Procedure for Resuscitation
The chart below details basic life support for a newborn. This is based on the Resuscitation Council’s Newborn Life Support Algorithm.
At all times during the process you need to ask yourself – do I need help?
We will now look at this chart in more detail.
Assess the baby using the following approach:
Select the headings to find out more information.
Dry and wrap the baby
Infants are born small and wet. They get cold very easily, especially if they remain wet and in a draught.
Whatever the situation it is important that the infant does not get cold. In all cases whether intervention is required or not, dry the term or near-term infant, remove the wet towels, and cover the infant with dry towels. Significantly preterm infants are best placed, without drying, into polyethylene wrapping under a radiant heater. In infants of all gestations, the head should be covered with an appropriately sized hat.
The temperature must be actively maintained between 36.5°C and 37.5°C after birth unless a decision has been taken to start therapeutic hypothermia. The admission temperature should always be recorded as a predictor of outcomes as well as a quality indicator.
Do I need help?
Assess the situation
Is the baby breathing? Most babies breathe within 90 seconds
Heart rate should be >100 bpm
Tone - is the baby floppy?
Do I need help?
If gasping or not breathing
If gasping or not breathing, open the airway and give five inflation breaths. Inflation breaths for a term baby should be over 2-3 seconds with a peak inspiratory pressure of 30 cm water.
Place the baby head in a neutral position
Choose the correct size mask
Position the mask on the face (roll the mask on to the face from the chin upwards it should not press on the eyes.)
Pull the jaw up (jaw thrust)
Do I need help?
Chest not moving
If the chest is not moving:
Recheck head position
Recheck jaw thrust and mask position
If possible, use a two-person technique
Look for a response
SpO2 monitoring/ECG
Consider inspection of airway +/- suction
Oropharyngeal airway or supraglottic airway
Is the chest moving?
Do I need help?
Once the chest is moving
Once the chest is moving:
Reassess heart rate
Give 30 seconds of ventilation breaths (inspiratory time of approximately 1 second and a peak pressure of 20 cm water)
Does the chest rise? Look for chest movement
After 30 seconds of ventilation, reassess heart rate; if this remains slow or very slow start chest compressions
If heart rate is improving, continue ventilation breaths for 30 seconds and reassess
Continue till normal breathing is established
Do I need help?
Slow heart rate
If the heart rate is still slow - < 60 or absent, you must:
Start chest compressions with a ratio of three compressions to one inflation for 30 seconds
Reassess. If the heart rate remains slow or absent, consider vascular access and drugs
Do I need help?
The Resuscitation Council UK has created a video which demonstrates resuscitation of a newborn.
Drugs
Drugs are rarely needed and only if there is no significant cardiac output, despite effective lung inflation and chest compressions.
The outlook for most babies at this stage is poor, although a small number have had good outcomes after a return of spontaneous circulation followed by therapeutic hypothermia.
How should drugs be given?
In the baby who requires drugs, the circulation is not functioning and so drugs must be delivered as close as possible to the heart. This is best achieved by an umbilical venous catheter (UVC). An alternative to the UVC route is the intraosseous route.
Adrenaline is the only drug that may be given by the tracheal route, although of unknown efficacy at birth. If this is used, it must not interfere with ventilation or delay acquisition of intravenous access.
After each of the drugs has been given use a small flush of 0.9% sodium chloride to ensure the drug reaches the circulation and a few chest compressions to ensure the drug reaches the heart, then assess the effect.
What drugs should be used?
Adrenaline
Preparation: 1:10,000 (=1g/10,000 mL = 100 mg/L =100 microgram/mL)
Dose: 0.1-0.3 mL kg-¹ of 1:10,000 (10 microgram kg-¹)
Route: UVC or intraosseous needle or tracheal tube
Animal evidence suggests that adrenaline cannot bind to its receptors at very low pH. If no response to 10 microgram Kg (0.1 ml kg-¹), it is arguably worth giving a dose of bicarbonate and then a further larger dose of adrenaline (0.3 ml kg).
In order to overcome some of the delay associated with intravenous administration, it has been suggested that adrenaline can be effective when given down a tracheal tube. Standard dose is not likely to be effective via tracheal tube and a higher dose may be required.
