1. Neonatal Resuscitation Program Slide Presentation Kit
Lesson 2:
INITIAL STEPS IN RESUSCITATION
Neonatal Resuscitation Program Slide Presentation Kit

2. Initial Steps Lesson content: Decide if resuscitation is needed
Open airway and provide initial steps
Manage if meconium present
Provide free-flow oxygen when needed
In Lesson 2 you will learn how to
Lesson 2 presents the initial steps in resuscitation.
Decide if a newborn needs to be resuscitated.
Open the airway, and provide the initial steps of resuscitation.
Resuscitate a newborn when meconium is present.
Provide free-flow oxygen when needed.

3. Evaluating the Newborn
Immediately after birth, the following questions must be asked:
If the answer to all of the initial questions is “Yes,” and the newborn is term, the newborn may receive routine care to continue transition. If the answer to any one of these questions is “No,” the newborn will require some form of resuscitation.
Instructor Tip: Assess these criteria simultaneously. The decision to provide routine care or proceed with initial steps takes only a few seconds.

4. Initial Steps Provide warmth Position; clear airway (as necessary)
Dry, stimulate, reposition
If the newborn is term and vigorous, the initial steps, such as thermoregulation and clearing the upper airway, may be provided in modified form, as described in Lesson 1.
Babies born preterm are more likely to have difficulty with transition and should be evaluated carefully under a radiant warmer while the initial steps are performed.

5. Initial Steps: Meconium Present
Newborn is not vigorous: Suction the baby’s trachea before proceeding with any other steps
Newborn is vigorous: Suction the mouth and nose only, and proceed with resuscitation as required 
“Vigorous” is defined as a newborn who has strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute.
If meconium is present and the newborn is not vigorous, suction the baby’s trachea before proceeding with any other steps. If the baby is vigorous, suction the mouth and nose only, and proceed with resuscitation as required.

6. Provide Warmth Prevent heat loss by
Placing newborn under radiant warmer
Drying thoroughly
Removing wet towels
Prevention of heat loss is critical during resuscitation.
Place the newborn in a preheated overhead radiant warmer. It is important to preheat the radiant warmer so that the newborn is placed on a warm mattress.
Instructor Tip: Do not pre-warm blankets or towels by placing them on top of the warmer, because of the risk of fire. Put the newborn’s head at the foot of the warmer for easy access to the airway.
Quickly dry the newborn with a warm towel to remove amniotic fluid and prevent evaporative heat loss. This act of drying also provides gentle stimulation, which may initiate or help maintain breathing. The exception is when meconium is present in the trachea. Then it is preferable to delay stimulation that may be caused by drying until the meconium has been suctioned from the trachea.
It is imperative to remember to remove wet towels. Don’t block the radiant heat with towels, blankets, or team members’ heads or upper bodies.
Very preterm newborns may require placement, below the neck, in a food-grade plastic reclosable bag without drying to prevent heat loss. (See Lesson 8.)
A pre-warmed overhead radiant warmer minimizes radiant heat loss and allows access to, and visualization of, the newborn.

7. Opening the Airway Open the airway by positioning the
newborn in a “sniffing” position
Positioning on back or side, slightly extending neck
“Sniffing” position aligns posterior pharynx, larynx, and trachea 
Once the newborn has been placed under a preheated radiant warmer and dried, the next step is to ensure “A” of the ABCs—establishment of an open airway. Correct positioning of the newborn will bring the posterior pharynx, larynx, and trachea in line, which will facilitate unrestricted air entry.
Instructor Tip: Although positioning before suctioning is suggested, if meconium is not present, you may position the newborn before or after suctioning. The important point is that opening the airway consists of both suctioning and positioning.

8. Opening the Airway
The newborn should be placed on his or her back, with the neck slightly extended.
Care should be taken to prevent hyperextension or flexion of the neck, since either may decrease air entry.
To help maintain correct position, you may place a rolled blanket or towel under the shoulders, elevating them three fourths of an inch to 1 inch off the mattress. This roll may be particularly useful if the newborn has a large occiput.
Correct positioning allows an open airway to be maintained. In addition, the newborn will be in the optimal position if assisted ventilation becomes necessary.

