Where placental oxygen supply is interrupted, the fetus begins breathing movements. Should these fail to improve oxygen supply, the baby loses consciousness. After 2-3 minutes the respiratory centre stops initiating breathing (primary apnoea). Bradycardia follows, although BP ismaintinaed. Primitive gasping breaths (deep, involving all accessory muscles, 6-12/min) may last for 20 minutes.
NEUTRAL head position. Gentle suction.
If meconium - aspirate mouth/nose on perineum. If baby is not vigorous inspect the oropharynx and aspirate using wide bore catheter.
5 inflation breaths (2-3 secs). Chest movement may be absent during first few breaths as fluid displaced. Apply jaw thrust if no response, try again.
If still no response, use a second person to help, repeat inflation breaths. Or try orophayngeal airway.
If undetectable OR <60 and NOT rising start chest compressions 3:1 for 30 secs. 2 hands around chest, thumbs on sternum just below inter-nipple line. Compress by 1/3 depth of chest.
Reassess - if improving, stop chest compressions. If heart rate still slow, continue ventilation and chest compressions, consider venous access and drugs.
AT ALL STAGES - do you need help?
Epinephrine for profound, unresponsive bradycardia or circulatory standstill (10 mcg/kg, 0.1 ml/kg 1:10 000) at 3-5 minute intervals. Bicarb for absence of discernible cardiac output or profound and unresponsive bradycardia (1 mmol/kg = 2 ml/kg of 4.2% solution). Dextrose (5 ml/kg 10% dextrose IV slowly).
If suspected fluid loss (eg APH, placenta praevia, unclamped cord) give 10 ml/kg volume expansion with normal saline; alternatively Gelofusine, and if acute and severe, non-cross-matched O-negative blood.
Naloxone is not a drug of resuscitation. If respiratory depressant effects are suspected, Naloxone 200 mcg (for full term baby) IM can be given else smaller doses of 10 mcg/kg (duration 20 minutes if IV, a few hours if IM).
Atropine and calcium have no place in newborn resuscitation. Atropine may however he useful when vagal stimulation has produced resistant bradycardia or asystole.
Most babies can be resuscitated using a mask system. Intubation is especially useful for prolonged resuscitation, preterm babies and meconium aspiration. It should be considered if mask ventilation has failed although the most common reason for failure is poor head positioning. A normal full term newborn needs a 3.5 mm ETT.
Babies born before 32 weeks are likely to need help to establish prompt aeration and ventilation. Surfactant deficiency may lead to relatively higher inflation pressures than in term babies. It is appropriate to start with a pressure of 2-2.5 kPa (20-25 cm H2O) but to increase this if there is no heart rate response and inaequate chest movement.