Justin Hunter, NREMT-P, B.A.S.
Objectives for this lesson
 Changes in physiology that occur when a baby is born
 The sequence of steps to follow during resuscitation
 The risk factors that can help predict which babies will
require resuscitation
 The equipment and personnel needed to resuscitate a
newborn
 The importance of communication and teamwork
among team members during resuscitation
Why learn neonatal resuscitation?
 4 million neonatal deaths occur each year world wide.
 Birth asphyxia accounts for 23% of these deaths
Which babies require
resuscitation?
 Approx 10% of newborns require some assistance to
begin breathing at birth
 Less than 1% need extensive resuscitative efforts
 Over 90% of newborns are born with little to no
difficulty
Always needed by newborns!
 Assess baby’s risk for resuscitation
 Provide warmth
 Position, clear airway if required
 Dry and stimulate to breath
Sometimes needed by newborns
 Give supplemental oxygen
 Assist ventilations
 Intubation
Rarely needed!!
 Chest compressions
 Medication administration
So,,,,How does a baby receive
oxygen before birth?
 Only a very small amount of fetal blood actually passes through
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the lungs
Fetal lungs are NOT functioning as a route to transport oxygen or
to excrete CO2
Fetal alveoli are filled with fluid
Arterioles that feed the lungs are generally constricted causing
hardly any flow through the lungs
Much of the blood that would normally go through the lungs
simply bypasses the lungs through the ductous arteriosus.
Some of this blood is then circulated through the body while the
rest is circulated to the placenta through the umbilical cord. The
placenta is where gas exchange takes place
Then how does the newborn get
oxygen into the lungs?
 First, the fluid in the alveoli is absorbed into the
pulmonary lymph system. There is now 21% O2
available for gas exchange to take place in the alveoli.
 Second, the umbilical arteries constrict and then the
umbilical arteries and veins are closed when the cord is
clamped. This drastically increases systemic blood
pressure.
 Finally, due to the increase in oxygen levels, the blood
vessels in the lung tissue relax, allowing increased
blood flow through the pulmonary arteries.
cont….
 As oxygen levels increase and pulmonary blood vessels
relax, the ductous arteriosus begins to constrict
 Skin gradually turns from gray/blue to pink
 This entire process starts within a few moments of
birth but the entire process will not be completed until
hours or days after delivery.
 It can take up to 10 minutes to achieve on O2
saturation of 90% or greater
What can go wrong with this
transition?
 The lungs may not fill with air for some reason. The
initial breaths may simply not be strong enough.
 The expected increase in blood pressure may not occur
possibly due to blood loss or hypoxia
 The pulmonary arterioles may remain constricted after
birth possibly due to inadequate filling of the lungs or
hypoxia during delivery.
 Any perinatal stress may result in an initial period of
rapid breathing followed by a period of primary apnea.
During this time, stimulation will cause a resumption
in breathing
 However, if the baby enters an additional period of
apnea called secondary apnea, assisted ventilations
will be required to reverse process.
Three questions to ask!!!
 1. Was he born at term?
 2. Is he breathing or crying?
 3. Does he have good tone?
 If yes to all 3 then toss baby to momma and you’re
done!!
 But, if ANY answer is no, you should continue the
initial steps of resuscitation
Resuscitation flow diagram
 We’ve all heard this before!!!
A
 B!
 C!!
 and
 D!!!!!!
A=Airway
 Position the head and open the airway
 Clear as necessary
 May have to suction trachea (explained later)
 During this time you must evaluate if the baby is
breathing AND if the heart rate is 100bpm or lower
 If the baby is not breathing or the heart rate is below
100, go straight to B!!
B= Breathing
 If the baby is not breathing or the heart rate is below
100bpm you must immediately provide positive
pressure ventilation, PPV.
 Apply pulse oximeter
 Provide PPV for 30 seconds and then reevaluate
 If the heart rates drops below 60bpm proceed straight
to C!!
C= Circulation
 Once you have determined heart rate is below 60bpm
AND you have already tried PPV for 30 seconds,,,,start
chest compressions.
 Intubation is recommended at this point
 After a minute or two of compressions, reevaluate the
newborn
 If heart rate still below 60bpm, go straight to D!!
D=Drug!!
 Administer epinephrine while continuing CPR
 Reevaluate….if heart rate still below 60 bpm repeat C
and D,,,C,D,C,D,C,D,C, etc……
 When heart rate rises above 60, you may stop
compressions but continue PPV until heart rate is
above 100bpm
 Important to note that this was all done with room
air..21%
 We will discuss later when to use supplemental oxygen
 APGAR is only useful for documenting condition
and/or relaying information
 1 min and 5 min
Some case studies….
