING IS OCCLUDED.
• ROUTINE SUCTION FOR A CRYING, VIGOROUS BABY IS NOT INDICATED
• BE CAREFUL NOT TO SUCTION VIGOROUSLY OR DEEPLY

36. • IF THE BABY HAS NOT RESPONDED TO THE INITIAL STEPS WITHIN THE FIRST
MINUTE OF LIFE, IT IS NOT APPROPRIATE TO CONTINUE TO PROVIDE ONLY
TACTILE STIMULATION. FOR BABIES WHO REMAIN APNEIC OR BRADYCARDIC,
DELAYING THE START OF PPV BEYOND THE FIRST MINUTE OF LIFE WORSENS
OUTCOMES.
• REMEMBER: VENTILATION OF THE BABY'S LUNGS IS THE MOST
IMPORTANT AND EFFECTIVE STEP DURING NEONATAL
RESUSCITATION.

37. • AFTER THE INITIAL STEPS (AFTER AROUND 1 MINUTE OF LIFE), IF BABY:
• 1/ APNEIC OR GASPING>>>> PPV
• 2/BREATHING BUT HEART RATE BELOW 100 B/M >>>> PPV
• ESTIMATE THE HEART RATE BY COUNTING THE NU1NBER OF BEATS IN 6
SECONDS AND MULTIPLYING BY 1O .

38. WHAT DO YOU DO IF THE BABY IS BREATHING AND
THE HEART RATE IS AT LEAST L 00 BPM, BUT THE
BABY APPEARS PERSISTENTLY CYANOTIC?
• CYANOSIS LIMITED TO THE HANDS AND FEET ( ACROCYANOSIS) IS A COMMON
FINDING IN THE NEWBORN AND DOES NOT INDICATE POOR OXYGENATION
• IF PERSISTENT CENTRAL CYANOSIS IS SUSPECTED, A PULSE OXIMETER PLACED
ON THE RIGHT HAND OR WRIST SHOULD BE USED TO ASSESS THE BABY'S
OXYGENATION.

39. • PLACE THE PULSE OXIMETER SENSOR ON THE BABY'S RIGHT HAND OR WRIST
(PREDUCTAL)

40. • IF OXYGEN SATURATION IS BELOW THE TARGET RANGE, FREE-FLOW OXYGEN
CAN BE GIVEN TO A SPONTANEOUSLY BREATHING BABY BY HOLDING OXYGEN
TUBING CLOSE TO THE BABY'S MOUTH AND NOSE

41. • THE FREE FLOW OXYGEN CAN BE GIVEN ALSO BY T-PIECE RESUSCITATOR

42. • DO NOT ATTEMPT TO ADMINISTER FREE-FLOW OXYGEN THROUGH
THE MASK OF A SELF-INFLATING BAG

43. POSITIVE-PRESSURE VENTILATION

44. • VENTILATION OF THE NEWBORN'S LUNGS IS THE SINGLE MOST IMPORTANT AND
MOST EFFECTIVE STEP IN NEONATAL RESUSCITATION.
• AFTER COMPLETING THE INITIAL STEPS, POSITIVE-PRESSURE VENTILATION (PPV)
IS INDICATED IF THE BABY IS NOT BREATHING, OR IF THE BABY IS GASPING, OR
IF THE BABY'S HEART RATE IS LESS THAN 100 BEATS PER MINUTE (BPM).

45. • DURING PPV, THE INITIAL OXYGEN CONCENTRATION (FRO2) FOR NEWBORNS
GREATER THAN OR EQUAL TO 35 WEEKS' GESTATION IS 21 %.
• THE INITIAL FRO2 FOR PRETERM NEWBORNS LESS THAN 35 WEEKS' GESTATION IS
21 % TO 30%.
• THE VENTILATION RATE IS 40 TO 60 BREATHS PER MINUTE AND THE INITIAL
VENTILATION PRESSURE IS 20 TO 25 CM H20 .

