Neonatal Resuscitation
Neonatal resuscitation follows the Newborn Life Support (NLS) algorithm. The primary focus is establishing effective ventilation, as the vast majority of neonatal resuscitation responds to airway management and lung inflation breaths.
Key Facts
~10% of newborns require some assistance at birth; ~1% require advanced resuscitation (intubation, drugs) Airway and breathing are the priority — neonatal cardiac arrest is almost always secondary to respiratory failure/hypoxia 5 inflation breaths: 2-3 second sustained pressure breaths at 30 cmH2O (term) — this is the single most important intervention Heart rate response is the best indicator of effective ventilation — if HR increasing, ventilation is working Chest compressions: If HR <60 despite effective ventilation; 3:1 ratio (3 compressions:1 breath); rate 120 events/min Adrenaline: 10mcg/kg IV (or 50-100mcg/kg via ETT) if HR <60 despite effective ventilation + compressions Delayed cord clamping: At least 60 seconds in well babies; milking in very preterm if cord clamping needed Thermoregulation: Critical — dry, wrap, hat, radiant warmer; <28 weeks: plastic wrap without drying
Overview
Key Facts
Neonatal resuscitation is fundamentally different from adult resuscitation because the primary pathology is respiratory rather than cardiac. Establishing effective ventilation (lung inflation) is the single most important intervention and resolves the majority of cases.
Epidemiology
Approximately 10% of newborns require some form of resuscitation at birth (stimulation, airway positioning, inflation breaths). Approximately 3-6% require ventilation breaths. Approximately 1% require intubation, chest compressions, or drugs. Neonatal mortality in the UK is approximately 2.7 per 1,000 live births.
Aetiology
Causes of need for resuscitation at birth:
- Respiratory: Failure to establish breathing, meconium aspiration, diaphragmatic hernia, pneumothorax
- Cardiovascular: Congenital heart disease (duct-dependent), hypovolaemia
- Neurological: Birth asphyxia, maternal sedation (opioids), neuromuscular disease
- Prematurity: Surfactant deficiency, immature respiratory drive
- Other: Sepsis, congenital anomalies
Pathophysiology
At birth, the lungs must transition from fluid-filled to air-filled. This requires clearance of fetal lung fluid and establishment of functional residual capacity (FRC). In asphyxia, the fetus progresses through primary apnoea (responds to stimulation) → gasping → terminal apnoea (requires positive pressure ventilation). Heart rate falls secondary to hypoxia and responds to effective ventilation.
Clinical Presentation
Assessment at Birth
- Colour: Pink/blue
- Tone: Good/floppy
- Breathing: Regular/irregular/absent
- Heart rate: >100 (good), 60-100 (concerning), <60 (critical)
Apgar Score (1 and 5 minutes)
| Component | 0 | 1 | 2 |
|---|---|---|---|
| Appearance | Blue/pale | Blue extremities | Completely pink |
| Pulse | Absent | <100 | ≥100 |
| Grimace | None | Grimace | Cry/cough |
| Activity | Limp | Some flexion | Active |
| Respiration | Absent | Weak/irregular | Strong cry |
Red Flags Requiring Resuscitation
- Not breathing or gasping at 30 seconds despite drying and stimulation
- Heart rate <100 after inflation breaths
- Heart rate <60 despite effective ventilation — start compressions
- Meconium-stained liquor with depressed baby — consider airway suctioning
- Hydrops fetalis — may need immediate drainage and ventilation
Differential Diagnosis
| Cause of Poor Response | Key Features | Specific Action |
|---|---|---|
| Inadequate ventilation | Most common cause of failed resuscitation | Reposition, jaw thrust, 2-person technique |
