What Are the Steps in Neonatal Resuscitation?

Neonatal resuscitation is used to revive a newborn who is not breathing or has other serious problems.

Neonatal resuscitation is a series of emergency procedures performed by a doctor to support newborn babies who are not breathing, are gasping or have a weak heartbeat at birth. These skills allow a doctor to save the lives of newborn babies.

The chances of a baby needing resuscitation are high in case of 

• Twins
• Preterm or small babies
• Mothers with infection or bleeding during pregnancy
• Prolonged labor

Globally, about one-quarter of all newborn deaths are caused by lack of oxygen (asphyxia) at birth, which can be prevented by effective and rapid resuscitation.

As the need for resuscitation is often unexpected, before every delivery a nurse will have on hand

• A warm labor room with good light sources to assess the baby
• Equipment
  • An Ambu bag with a baby-sized mask
  • Stethoscope
  • Clock 
  • Clean ties
  • Scissors
  • Clean towels 

The first 60 seconds after delivery are the most critical. The doctor will quickly assess and start resuscitation for the baby with

• Abnormal breathing or poor cry
• Floppy baby
• Blue or pale lips and tongue
• Low heart rate ( less than 100 beats/minute)

The doctor will follow the steps below and they will have about 30 seconds to achieve a response from one step before deciding on another intervention.

• Keeping the baby warm
  • Immediately after birth, the baby will be wrapped in a dry, warm towel and rubbed gently, which may stimulate some babies to breathe.
  • The baby’s back and soles of feet may be rubbed gently for five seconds to stimulate breathing.
  • The baby is dried with warmed towels or blankets to avoid lowering of body heat, which may cause complications including death, especially in small preterm babies.
• Clearing the airway
  • The doctor will clear the airway by sucking mouth secretions with a bulb syringe quickly within five seconds.
  • The doctor will remove thick meconium (if present) using a wide port tube.
• Clamping and cutting the cord: If the baby is breathing adequately, then the doctor will
  • Keep the baby at the same height as the placenta or below the placenta until the cord is clamped to enhance blood transfusion.
  • Clamp the cord approximately one to three minutes after birth to minimize anemia (low red blood cells in the blood).
  • Return the baby to the mother for skin-to-skin contact to keep the baby warm.
• Opening the airway for breathing: If the baby is still not breathing, to open the airways
  • They will be kept on a flat surface on their back.
  • Their head will be kept in a neutral position (parallel to the surface).
  • A two to three centimeter thick folded towel will be placed beneath their shoulders.
• Keeping the baby breathing: If the baby still does not breathe with a low heart rate (less than 100 beats/minute), then the doctor will
  • Place a mask over the baby’s mouth and nose, connecting it with an Ambu bag.
  • Provide five inflation breaths by slowly squeezing the bag.
  • Provide a two- to three-second long breath by counting out loud to allow accurate rhythm.
  • Inspect the baby’s chest movement.
  • Reassess the inflation and listen to the heart rate (normal is greater than 100 beats/minute) and check whether the baby is breathing.
  • Repeat the maneuver if the baby is still not responding or use jaw thrust alone by himself or with the help of another attendant to open the airway.
  • Return the baby to the mother for breastfeeding and skin-to-skin contact if the baby starts breathing.
  • Monitor the baby further for six hours.

           Infants who continuously have a heart rate higher than 100 beats/minute and adequate respiratory effort but who remain blue around the lips and tips should receive blow-by oxygen aided by oxygen tubing or a mask under expert guidance.

• Chest compression: Rarely, some babies may need chest compressions if the heart rate is absent or low (less than 60 beats/minute) and not responding to being resuscitated with an Ambu bag. Then the doctor will
  • Hold the baby’s chest with two hands while placing the thumbs below the nipples.
  • Press the baby’s chest with their thumbs quickly. Another method in smaller babies is using the index and middle fingers to gentle press over the breastbone.
  • Make sure there is time for the chest to recoil.
  • Provide three chest compressions to one breath with the help of an attendant.
  • Continue chest compression until the baby’s heart rate gets to normal.
  • Check for responses by listening to the baby's heart rate every 30 seconds to one minute and see chest movements with each breath, after each intervention.

In the majority of cases, the above steps are enough to save a baby. Even after this if there is no improvement, infants may require tracheal intubation if endotracheal (ET) administration of medications is desired, congenital diaphragmatic hernia is suspected or there is a prolonged need for assisted ventilation. Such measures are only done in a neonatal intensive care unit (NICU) supervised by an experienced doctor. These decisions should be made by the parents and clinician. Each country's guidelines vary as to when a doctor should stop resuscitation attempts (from 10 to 20 minutes after birth).