46. • THE MOST IMPORTANT INDICATOR OF SUCCESSFUL PPV IS A RISING HEART
RATE.
• IF THE HEART RATE IS NOT INCREASING WITHIN THE FIRST 15 SECONDS OF PPV
AND YOU DO NOT OBSERVE CHEST MOVEMENT, START THE VENTILATION
CORRECTIVE STEPS.

47. • THE VENTILATION CORRECTIVE STEPS (MR. SOPA) ARE:
-M>>>>MASK ADJUSTMENT.
-R>>>>REPOSITION THE HEAD AND NECK.
-S>>>>SUCTION THE MOUTH AND NOSE.
-O>>>>OPEN THE MOUTH.
-P>>>>PRESSURE INCREASE.
-A>>>>ALTERNATIVE AIRWAY.

48. • IF THE BABY CANNOT BE SUCCESSFULLY VENTILATED WITH A FACE MASK AND
INTUBATION IS UNFEASIBLE OR UNSUCCESSFUL, A LARYNGEAL MASK MAY
PROVIDE A SUCCESSFUL RESCUE AIRWAY.

49. • IF THE HEART RATE REMAINS LESS THAN 60 BPM DESPITE AT LEAST 30 SECONDS
OF FACE-MASK PPV THAT INFLATES THE LUNGS ( CHEST MOVEMENT), REASSESS
YOUR VENTILATION TECHNIQUE, CONSIDER PERFORMING THE VENTILATION
CORRECTIVE STEPS, ADJUST THE FRO2 AS INDICATED BY PULSE OXIMETRY,
INSERT AN ALTERNATIVE AIRWAY ( ENDOTRACHEAL TUBE OR LARYNGEAL
MASK), AND PROVIDE 30 SECONDS OF PPV THROUGH THE ALTERNATIVE
AIRWAY. AFTER THESE STEPS, IF THE HEART RATE REMAINS LESS THAN 60 BPM,
INCREASE THE F102 TO 100% AND BEGIN CHEST COMPRESSIONS.

50. • IF YOU CONTINUE FACE-MASK PPV OR CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP) FOR MORE THAN SEVERAL MINUTES, AN OROGASTRIC TUBE SHOULD BE
INSERTED TO ACT AS A VENT FOR GAS IN THE STOMACH.

51. WHAT ARE THE DIFFERENT TYPE OF
RESUSCITATION DEVICES USED TO VENTILATE
NEWBORNS?
• A SELF-INFLATING BAG FILLS SPONTANEOUSLY WITH GAS ( AIR, OXYGEN, OR A
BLEND OF BOTH) AFTER IT HAS BEEN SQUEEZED AND RELEASED.

52. • A FLOW-INFLATING BAG

53. • A T-PIECE RESUSCITATOR

54. • VENTILATION WILL NOT BE SUCCESSFUL IF THERE IS A LARGE AIR LEAK FROM AN
IMPROPERLY PLACED MASK.
• SET THE FLOWMETER TO 10 L/MINUTE

55. • BREATHS SHOULD BE GIVEN AT A RATE OF 40 TO 60 BREATHS PER MINUTE.
• COUNT OUT LOUD TO HELP MAINTAIN THE CORRECT RATE.
• USE THE RHYTHM, "BREATHE, TWO, THREE; BREATHE, TWO, THREE; BREATHE,
TWO, THREE:'
• SAY "BREATHE" AS YOU SQUEEZE THE BAG OR OCCLUDE THE T-PIECE CAP AND
RELEASE WHILE YOU SAY "TWO, THREE:'

56. • START WITH A PIP OF 20 TO 25 CM H20
• WHEN PEEP IS USED, THE SUGGESTED INITIAL SETTING IS 5 CM H20

58. • WITHIN 15 SECONDS OF STARTING PPV, THE BABY'S HEART RATE SHOULD BE
1NCREAS1NG.
• WITHIN 30 SECONDS OF STARTING PPV, THE BABY'S HEART RATE SHOULD BE
GREATER THAN 100 BPM

