What is the resuscitation protocol for a full-term newborn with no cry and no respiration (apnea)?

Neonatal Resuscitation Protocol for Full-Term Newborn with No Cry and No Respiration

For a full-term newborn with no cry and no respiration (apnea), immediate initiation of positive pressure ventilation (PPV) within 60 seconds of birth is essential to prevent progression to circulatory collapse and death.

Initial Assessment and Steps (0-30 seconds)

1. Rapid evaluation:

   • Place infant on a warm, flat surface under radiant warmer
   • Position head in "sniffing" position to open airway
   • Quickly dry the infant to prevent hypothermia
   • Provide tactile stimulation (rubbing the back)

2. Airway assessment:

   • Clear secretions only if copious and/or obstructing the airway
   • Avoid blind finger sweeps of the pharynx 1
   • Assess breathing and heart rate simultaneously

Positive Pressure Ventilation (30-60 seconds)

1. If still apneic after initial steps:

   • Begin PPV immediately using a flow-inflating bag, self-inflating bag, or T-piece resuscitator 1
   • Use proper mask size covering mouth and nose with good seal
   • Initial ventilation rate: 40-60 breaths per minute 1
   • Initial inflation pressure: 20 cm H₂O (may require 30-40 cm H₂O if needed) 1
   • Consider PEEP of approximately 5 cm H₂O 1

2. Oxygen administration:

   • Begin resuscitation with room air (21% oxygen) for term infants 1
   • Use pulse oximetry to guide oxygen titration if available
   • If heart rate remains <60/min after 90 seconds despite ventilation with lower oxygen concentration, increase to 100% oxygen until recovery of normal heart rate 1

Reassessment (60-90 seconds)

1. Evaluate effectiveness of ventilation:

   • Primary indicator: Prompt improvement in heart rate
   • Secondary indicators: Chest movement, breath sounds, improving color
   • Heart rate should be >100/min within 30 seconds of effective ventilation 1

2. If heart rate remains <100/min despite PPV:

   • Check mask seal and reposition if needed
   • Consider increasing inflation pressure
   • Consider advanced airway management

Advanced Airway Management (if needed)

1. If face-mask ventilation is unsuccessful:

   • Consider laryngeal mask airway (LMA) as an alternative to endotracheal intubation 1, 2
   • LMA is recommended for term newborns when face-mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible 1

2. If ventilation remains inadequate:

   • Proceed to endotracheal intubation
   • Confirm tube placement using exhaled CO₂ detection 1

Chest Compressions (if needed)

1. If heart rate remains <60/min despite 30 seconds of effective ventilation:
   • Begin chest compressions while continuing ventilation
   • Compress lower third of sternum to depth of approximately one-third of anterior-posterior chest diameter 1
   • Use two thumb-encircling hands technique (preferred method) 1
   • Compression to ventilation ratio: 3:1 (90 compressions and 30 breaths per minute) 1
   • Increase oxygen to 100% during chest compressions 1

Medications (if needed)

1. If heart rate remains <60/min despite effective ventilation and chest compressions:
   • Consider epinephrine administration
   • Consider volume expansion if blood loss is suspected 1

Common Pitfalls and How to Avoid Them

• Delayed initiation of PPV: Research shows risk of death increases 16% for every 30-second delay in initiating ventilation 3. Begin PPV promptly within 60 seconds if infant remains apneic after initial steps.

• Ineffective ventilation: Ensure proper mask seal, appropriate head position, and adequate inflation pressure. Ventilation is the most critical step in neonatal resuscitation 1.

• Interruptions in ventilation: Studies show 56% of resuscitations have frequent interruptions with only 60% ventilation fraction during the first 30 seconds 4. Minimize interruptions for improved outcomes.

• Excessive oxygen: Avoid hyperoxemia by starting with room air for term infants and titrating oxygen based on response and pulse oximetry 1.

• Inappropriate progression: Do not proceed to chest compressions before ensuring effective ventilation, as most non-breathing newborns will respond to proper ventilation alone 1.

By following this protocol, you can provide effective resuscitation for a full-term newborn with no cry and no respiration, with the primary goal of establishing adequate ventilation to support the transition from intrauterine to extrauterine life.