What is the initial protocol for newborn resuscitation?

Initial Protocol for Newborn Resuscitation

The initial protocol for newborn resuscitation should begin with maintaining normal temperature, assessing breathing and heart rate, and initiating positive pressure ventilation with room air (21% oxygen) if the infant is not breathing adequately or has a heart rate <100 beats per minute. 1, 2

Initial Assessment and Stabilization

• Thermal Management: Maintain normal temperature (36.5-37.5°C) by drying the infant, removing wet linens, and placing under a radiant warmer 1
• Positioning: Place infant in "sniffing position" to open airway
• Assessment: Evaluate breathing, heart rate, and tone
• Stimulation: Provide tactile stimulation by rubbing the back or soles of feet if breathing is inadequate

Ventilation Protocol

If the infant remains apneic, gasping, or has a heart rate <100/min after initial steps:

1. Begin positive pressure ventilation (PPV) within the "Golden Minute" (first 60 seconds of life) 1

   • Use appropriate device (flow-inflating bag, self-inflating bag, or T-piece resuscitator)
   • Initial inflation pressure of 20 cm H₂O, may require 30-40 cm H₂O in some cases 2
   • Ventilation rate of 40-60 breaths per minute 2

2. Oxygen Administration:

   • For term and late-preterm newborns (≥35 weeks): Begin with 21% oxygen (room air) 2
   • For preterm newborns (<35 weeks): Begin with 21-30% oxygen 2
   • Do not initiate resuscitation with 100% oxygen as it is associated with excess mortality 2
   • Titrate oxygen based on preductal SpO₂ targets:
     • 60-65% at 1 min
     • 65-70% at 2 min
     • 70-75% at 3 min
     • 75-80% at 4 min
     • 80-85% at 5 min
     • 85-95% at 10 min 1

3. Assess Effectiveness:

   • Primary indicator of adequate ventilation is prompt improvement in heart rate 2
   • Observe for chest movement if heart rate does not improve 2
   • Minimize interruptions in ventilation - studies show only 60% ventilation fraction during first 30 seconds of PPV in many cases 3

Chest Compressions

If heart rate remains <60/min after 30 seconds of effective ventilation:

1. Begin chest compressions at lower third of sternum
2. Use two-thumb, hands-encircling-the-chest method (preferred technique) 2
3. Compression depth of one-third AP diameter of chest
4. Use 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths per minute) 2, 1
5. Increase oxygen to 100% if bradycardia persists 2

Medication Administration

If heart rate remains <60/min despite effective ventilation and chest compressions:

1. Establish vascular access (umbilical vein preferred, intraosseous as alternative)
2. Administer epinephrine (1:10,000 concentration):
   • Dose: 0.01-0.03 mg/kg (0.1-0.3 mL/kg)
   • Route: IV preferred; may give via endotracheal tube if IV access not available 1
3. Consider volume expansion (10 mL/kg) for suspected blood loss or signs of shock 1

Special Considerations

• Laryngeal Mask Airway (LMA): Consider as an alternative when bag-mask ventilation is ineffective or intubation attempts fail 4
• PEEP: Consider using PEEP of approximately 5 cm H₂O, particularly for preterm infants 1
• Exhaled CO₂ detection: Useful for confirming endotracheal tube placement 2

Common Pitfalls to Avoid

1. Delayed initiation of ventilation beyond the "Golden Minute" - this is the most critical step for successful resuscitation 1
2. Using 100% oxygen initially - associated with increased mortality compared to room air 5, 2
3. Frequent interruptions in ventilation - maintain continuous ventilation efforts 3
4. Poor mask seal - ensure proper fit to achieve effective ventilation 1
5. Inadequate ventilation pressure - adjust based on chest rise and heart rate response 2
6. Failure to reassess - continuously monitor heart rate, breathing, and oxygen saturation 1

Remember that most compromised newborns will respond to effective ventilation alone, and chest compressions and medications are rarely needed when ventilation is performed correctly.