60. • AFTER 30 SECONDS OF PPV THAT VENTILATES THE LUNGS, AS INDICATED BY AN
INCREASING HEART RATE OR CHEST MOVEMENT, YOU WILL CHECK THE BABY’S
HEART RATE RESPONSE AGAIN.
• POSITIVE-PRESSURE VENTILATION MAY BE DISCONTINUED WHEN THE BABY HAS
A HEART RATE CONTINUOUSLY GREATER THAN 100 BPM AND SUSTAINED
SPONTANEOUS BREATHING

62. WHEN SHOULD INSERTION OF AN
ENDOTRACHEAL TUBE BE CONSIDERED?
• IF THE BABY'S HEART RATE REMAINS LESS THAN 100 BPM AND IS NOT INCREASING AFTER PPV
WITH A FACE MASK OR LARYNGEAL MASK.
• BEFORE STARTING CHEST COMPRESSIONS.
• FOR SURFACTANT ADMINISTRATION, AND FOR STABILIZATION OF A NEWBORN WITH A SUSPECTED
DIAPHRAGMATIC HERNIA.
• IF PPV IS PROLONGED, AN ENDOTRACHEAL TUBE MAY BE CONSIDERED TO IMPROVE THE
EFFICACY AND EASE OF ASSISTED VENTILATION.

67. HOW DO YOU PERFORM THE INTUBATION PROCEDURE?

68. HOW DO YOU CONFIRM THAT THE ENDOTRACHEAL TUBE IS IN THE
TRACHEA?

69. HOW DEEPLY SHOULD THE TUBE BE INSERTED IN THE TRACHEA?
• THE GOAL IS TO INSERT THE ENDOTRACHEAL TUBE TIP IN THE MIDDLE PORTION OF
THE TRACHEA. THIS GENERALLY REQUIRES INSERTING THE TUBE SO THAT THE TIP IS
ONLY 1 TO 2 CENTIMETRES BELOW THE VOCAL CORDS.
• THE NASAL-TRAGUS LENGTH (NTL) IS A METHOD THAT HAS BEEN VALIDATED IN BOTH
FULL-TERM AND PRETERM NEWBORNS.

73. CHEST COPRESSION
• CHEST COMPRESSIONS ARE INDICATED WHEN THE HEART RATE REMAINS LESS THAN 60 BEATS
PER MINUTE (BPM) DESPITE AT LEAST 30 SECONDS OF POSITIVE-PRESSURE VENTILATION (PPV)
THAT INFLATES THE LUNGS (CHEST
• MOVEMENT).

74. WHEN DO YOU BEGIN CHEST
COMPRESSIONS?
• CHEST COMPRESSIONS ARE INDICATED IF THE BABY’S HEART
RATE REMAINS LESS THAN 60 BPM AFTER AT LEAST 30 SECONDS
OF PPV THAT INFLATES THE LUNGS, AS EVIDENCED BY CHEST
MOVEMENT WITH VENTILATION.

75. • IF COMPRESSIONS ARE STARTED, CALL FOR HELP IF NEEDED AS
ADDITIONAL PERSONNEL MAY BE REQUIRED TO PREPARE FOR
VASCULAR ACCESS AND EPINEPHRINE ADMINISTRATION

76. WHERE DO YOU STAND TO ADMINISTER CHEST COMPRESSIONS?

78. HOW DEEPLY DO YOU COMPRESS THE
CHEST?
• APPROXIMATELY ONE-THIRD OF THE ANTERIOR-POSTERIOR (AP) DIAMETER OF THE
CHEST

79. HOW DEEPLY DO YOU COMPRESS THE CHEST?

80. WHAT IS THE COMPRESSION RATE?
• THE COMPRESSION RATE IS 90 COMPRESSIONS PER MINUTE.
• TO ACHIEVE THIS RATE, YOU WILL GIVE 3 RAPID COMPRESSIONS AND 1 VENTILATION
DURING EACH 2-SECOND CYCLE.