 A 24-year-old woman is in labor. Water broke 1 hour
ago and the amniotic fluid was clear. She dilates
progressively and a baby girl is born 3 hours later.
 The cord is clamped and cut and she begins to cry as
she is dried with a warm towel.
 She was born at term and has good muscle tone.
 Stay with mom? Or proceed to A=airway?
Next case…
 A woman presents at term in the early stages of labor.
Her membranes have ruptured and the amniotic fluid
was stained with meconium.
 At birth the baby has poor tone and minimal resp
effort.
 Give to momma? Or proceed to A=airway??
Proceed to airway…..
 We never move passed a, b, or c until each one is
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completed
Baby warmed, dried, and airway cleared of meconium.
Trachea is intubated and suctioned and baby still has
weak resp efforts
Baby is stimulated and airway opened. Now, baby
starts to breathe more effectively and heart rate is 120
Baby still has poor tone
Give to momma? Or proceed to B=breathing??
Proceed to breathing…
 Baby still has poor tone 5 minutes after birth so blow-
by oxygen is now given.
 Oxygen saturation is at 92% so o2 is discontinued per
chart
 After 10 minutes heart rate is 150 and is breathing
adequately with good tone
 Give to momma? Or proceed to C=circulation??
Give to momma!!
 Baby is still monitored while resting on mother’s chest
Targeted SPo2 after birth…..
 1 min
 2 min
 3 min
 4 min
 5 min
 10 min
60-65%
65-70%
70-75%
75-80%
80-85%
85-95%
Remember…
 Was the baby born at term?
 Is the baby breathing or crying?
 Is there good muscle tone?
Meconium
Suctioning
 Always mouth before nose!!!
 M comes before N
How to assess for cyanosis
 The most rapid and visible indicator of the state of the
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baby’s oxygenation is the baby’s skin color
Best determined by looking at the central part of the
body
Blue feet and blue hands are NOT a reliable indicator
of poor perfusion
Use pulse oximeter
Remember that newborns come out starting around
60%SPo2 and gradually increase during their
physiologic transitions
 Pulse oximeters must be placed where there is good
CAPPILARY blood flow
 Fingers, palms, forehead, toes, ears, etc…
 Remember that neonates usually won’t require
supplemental oxygen during the beginning of
resuscitation
Devices for PPV
 Many devices out there….
 Prehospital will mostly only have a manual BVM or a vent
 Always start with BVM
 NEVER use a BVM on a neonate without a pop-off valve!!
 They should be rated around 30-40cm H2O
 Choose the appropriate sized BVM. Should have a volume
of around 200mL
 Most people (neonate or adult) only require 4-6mL/kg
 When you see chest rise……..STOP!
 Rising heart rate is the MOST important indicator of
successful resuscitation efforts
 Assess effectiveness of ventilation by listening for
breath sounds and looking for CHEST movement
 Always start with 21% and then gradually increase
oxygen use according to the chart
 Remember that the fetus’ lungs are filled with fluid
and the first few PPV may require a slightly higher
force than normal
3 possible reason for ineffective
ventilations
 Inadequate seal between the mask and the baby’s face
 The baby’s airway is blocked
 Not enough pressure being used
Rate??
 Paramedics should be great this because they bag
everyone at 50 times per minute!!
 40-60 breaths per minute
 Gastric distention could also be a problem
 Distention puts upward pressure on the diaphragm,
preventing full expansion of the lungs
 Distention may also cause regurgitation of gastric
contents, which then may be aspirated
Chest compressions
 When?
 How?
 Coordination
 When to stop?
Case study……
 Baby is born at term, limp, without respirations….
 We did A then went to B,,,,baby is still not
responding,,,,now we go to…………C
 Remember that we had to try 30 seconds of PPV before
actually jumping to C
 Heart rate still remains below 60 bpm WHILE being
limp and cyanotic
 Chest compressions are started with a ration of 3:1
 Chest compressions are indicated whenever the heart
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rate is below 60 bpm, despite at least 30 seconds of
effective PPV.
We need at least 2 people present to properly and
effectively do CPR
Thumb technique is preferred
Remember ‘sniffing’ position. Do not hyper extend
Compress to a depth of 1/3 the diameter of the chest
Allow FULL recoil
 One-and-two-and-three-and-BREATHE
 One-and-two-and-three-and-BREATHE
 One-and-two-and-three-and-BREATHE
 One-and-two-and-three-and-BREATHE
 One-and-two-and-three-and-BREATHE
 One-and-two-and-three-and-BREATHE
 During initial resuscitation..reevaluate every 30
seconds
 However, once compressions have started reevaluate
about every 60 seconds
 Stop compressions once heart rate climbs beyond 60
 If the baby still will not improve then we move
to………………..D (we’ll get back to this)
Intubation notes…
 Have all of your equipment ready before you need it
 Have the obvious equipment PLUS:
 CO2 detection devices
 Suction supplies
 Meconium aspirator
 BACKUP AIRWAY!!!! LMA or King
 ET Tube sizes,,,,,,no one ever memorizes the charts and
formulas.