9. Management of Meconium
After delivery, the appropriate method for clearing the airway further will depend on
The presence of meconium
The baby’s level of activity
Studies have shown that direct suctioning of the trachea should be performed only if a meconium-stained newborn has depressed respirations, depressed muscle tone, and/or a heart rate less than 100 beats per minute.
Instructor Tip: No clinical studies warrant basing tracheal suctioning guidelines on meconium consistency.

10. Meconium Present and Newborn VigorousIf
Respiratory effort strong, and
Muscle tone good, and
Heart rate greater than 100 beats per minute (bpm)
Then
Use bulb syringe or large-bore suction catheter to clear mouth and nose 
A vigorous newborn is defined as one who has strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute. Then simply use a bulb syringe or large-bore suction catheter (12F or 14F) to clear secretions and any meconium from the mouth and nose. When you suction, particularly when using a catheter, be careful not to suction vigorously or deeply. Stimulation of the posterior pharynx during the first few minutes after birth can produce a vagal response that causes severe bradycardia or apnea.
Instructor Tip: Routine gastric suction is unnecessary and invasive.

11. Meconium Present and Newborn Not Vigorous
Tracheal Suction
Administer oxygen, monitor heart rate
Insert laryngoscope, use 12F or 14F suction catheter to clear mouth
Insert endotracheal tube into trachea
Attach endotracheal tube to suction source
Apply suction as tube is withdrawn
Repeat as necessary
If the newborn has depressed respirations, depressed muscle tone, and/or a heart rate less than 100 beats per minute, direct suctioning of the trachea soon after delivery is indicated before many spontaneous respirations or assisted ventilation has occurred.
The procedure for suctioning should be repeated as necessary until little additional meconium is recovered, or until the newborn’s heart rate indicates that resuscitation must proceed without delay.

12. Suctioning Meconium Click on the image to play video
Visualizing the glottis and suctioning meconium from the trachea using a laryngoscope and endotracheal tube are demonstrated in this video. Lesson 5 provides details on endotracheal intubation. When using suction from the wall or from a pump, the suction pressure should be set so that, when the suction tubing is blocked, the negative pressure (vacuum) reads approximately 100 mm Hg. Monitor heart rate during this procedure.
Click on the image to play video

13. Clear Airway: No Meconium Present
Suction mouth first, then nose
“M” before “N”
If no meconium is present, simply suction the mouth, then nose, with a bulb syringe. The mouth is suctioned before the nose to ensure that there is nothing for the newborn to aspirate if he or she should gasp when the nose is suctioned. If the newborn has copious secretions coming from the mouth, turn the head to the side so that secretions will collect in the cheek and be easily removed.
Click on the image to play video

14. Dry, Stimulate to Breathe, Reposition
Often, positioning the newborn and suctioning secretions will provide enough stimulation to initiate breathing. Drying also will provide stimulation. Drying the body and head also will help to prevent heat loss. While drying the baby, keep the head in the “sniffing” position to maintain a good airway. As part of preparation for resuscitation, several pre-warmed absorbent towels or blankets should be available.
Instructor Tip: Towels are often more absorbent than blankets. Handle a limp baby carefully. Without protective muscle tone, the baby can be injured if moved roughly or carelessly.
Click on the image to play video

15. Tactile Stimulation  Click on the image to play video
If, after drying and repositioning, the newborn does not have adequate respirations, additional tactile stimulation may be provided briefly to stimulate breathing. Safe and appropriate methods of providing additional tactile stimulation include
Slapping or flicking the soles of the feet
Gently rubbing the back, trunk, or extremities 
Click on the image to play video

16. Potentially Hazardous Forms of Stimulation
Slapping back or buttocks
Squeezing rib cage
Forcing thighs onto abdomen
Dilating anal sphincter
Hot or cold compresses or baths
Shaking
Overly vigorous stimulation is not helpful and can cause serious injury. The forms of stimulation listed in this slide may cause bruising, fractures, tearing of internal organs, brain damage, or other consequences.
If a baby is in primary apnea, almost any gentle stimulation will initiate breathing. If a baby is in secondary apnea, no amount of stimulation will work.

