Discuss Neonatal Resuscitation — its causes, clinical features and management.

Introduction

• Birth is the most dangerous journey of life.
• Approximately 10% of newborns require some assistance to begin breathing at birth, and about 1% need extensive resuscitation.
• The single most important and effective step of neonatal resuscitation is the establishment of adequate ventilation of the lungs.
• Resuscitation is carried out according to the NRP (Neonatal Resuscitation Program) 2020 algorithm.

Overview of the Algorithm

Rapid assessment (term? Tone? Breathing?) → Initial steps (warm, position, clear, dry, stimulate) → Evaluate breathing + heart rate → PPV if apnoeic or HR < 100 → Chest compressions if HR < 60 → Adrenaline if HR < 60 persists

Preparation & Anticipation

• Every delivery must have at least one person skilled in initiating resuscitation whose sole responsibility is the baby.
• Prepare a pre-warmed radiant warmer, warm linen, functioning self-inflating bag & masks (sizes 0 and 1), suction, oxygen source with blender, laryngoscope, ET tubes and a functioning clock.
• Identify antenatal / intrapartum risk factors — prematurity, meconium-stained liquor, fetal distress, multiple gestation, maternal fever, antepartum haemorrhage.
• Perform a pre-resuscitation team briefing and equipment check.

Initial Rapid Assessment (at Birth, Within Seconds)

Ask three questions: Term gestation? Good tone? Breathing or crying?

• If all three are yes → routine care with the mother (warmth, dry, skin-to-skin, delayed cord clamping ≥ 30–60 s).
• If any is NO → move the baby to a radiant warmer and begin the initial steps.

Initial Steps — the 'golden Minute'

The initial steps and, if needed, the start of ventilation must be completed within the first 60 seconds ('Golden Minute'):

• Provide warmth — place under a radiant warmer (preterm < 32 weeks: place in a polyethylene bag/wrap without drying, add a cap).
• Position the airway — slight extension ('sniffing' position); a shoulder roll may help.
• Clear the airway if needed — suction mouth before nose ('M before N') only if secretions obstruct or PPV is anticipated.
• Dry, stimulate, reposition — flick the soles / rub the back; remove wet linen.

Evaluation — Two Vital Signs

• After the initial steps, evaluate respirations and heart rate.
• Heart rate is the most important indicator of successful resuscitation; it is best assessed with ECG leads / auscultation (a pulse oximeter responds more slowly).

Positive Pressure Ventilation (PPV) — the Key Intervention

Indications for PPV: apnoea / gasping, OR a heart rate < 100/min despite the initial steps.

• Start PPV with a mask covering the nose & mouth (not the eyes/chin), at a rate of 40–60 breaths/min ('Breathe… two… three…').
• Start with 21% O2 (room air) for term and 21–30% for preterm, titrated to the target pre-ductal SpO2.
• The best sign of effective PPV is a rising heart rate (also chest rise and improving colour).

If the HR does not rise or the chest does not move, apply the MR SOPA corrective steps in sequence:

Target Pre-ductal Spo2 (right Hand)

Chest Compressions

• Indicated if HR < 60/min despite 30 seconds of effective PPV (ideally after an alternative airway is placed and O2 increased to 100%).
• Technique: two-thumb encircling technique (preferred) over the lower third of the sternum; depth ≈ one-third of the AP chest diameter.
• Coordinate with PPV in a 3:1 ratio → 90 compressions + 30 breaths = 120 events/min. Rhythm cue: 'One-and-Two-and-Three-and-Breathe-and'.
• Reassess HR every 60 seconds.

Medications

Rarely needed if ventilation is effective. Indicated if the HR remains < 60/min despite effective PPV and 60 s of coordinated compressions:

• Adrenaline (epinephrine) 1:10,000 — IV/UVC preferred: 0.01–0.03 mg/kg (0.1–0.3 mL/kg); ET route (0.05–0.1 mg/kg) only while access is being secured. Repeat every 3–5 min.
• Volume expansion — Normal saline / Ringer lactate 10 mL/kg over 5–10 min, or O-negative blood, if hypovolaemia / blood loss is suspected and there is no response.
• Sodium bicarbonate and naloxone are not recommended during acute resuscitation.

Apgar Score — for Documentation, Not to Guide Resuscitation

• Recorded at 1 and 5 minutes (and every 5 min up to 20 min if low).
• Resuscitation is guided by respirations and heart rate and is never delayed to assign an Apgar score.

Post-resuscitation Care

• Monitor temperature, glucose, oxygenation and perfusion; shift to the NICU.
• Consider therapeutic hypothermia for moderate–severe HIE in term/late-preterm babies (start within 6 hours of birth).
• Watch for post-asphyxial multi-organ complications (renal, cardiac, metabolic).
• Communicate with and support the parents; document events accurately.

When to Stop / When Not to Start

• If the heart rate remains undetectable after 20 minutes of adequate, effective resuscitation, discontinuation may be reasonable after team and family discussion.
• Non-initiation may be considered for confirmed extreme prematurity or lethal anomalies, per local ethical guidelines.