What are the guidelines for neonatal (newborn) resuscitation?

From the Guidelines

Newborn resuscitation should follow a systematic approach, prioritizing effective ventilation and using a 3:1 compression-to-ventilation ratio for chest compressions, as recommended by the 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.

Key Steps in Newborn Resuscitation

• Assess the newborn immediately after birth, focusing on breathing, heart rate, and tone.
• For a non-responsive newborn, start with warming, positioning, clearing the airway, drying, and stimulating.
• If the baby doesn't respond, begin positive pressure ventilation with a bag-mask device at a rate of 40-60 breaths per minute, ensuring proper mask seal and observing for chest rise.
• If the heart rate remains below 60 beats per minute despite effective ventilation for 30 seconds, begin chest compressions at a 3:1 ratio, delivering 90 compressions and 30 breaths per minute, as supported by the evidence from the 2020 international consensus 1 and the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Importance of Effective Ventilation

• Most newborns requiring resuscitation respond to proper airway management and ventilation alone, as the primary problem is typically respiratory rather than cardiac in nature.
• Effective resuscitation within the first minute of life ("the golden minute") significantly improves outcomes for compromised newborns.

Additional Interventions

• For persistent bradycardia, administer epinephrine at 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) intravenously or through an umbilical venous catheter.
• Volume expansion with normal saline at 10 mL/kg may be needed for suspected blood loss or poor response to resuscitation.

Continuous Reassessment and Adjustment

• Throughout the process, continuously reassess the baby's response and adjust interventions accordingly.

From the Research

Newborn Resuscitation Techniques

• The success of cardiopulmonary resuscitation (CPR) in newborns largely depends on effective lung ventilation 2.
• Ventilation using a mechanical ventilator seemed to provide the best approach during CPR, especially in a population of preterm infants prone to volutrauma 2.
• Manual inflation resuscitation devices can be classified into two types: flow generating (e.g., bag valve mask) and flow dependent (e.g., T-piece resuscitator) 3.

Devices Used in Newborn Resuscitation

• T-piece resuscitators have become the dominant device, particularly in high-income countries 3.
• The laryngeal mask airway (LMA) can achieve effective ventilation during neonatal resuscitation in a time frame consistent with current guidelines 4.
• LMA is more effective than bag-mask ventilation (BMV) in terms of shorter resuscitation and ventilation times, and less need for endotracheal intubation 4.

Positive Pressure Ventilation

• Positive pressure ventilation (PPV) is the most important procedure during neonatal resuscitation 5.
• PPV coaching during neonatal bag-mask ventilation can improve performance, resulting in more appropriate peak inspiratory pressures, lower tidal volumes, and less mask leak 5.
• Effective PPV is crucial, as two-thirds of continued neonatal respiratory depression after birth is caused by ineffective or improperly provided PPV 5.

Resuscitation Guidelines

• The International Liaison Committee on Resuscitation (ILCOR) provides guidelines for neonatal resuscitation, including the use of positive pressure ventilation and chest compressions 6.
• Personnel trained in basic resuscitation skills should be present at every delivery, and attention to ventilation should be the primary concern 6.
• Chest compressions should be provided if the heart rate is absent or remains less than 60 bpm despite adequate assisted ventilation for 30 s 6.