 Have several sizes ready. Close to the size of the nare or pinky
 Uncuffed! But, we want the biggest that will fit appropriately
cont….
 Consider cutting the tube to shorten it
 Stylets are not required
 Try to take only 5-10 seconds to actually stop CPR
 If suctioning meconium have an aspirator ready
 Have multiple ET tubes prepared as you typically can
only get one good suction from each tube
 Do not suction longer than 5 seconds
cont…
 Remember the gold standard for confirmation of ET
tube placement is capnography waveform.
 Keep in mind that uncuffed ET tubes that are too small
in diameter may actually allow blow-by around the
vocal cords causing a problem with the waveform
 Breath sounds can echo throughout the thorax of a
newborn
 A rapid increase in heart rate is the best indicator of
effective PPV.
Backup airways
 LMAs and/or King airways must be available as a
backup device
 Some limitations: cannot suction trachea and do not
protect as well as ETT against aspiration
D= DRUGS!!!
Venous access in the neonate
 The umbilical vein is the most quickly accessible direct
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IV route in the newborn.
Yes, it is better than an IO.
Direct path to the heart
Usually reserved for hospitals and/or flight services
Umbilical cord has 2 arteries and 1 big vein
Alternatives?
 May be given ET but this is unreliable and makes for
slow absorption time
 The ET may be used while another route is being
established
 Prehospital: quickest route is obviously IO
 UVC route is still the preferred if available
Epinephrine
 Epinephrine is not indicated before you have
established adequate ventilation
 Yes, epi has beta effects that do increase strength and
rate of cardiac contractions HOWEVER…..
 The most important effect of epi is the peripheral
vasoconstriction, which will increase blood flow to the
brain and the coronary arteries.
Epi cont….
 1:10,000 should be used for neonates
 IV dose is 0.01 mg/kg which equates to 0.1 mL/kg in
volume
 Dose should be doubled if giving ET
 IV: flush with 1cc after
Epi cont….how will you draw it
up??
 A 1cc syringe will be needed to get the most accurate
dose.
 Can either connect to stopcock and epi syringe
 Or, can draw up directly from epi container
 Get the right dose and don’t guess!!
Possible hypovolemia…
 If there has been a placenta previa, or blood loss from the
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umbilical cord, the baby may be in hypovolemic shock
Fluids may be indicated if the baby does not respond to
ventilations, chest compression, AND epinephrine
Must be isotonic: NaCl or LR
Dose??? 10 mL/kg
Never, ever, ever, ever,,,,,,,,EVER,,,,,hook up an IV fluid bag
to a child under 1 without a Buretrol chamber, an IV pump,
or a regular syringe
Just a few cc’s too much can be massive fluid overload
Special situations…
 Choanal atresia congenital blockage of the nasal
airway
 Remember that newborns are nose breathers and any
blockage of the nasal passage may inhibit respirations
 Test for choanal atresia by inserting a small suction
catheter and feeling for resistance
 Insert OPA to help maintain airway
Pharyngeal airway malformation
Pharyngeal airway malformation
 Tongue falls into the pharynx and blocks the airway
 If you suspect this, first step is to place baby prone to
help the tongue fall forward
 If this doesn’t help, you can nasally intubate the
newborn. Not all the way to the trachea but rather to
act as a long NPA
Pneumothorax
 Spontaneous leaks in the lung are not uncommon
 Risk is increased dramatically if PPV is taking place
 If pneumo becomes a tension pneumothorax that is
effecting breathing and circulation, chest
decompression may be indicated
 Decompression with 18g or 20g should take place at
2nd intercostal space mid-clavicular OR 4th intercostal
space anterior-axillary
 Attach stopcock or other one-way valve
Narcotics??
 Either from mother’s use or pain medicine given
during labor could be passed to newborn
 Administration of narcan may be indicated if ALL
OTHER steps have already been completed.
 Dose of narcan is 0.1 mg/kg and can be given just
about any route
Premies?
 Keep in mind that babies born earlier than 23 weeks
have a small likelihood of survival
 What if the parents don’t want you to do CPR?
 Use good judgment and involve medical control
 When in doubt…..RESUSCITATE
Questions????
www.EMSSuccess.org
References
 Lancet. 2010;375:1969-1987
 Neonatal Resuscitation. (2011) 6th edition
 Aehlert, B. (2010). Paramedic Practice Today: Above and Beyond.
Volume 2. St. Louis, MO:Mosby JEMS Elsvier.