What are the steps for a neonatal resuscitation programme in a newborn with respiratory distress and bradycardia?

Neonatal Resuscitation Programme for Respiratory Distress and Bradycardia

For a newborn with respiratory distress and bradycardia, immediately begin positive-pressure ventilation (PPV) at 40-60 breaths per minute with an initial pressure of 20 cm H₂O and PEEP of 5 cm H₂O, starting with room air (21% oxygen) for term infants, and if the heart rate remains <60 bpm after 30 seconds of adequate ventilation, escalate to chest compressions with 100% oxygen using a 3:1 compression-to-ventilation ratio. 1, 2, 3

Initial Assessment and Immediate Actions (The "Golden Minute")

Within 60 seconds of birth, rapidly assess three critical questions: 1, 3

• Is the baby term gestation?
• Does the baby have good muscle tone?
• Is the baby breathing or crying?

If any answer is "no" (which applies to your scenario with respiratory distress), immediately proceed to resuscitation under a radiant warmer. 2, 3

Initial Steps (Complete within 60 seconds):

• Provide warmth: Place infant under radiant heat source; for preterm infants <32 weeks, wrap in plastic up to neck level and maintain room temperature >25°C to achieve target temperature of 36.5-37.5°C 2
• Position airway: Place head in "sniffing" position 4, 2
• Clear secretions: Only if copious and obstructing—avoid routine nasopharyngeal suctioning as it causes bradycardia 2
• Dry thoroughly and remove wet linen 2
• Stimulate breathing through drying and gentle tactile stimulation 2

Critical pitfall: Do not perform routine endotracheal suctioning for meconium-stained fluid—this practice is no longer recommended. 4, 2

Heart Rate Assessment

The heart rate is the most sensitive indicator of successful resuscitation. 4 Use these methods in order of reliability:

1. 3-lead ECG (most rapid and accurate—reasonable to use) 4
2. Auscultation with stethoscope (most reliable clinical method) 5
3. Umbilical cord palpation (acceptable but less reliable—detects >100 bpm only 55% of the time in healthy newborns) 5
4. Avoid brachial/femoral pulses (unreliable—undetectable 60% and 45% of the time respectively in healthy newborns) 5

Attach pulse oximetry to the right hand/wrist (preductal location) before connecting to the instrument for fastest signal acquisition. 4 Target saturations: 60-65% at 1 minute, progressing to 85-95% by 10 minutes. 2

Positive-Pressure Ventilation Protocol

Begin PPV immediately if the infant has respiratory distress or heart rate <100 bpm. 4, 1, 3

Ventilation Parameters:

• Rate: 40-60 breaths per minute 4, 1
• Initial pressure: 20 cm H₂O (may require 30-40 cm H₂O in some term infants without spontaneous ventilation) 4, 2
• PEEP: Approximately 5 cm H₂O 4, 2
• Initial oxygen concentration:
  • Term/late-preterm infants: 21% (room air) 1, 2, 3
  • Preterm <35 weeks: 21-30% 4

Device Options (all equally effective):

• Flow-inflating bag 4, 2
• Self-inflating bag 4, 2
• T-piece resuscitator 4, 2

The primary measure of adequate ventilation is prompt improvement in heart rate, NOT chest rise. 4, 1 If heart rate does not improve, assess chest wall movement and adjust pressure accordingly. 4

Critical pitfall: Never delay PPV beyond 60 seconds to establish IV access or prepare for intubation. 1, 2

Escalation Algorithm for Persistent Bradycardia

After 30 Seconds of PPV:

Reassess heart rate and respirations simultaneously. 3

If heart rate remains <60 bpm despite adequate ventilation with chest rise:

1. Increase oxygen to 100% 4, 1
2. Verify ventilation is adequate (chest rise with each breath) 4
3. Begin chest compressions using two-thumb encircling hands technique 1, 2, 3

Critical pitfall: Never start chest compressions before achieving 30 seconds of effective ventilation with visible chest rise. 2, 3 Inadequate ventilation is the most common cause of persistent bradycardia. 4

Chest Compression Technique:

• Location: Lower third of sternum 2
• Depth: One-third of anterior-posterior diameter of chest 2, 3
• Ratio: 3:1 compression-to-ventilation (90 compressions:30 breaths = 120 events/minute) 1, 2, 3
• Method: Two-thumb encircling hands technique 1, 2, 3

After 60 Seconds of Chest Compressions and PPV with 100% Oxygen:

If heart rate remains <60 bpm, administer epinephrine:

• IV route (preferred): 0.01-0.03 mg/kg 2
• Endotracheal route (if IV not yet available): 0.05-0.1 mg/kg (less effective, requires higher dose) 2

Follow epinephrine with appropriate flush volume to ensure delivery. 6

Special Considerations for Meconium

If meconium-stained amniotic fluid is present and the infant has poor muscle tone and inadequate breathing, complete the initial steps under the radiant warmer and initiate PPV if needed—do NOT perform routine endotracheal intubation for tracheal suction. 4 This practice has been abandoned because there is insufficient evidence it reduces meconium aspiration syndrome or mortality. 4

Temperature Management

Maintain temperature between 36.5-37.5°C. 2 Both hypothermia and hyperthermia (>38°C) must be avoided. 4, 2 Hyperthermia is associated with increased risk of perinatal respiratory depression, neonatal seizures, cerebral palsy, and mortality. 4

For very low-birth-weight infants (<1500 g), use additional warming techniques: 4

• Prewarm delivery room to 26°C 4
• Cover baby in plastic wrapping (food or medical grade) 4
• Place on exothermic mattress 4
• Monitor temperature closely to avoid hyperthermia 4

Oxygen Titration Strategy

Start with room air (21% oxygen) for term infants and titrate based on pulse oximetry readings to match the interquartile range of healthy term infants. 4 Two meta-analyses demonstrated increased survival when resuscitation was initiated with room air versus 100% oxygen. 4

If the baby remains bradycardic (HR <60 bpm) after 90 seconds of resuscitation with lower oxygen concentration, increase to 100% oxygen until heart rate recovers. 4

For preterm infants <35 weeks, initiate resuscitation with 21-30% oxygen and titrate to target saturations—do NOT start with high oxygen (≥65%). 4

Common Pitfalls to Avoid

• Never rely solely on chest rise as an indicator of effective ventilation—heart rate response is the primary measure 1, 2
• Never start with 100% oxygen in term infants—begin with room air and titrate 1, 2
• Never delay ventilation to establish IV access or prepare for intubation 1, 2
• Never use bicarbonate in the delivery room during acute resuscitation 2
• Never neglect temperature management in preterm infants—hypothermia significantly worsens outcomes 1

Endotracheal Tube Confirmation

If intubation is performed, confirm tube placement using exhaled CO₂ detection (most reliable method). 4 A positive result (CO₂ detected) confirms tracheal placement in patients with adequate cardiac output, while a negative result strongly suggests esophageal intubation. 4 However, be aware that poor pulmonary blood flow may give false-negative results despite correct tracheal placement. 4

Duration of Resuscitation

If there has been no detectable heart rate for 10 minutes despite adequate resuscitation, it is appropriate to consider discontinuing resuscitation. 2 Infants without signs of life after 10 minutes show either high mortality or severe neurodevelopmental disability. 7