81. HOW ARE COMPRESSIONS COORDINATED WITH POSITIVE-PRESSURE
VENTILATION?

83. • WHEN CHEST COMPRESSIONS ARE STARTED, INCREASE THE FIO 2 TO 100%. ONCE THE
HEART RATE IS GREATER THAN 60 BPM AND A RELIABLE PULSE OXIMETER SIGNAL IS
ACHIEVED, ADJUST THE F10 2 TO MEET THE TARGET OXYGEN SATURATION GUIDELINES.

84. WHEN SHOULD YOU CHECK THE BABY' S
HEART RATE AFTER STARTING
COMPRESSIONS?
• WAIT 60 SECONDS AFTER STARTING COORDINATED CHEST COMPRESSIONS AND
VENTILATION

87. EMERGENCY UMBILICAL VENOUS CATHETER INSERTION

93. LNTRAOSSEOUS NEEDLE INSERTION

98. WHY DO PRETERM BABIES HAVE A HIGHER
RISK OF COMPLICATIONS?
• • THIN SKIN, DECREASED SUBCUTANEOUS FAT, LARGE SURFACE AREA RELATIVE TO
BODY MASS, AND LIMITED METABOLIC RESPONSE TO COLD LEAD TO RAPID HEAT LOSS.
• WEAK CHEST MUSCLES, POORLY COMPLIANT (STIFF) LUNGS.
• IMMATURE LUNGS THAT LACK SURFACTANT ARE MORE DIFFICULT TO VENTILATE AND
ARE AT GREATER RISK OF INJURY FROM PPV.
• IMMATURE TISSUES ARE MORE EASILY DAMAGED BY OXYGEN.

99. • INFECTION OF THE AMNIOTIC FLUID AND PLACENTA ( CHORIOAMNIONITIS) MAY INITIATE PRETERM LABOR,
AND THE BABY'S IMMATURE IMMUNE SYSTEM INCREASES THE RISK OF DEVELOPING SEVERE
INFECTIONS.
• A SMALLER BLOOD VOLUME IN CREASES THE RISK OF HYPOVOLEMIA FROM BLOOD LOSS.
• IMMATURE BLOOD VESSELS IN THE BRAIN CANNOT ADJUST TO RAPID CHANGES IN BLOOD FLOW, WHICH
MAY CAUSE BLEEDING OR DAMAGE FROM INSUFFICIENT BLOOD SUPPLY.
• LIMITED METABOLIC RESERVES AND IMMATURE COMPENSATORY MECHANISMS INCREASE THE RISK OF
HYPOGLYCEMIA AFTER BIRTH.

100. HOW DO YOU KEEP THE PRETERM NEWBORN WARM?
• SET THE TEMPERATURE IN THE ROOM APPROXIMATELY 23° C TO 25° C (74° F TO 77º F).
• PREHEAT THE RADIANT WARMER WELL BEFORE THE TIME OF BIRTH.
• AFTER DELIVERY, QUICKLY PLACE A HAT ON THE BABY'S HEAD.
• USE A PRE-WARMED TRANSPORT INCUBATOR IF THE BABY WILL BE MOVED AFTER INITIAL CARE IS COMPLETED.
• MAINTAIN THE BABY'S AXILLARY TEMPERATURE BETWEEN 36.S º C AND 37.Sº C .

102. WHAT SPECIAL PRECAUTIONS SHOULD BE TAKEN AF TER THE INITIAL
STABILIZATION PERIOD?
• MONITOR THE BABY'S TEMPERATURE
• MONITOR BLOOD GLUCOSE.
• MONITOR THE BABY FOR APNEA AND BRADYCARDIA.