| Pneumothorax | Asymmetric chest movement, difficult ventilation | Needle decompression |
| Diaphragmatic hernia | Scaphoid abdomen, absent breath sounds left | Intubate (do NOT bag-mask); NG tube |
| Hypovolaemia | Pale, poor response to resuscitation | Volume (10mL/kg 0.9% NaCl or O-neg blood) |
| Maternal opioids | Respiratory depression, known maternal use | Naloxone ONLY after establishing ventilation |
| Congenital heart disease | Persistent cyanosis despite ventilation | Prostaglandin E1 infusion |
Diagnosis / Investigation
Bedside
- Heart rate: Best assessed by auscultation or pulse oximetry (right hand — pre-ductal)
- SpO2: Pre-ductal (right hand); normal SpO2 at 2 min = 60%, at 5 min = 80%, at 10 min = 90%
- Colour and tone: Clinical assessment
Bloods
- Cord blood gas: Arterial pH, base excess — assess degree of birth asphyxia
- FBC, blood glucose: After initial stabilisation
- Blood gas (capillary/arterial): Guide ongoing ventilation
Imaging
- CXR: If intubated (confirm ETT position), respiratory distress, suspected pneumothorax or diaphragmatic hernia
Special Tests
- aEEG: If suspected HIE — guide therapeutic hypothermia decision
Management
NLS Algorithm (Resuscitation Council UK)
- Birth: Dry, wrap, hat, start clock
- Assess: Tone, breathing, heart rate at 60 seconds
- If not breathing/gasping: Open airway (neutral position); 5 inflation breaths (30 cmH2O, 2-3 sec each)
- Reassess: If HR not increasing — check chest movement; reposition; consider 2-person jaw thrust, oropharyngeal airway
- If HR <60 after effective ventilation: Chest compressions 3:1 ratio at 120 events/min (90 compressions, 30 ventilations)
- If HR still <60: IV/IO adrenaline 10mcg/kg (0.1mL/kg of 1:10,000); consider IV fluids 10mL/kg
- Consider: Intubation, UVC access, volume replacement, treatable causes
Key Equipment and Sizes
- ETT: Term = 3.5mm; 34-38 weeks = 3.0mm; <34 weeks = 2.5mm
- Laryngoscope: Straight blade size 1 (term), size 0 (preterm)
- Suction: Max pressure 100 mmHg (150 for meconium)
Pharmacological
- Adrenaline: 10mcg/kg (0.1mL/kg of 1:10,000) via UVC or IO; 50-100mcg/kg via ETT if no IV
- Volume: 10mL/kg 0.9% NaCl or O-negative blood if hypovolaemia suspected
- Glucose 10%: 2.5mL/kg if hypoglycaemic
Post-Resuscitation Care
- Therapeutic hypothermia: For moderate-severe HIE — cool to 33.5°C for 72h; start within 6h of birth
- Monitoring: Continuous SpO2, HR; blood gas, glucose
- NICU admission: All babies requiring prolonged resuscitation
- Debrief: Family communication; documentation; team debrief
Prognosis
- Response to inflation breaths alone: ~90% of babies requiring resuscitation respond to effective ventilation
- Need for chest compressions: ~0.03% of deliveries; prognosis depends on cause and duration
- Therapeutic hypothermia for HIE: NNT 7 to prevent death or disability (TOBY trial)
- Severe HIE (Sarnat 3): ~30% mortality; ~70% of survivors have disability
- Moderate HIE (Sarnat 2) with cooling: ~50% have normal outcome; significantly improved with therapeutic hypothermia
Other Relevant Information
NLS Algorithm Summary
| Time | Action |
|---|---|
| Birth | Dry, wrap, hat, start clock |
| 30 sec | Assess tone, breathing, HR |
| 60 sec | If not breathing → 5 inflation breaths |
| 90 sec | Reassess — if HR not rising, optimise ventilation |
| 120 sec | If HR <60 → chest compressions (3:1) |
| Ongoing | Adrenaline if HR <60 despite ventilation + compressions |
Expected SpO2 After Birth (Pre-Ductal)
| Time | Target SpO2 |
|---|---|
| 2 min | 60% |
| 3 min | 70% |
| 5 min | 80% |
| 10 min | 90% |