17. Evaluation: Respirations, Heart Rate, Color
Decisions and actions during newborn resuscitation are based on Respirations, Heart Rate, and Color
Evaluate vital signs to determine if further resuscitation is necessary.
Respirations: good chest movement with adequate rate and depth of respirations. (Gasping is ineffective.)
Heart rate: should be >100 bpm. Count beats in 6 seconds (eg, 7 beats), multiply by 10 (equals 70 bpm), and announce the actual heart rate.
Color: pink lips and pink trunk. (Central cyanosis indicates hypoxemia.)
Instructor Tip: Feel the umbilical pulse at every delivery so that you are skilled at this procedure. If you cannot palpate the pulse, use a stethoscope. 
Click on the image to play video

18. Central Cyanosis and Acrocyanosis
Central cyanosis is caused by too little oxygen in the blood and causes a blue hue to the lips, tongue, and central trunk. Acrocyanosis is a blue hue to the hands and feet. Only central cyanosis requires intervention.
Instructor Tip: Even babies who will eventually become heavily pigmented will appear “pink” when adequately oxygenated after birth.
The issue of resuscitation with room air versus supplemental oxygen is further discussed in Lessons 3 and 8.

19. Free-flow Oxygen  Free-flow oxygen is indicated for central cyanosis
Free-flow oxygen cannot be given reliably by a mask attached to a self-inflating bag
Flow-inflating bag and mask
Oxygen tubing
Oxygen mask
Deprivation of oxygen to vital tissues is one of the primary reasons for the clinical consequences associated with perinatal compromise. Free-flow oxygen refers to blowing oxygen over the newborn’s nose so that the newborn breathes oxygen-enriched air.
For a brief time, free-flow oxygen can be given using one of the following methods:
Flow-inflating bag and mask
Oxygen tubing
Oxygen mask
Free-flow oxygen CANNOT be given reliably by a mask attached to a self-inflating bag. Wall or portable oxygen sources send 100% oxygen through the tubing. As oxygen flows out of the tubing or mask, it mixes with room air, which contains only 21% oxygen. The concentration of oxygen that reaches the newborn’s nose is determined by the amount of 100% oxygen coming from the tube or mask (usually at least 5 L/min) and the amount of room air it must pass through to reach the newborn. Therefore, it is important to have the oxygen mask or tube very close to the newborn’s nose to provide the highest possible concentration of oxygen. 

20. Delivering Free-flow Oxygen
Heated and humidified (if given for longer than few minutes)
Flow rate at approximately 5 L/min
Enough oxygen for newborn to become pink
To prevent heat loss and drying of the respiratory mucosa, oxygen given to a newborn for long periods should be heated and humidified. High flow rates of oxygen (greater than 10 L/min) can cause convective heat loss and chill the newborn. Once a newborn becomes pink and vital signs are normal, the oxygen should be gradually withdrawn until the newborn remains pink while breathing room air. Newborns who become cyanotic as oxygen is withdrawn should continue to receive enough oxygen to remain pink.

21. Evaluation: Persistent Cyanosis, Apnea, or Heart Rate <100
Continued use of tactile stimulation in an apneic newborn wastes valuable time. For persistent apnea, begin positive-pressure ventilation promptly
Continuing to administer free-flow oxygen or providing tactile stimulation to a nonbreathing or gasping newborn or baby whose heart rate remains <100 bpm is of little or no value and delays appropriate treatment. If cyanosis persists despite supplemental oxygen, a trial of positive-pressure ventilation is indicated. The entire process to this point should have taken no more than 30 seconds (or perhaps somewhat longer if suctioning of meconium from the trachea was required). 

22. End of Lesson 2

23. Free-Flow Oxygen Given Via Flow-Inflating Bag and Mask

24. Free-Flow Oxygen Given Via Oxygen Tubing

25. Free–Flow Oxygen Given Via Oxygen Mask
2-19C