Sodium Bicarbonate
Preparation: 4.2% (or 8.4% diluted 1:1 with 5% or 10% glucose)
Dose: 1-2 mmol kg-¹ (2-4 mL kg-¹ of 4.2%)
Route: UVC or intraosseous needle
If there is no effective cardiac output, or virtually none, then reversing intracardiac acidosis may be helpful. You are not attempting to correct the baby’s metabolic acidosis; you are merely trying to improve cardiac function by improving the pH of the blood within the heart.
Bicarbonate will normally produce cardiac acceleration within a couple of minutes if it is going to work.
Bicarbonate must never be given down the tracheal tube
Glucose
Preparation: 10% (=10 g/100 mL=100 mg/mL)
Dose: 2.5 mL kg-¹ of 10% (250 mg kg-¹)
Route: UVC or intraosseous needle
The heart cannot work without glucose and the glycogen stores present in the heart at birth are rapidly depleted during prolonged hypoxia.
Glucose can be tried if there is no response to adrenaline and bicarbonate.
Subsequent symptomatic hypoglycaemia, if present, is better managed with an infusion of 10% glucose rather than with repeated boluses.
Glucose must never be given down the tracheal tube.
Volume
Preparation: 0.9% saline (or a balanced salt solution)
Dose: 10 mL kg-¹ initially
Route: UVC or intraosseous needle
A bolus of about 10 mL kg-¹ is usually sufficient to produce a response and can be repeated if necessary. If blood loss is the cause of the problem, further transfusion with blood may be necessary later. Giving further volume to a severely compromised baby with a myocardium damaged by hypoxia is likely to do more harm than good.
Giving large volumes (more than 40 mL kg-¹) of solutions high in chloride (such as albumin or 0.9% saline) can also exacerbate metabolic acidosis through hyperchloremia.
Handover
A well-structured communication process that is simple, reliable and dependable will enable the caller to convey the important facts and urgency and will help the recipient to plan ahead.
Two examples of handover tools include:
SBAR - Situation, Background, Assessment and Recommendation
RSVP - Reason, Story, Vital signs and Plan
The use of the SBAR or the RSVP tool enables timely communication between individuals from different clinical backgrounds and hierarchies.
Situation/Reason
Introduce yourself and check that you are speaking to the correct person
Identify the patient you are calling about (who and where)
State what you need advice about
''I am midwife Brooks, is that the neonatal registrar?
I am concerned about baby Ali who is in the obstetric theatre. He is requiring face mask oxygen 30% to maintain saturations greater than 90%.
Background/Story
Background information about the patient
Reason for admission
Relevant past medical history
''He is 15 minutes old. Delivered at 39 weeks' gestation by elective caesarean section for breech presentation. He was fine at birth requiring no resuscitation; after being dried and wrapped he was noted to look cyanosed and was transferred to the resuscitaire. His mum is fit and well has no risk factors for infection.
Assessment/Vital Signs
Include specific observations and vital sign values based on ABCD approach
Air - colour/tone
Breathing
Circulation
Drugs
''He looks pale and his respiratory rate is about 70. He has sternal recession and his saturation was 76%; we are giving him 30% oxygen via facemask and his saturation level has improved to 90%. I am uncertain as to the cause of his respiratory distress.
Recommendation/Plan
State explicitly what you want the person you are calling to do
What and by when
Don’t forget to document the call, including date and time.
''I think he needs to be seen urgently. He will probably need transfer to the neonatal unit.
Would you like me to do anything else before you get here?
Case Study
Michelle is healthy and enjoying an unproblematic pregnancy. She is planning to have a home birth.
You are the professional responsible for Mary’s baby who has just been delivered. He is making no respiratory effort and his heart rate is 70 bpm. What would you do?
Select the number to sort your choices to the correct order and click the picture to reveal the answer.
Carry out chest compressions (if not response to inflation)
Dry, warm and cover the baby
Continue until help arrives
Assess breathing, heart rate and tone
SBAR handover
Call for help
Open the airway and use inflation breaths
The answer is:
6. Call for help
2. Dry, warm and cover the baby
4. Assess breathing, heart rate and tone
7. Open the airway and use inflation breaths
1 Carry out chest compressions (if not response to inflation)
3. Continue until help arrives
5. SBAR handover
