Position:

• Place head and neck in a neutral position avoiding neck flexion and head extension.

Suctioning:

• The vigorous newborn does not require suctioning unless born through meconium stained amniotic fluid and is showing signs of respiratory difficulty i.e. intercostal retraction. They usually clear their own airway very effectively.

• Newborns who are not vigorous at birth (not breathing and poor muscle tone) only require airway suctioning if born through meconium stained liquor.

• The mouth should be suctioned followed by the nose. The newborn is a nasal breather and may gasp pharyngeal fluid if the nose is cleared first.

• Intubation and suction of their trachea (if a person with the expertise to intubate is present) should follow where necessary in management of the non vigorous newborn.

• Pharyngeal suctioning can cause laryngospasm and bradycardia through vagal stimulation, thus suctioning must be gentle and brief (5 – 6 seconds) to avoid compromising the newborn further.

• A 10 or 12 FG catheter is the usual size for suctioning the newborn

Oropharyngeal Airway:
• size 00, 0
• Only use for airway obstruction or airway abnormalit
• Not recommended for routine use in newborns with a normal airway as it can cause obstruction and vagal reactions

Laryngoscope Blade:
• Straight Miller blade. Size 1 for term. Size 00 pre-term

LMA:
• Portex size 1 for baby >1500g
• Indicated for failed BVM and failed intubation

End Tidal CO2:

• An end tidal CO2 detector (Pedi- CapTM) is recommended to verify successful tracheal intubation in the newborn
• Paediatric EtCO2 is to be continuously monitored via the paediatric MRx attachment where available

• The majority of newborns needing resuscitation at birth are apnoeic and bradycardic but rarely asystolic. Hypoxia eventually depresses respiratory drive and causes bradycardia. Effective ventilation is the key to newborn resuscitation. Pulmonary pressure changes are integral in effecting necessary foetal circulation changes.

• Prompt improvement in HR >100 per minute (assessed using a stethoscope over the apex of the heart) is the primary indicator of adequate ventilation.

• Increased pressure may be required for initial breaths

Ventilation Rate:

• 40 to 60 per minute

Tidal Volume:

• 5 to 10 ml/kg initially with room air

• If HR remains <100 per minute after 30 seconds, supply high concentration oxygen

Ventilator Bag:

• Use a ~250 ml newborn self inflating bag

PEEP:

• Where available use 5 cm PEEP valve attached to BVM during IPPV • PEEP is important in improving lung volume and establishing and maintaining FRC

Chest Compressions:

• Chest compressions are rarely required unless the heart rate is below 60 beats per minute despite effective ventilation for at least 30 seconds.
• The first minute of resuscitation should not compromise airway techniques and ventilation where the HR < 100 per minute.
• If after one minute the HR remains < 60 per minute, compressions should be commenced.

CPR:

• 3 : 1 compression : ventilation ratio at 120 compressions per minute rate
• Achieve 90 compressions and 30 breaths per minute with 0.5 second pause in ventilation. There is no pause post intubation

Heart Rate:

• Reassess heart rate each 30 seconds until HR > 60 per minute where compressions may be ceased
• Continue IPPV/APPV until HR >100 per minute

Cardiac Monitor:

• Attaching electrodes for routine cardiac monitoring to pre-term babies may result in skin trauma due to its soft and fragile nature. ECG electrode attachment should be saved for the emergency resuscitation circumstance.

Pulse Oximeter:

• Where available, attach newborn oxygen saturation probe to right hand to allow continuous evaluation of heart rate and SpO2. This negates need to stop chest compressions to evaluate heart rate.

Compression Method:

• The 2 thumb method is preferred in the 2 rescuer setting
• The 2 finger alternative preferred in single rescuer situations to minimise transition time

Compression Depth:

• 1//3 depth of chest diameter