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NEONATAL RESUSCITATION PROTOCOL
The following protocol is that which is suggested by the American Heart Association/American
Academy of Pediatrics.
BIRTH
0sec
Clear of meconium?
Breathing or crying?
Good muscle tone?
Colour pink?
Term gestation?
YES
Routine care:
Provide warmth
Clear airway
Dry
NO
Provide warmth
Position, clear airway
Dry, stimulate, reposition
Give O2 as necessary
30sec
Breathing, pink
HR> 100
Evaluate respirations,
heart rate and colour
Supportive care
Apnoea or
HR < 100
Ventilating, pink
HR> 100
Provide positive
pressure ventilation
HR<60
60sec
HR>60
Positive pressure ventilation
and chest compressions
90sec
HR<60
HR>60
Administer adrenaline
Supportive care
A summary of this protocol with applicable timelines is:
 The initial steps include assessment of the overall condition of the neonate and
minimizing heat loss
 Within the first 20sec after birth, the neonate must be dried, placed under a warmer
and suctioned(mouth and nose)
 Within the first 30sec after birth, respiration is assessed and any problem treated
 Within the first minute of birth, the neonatal heart rate is assessed
Let us have a short look at these points in turn.
 The emphasis on minimizing heat loss is because cold stress in the neonate
results in hypoxemia, hypercarbia and metabolic acidosis, all of which hinder
resuscitation by promoting the persistence of the fetal circulation. This is
compounded in the depressed, asphyxiated neonate due to their unstable
thermoregulatory systems.
 On respiratory assessment, the response to a gasping or apneic neonate
should be positive pressure mask ventilation (PPMV)at 40-60 breaths per
minute with 100% oxygen. Most neonates will respond to these first 2 steps.
Be aware that it is often necessary to decompress the stomach after PPMV
by inserting an oro/nasogastric tube. Failure to do this may result in splinting
of the diaphragm, hypoventilation and hypoxemia.
 Indications for endotracheal intubation are ineffective bag-mask ventilation,
anticipating the need for prolonged mechanical ventilation and as a route for
administering emergency medications!
 It is interesting to note that the LMA has been successfully used in a number
of clinical trials involving neonatal resuscitation. Time for insertion was
generally less than 10sec, audible leaks occurred at ± 22cmH2O. Positive
pressure ventilation was easily managed without gastric distension. This
might be a good accessory airway to keep in reserve, especially for a difficult
neonatal airway, eg Pierre-Robin syndrome.
 It is important to note that it is no longer recommended that the presence of
meconium requires routine intubation and suction. Tracheal suctioning is
now only recommended if there is meconium AND the baby is not vigorous.
 Chest compressions are only done AFTER at least 30sec of PPMV and the
heart rate remains below 60. Chest compressions are done at a rate of 90
per min and should be stopped when the heart rate is above 60. The
compression-ventilation ratio should be 3:1 (ie 90:30 per min), applied to the
lower ⅓ of the sternum and producing a compression depth of about a ⅓ of
the AP diameter.
 NB! The resuscitation should not be stopped to do an Apgar evaluation.
 Medications must be considered if the heart rate remains below 60 after
30sec of effective compressions with adequate ventilation with 100% O 2.
MEDICATIONS
OXYGEN must be regarded as a drug, with its own side-effects. In the scenario of
resuscitation of the newborn, it is acceptable to use 100% O 2 for a short period, but this must
not be continued as a maintenance drug. Even short exposures to 100% O 2 may result in the
formation of highly toxic free radicals, resulting in pulmonary and retinal damage.
NALOXONE is indicated specifically for respiratory depression due to maternal opioids, but
not in the case of a narcotic-addicted mother.
ATROPINE is generally not indicated in neonatal resuscitation, because bradycardia in the
newborn is almost always related to hypoxia and not vagal stimulation.
SODIUM BICARBONATE should only be given if the neonate is being adequately ventilated
AND documented or presumed metabolic acidosis does not respond to other measures,
otherwise respiratory acidosis will replace metabolic acidosis.
VOLUME EXPANDERS are rarely indicated in neonatal resuscitation. They are specifically
used where there is acute blood loss with signs of shock. They may be detrimental in other
scenarios.
DEXTROSE should be remembered as a drug if the neonate is lethargic at birth without an
obvious cause. Approximately 10% of healthy term neonates may experience transient
hypoglycaemia, more especially in the diabetic mother, the mother who received dextrose
infusions in labour, macrosomic babies and neonates who are pre- or post-term.
Medications can be given via peripheral veins, umbilical veins or via the ET tube.
ENDOTRACHEAL MEDICATIONS
The following drugs may be given endotracheally and can easily be remembered with the
acronym LANE:
Lignocaine
Atropine
Naloxone
Epinephrine(Adrenaline)
NB! Effects of endotracheal adrenaline are delayed by about a minute as compared to
intravenous administration. Unlike the recommendations in pediatric resuscitation, where up
to 3x the intravenous dose is administered endotracheally, in the neonate THE SAME DOSE
IS GIVEN INTRAVENOUSLY OR ENDOTRACHEALLY (0.01mg/kg). This is to prevent the
devastating complication of an intracranial haemorrhage associated with adrenaline-induced
hypertension.
MEDICATION
Adrenaline
Naloxone
Sodium
bicarbonate
Dopamine
Volume
expanders
CONCENTRATION
1:10 000 (1 ampoule
diluted to 10ml)
0.4mg/ml
4.2% solution
(0.5mEq/ml)
200mg in 200ml N/S
=1mg/ml =1000µg/ml
O-negative blood or
normal saline
DOSAGE/ROUTE
0.1-0.3ml of the diluted solution
per kg, IV or via ET tube
0.1mg/kg IV or via ET tube
2mEq/kg (4ml/kg) IV and
ensure effective ventilation
2-20µg/kg/min IV
10ml/kg IV
RATE
Give rapidly and
flush with saline
Give rapidly
Give slowly, at
least over 2min
Give as a titrated
infusion