Key Points for Lessons 1 Through 9 in
Textbook of Neonatal Resuscitation, 5th Edition
Key Points - Lesson 1
1. Most newly born babies are vigorous. Only about 10% require some kind of assistance and only 1% need
major resuscitative measures (intubation, chest compressions, and/or medications) to survive.
2. The most important and effective action in neonatal resuscitation is to ventilate the baby’s lungs.
3. Lack of ventilation of the newborn’s lungs results in sustained constriction of the pulmonary arterioles,
preventing systemic arterial blood from becoming oxygenated. Prolonged lack of adequate perfusion and
oxygenation to the baby’s organs can lead to brain damage, damage to other organs, or death.
4. When a fetus/newborn first becomes deprived of oxygen, an initial period of attempted rapid breathing is
followed by primary apnea and dropping heart rate that will improve with tactile stimulation. If oxygen
deprivation continues, secondary apnea ensues, accompanied by a continued fall in heart rate and blood
pressure. Secondary apnea cannot be reversed with stimulation; assisted ventilation must be provided.
5. Initiation of effective positive-pressure ventilation during secondary apnea usually results in a rapid
improvement in heart rate.
6. The majority of, but not all, neonatal resuscitations can be anticipated by identifying the presence of
antepartum and intrapartum risk factors associated with the need for neonatal resuscitation.
7. All newborns require initial assessment to determine whether resuscitation is required.
8. Every birth should be attended by at least 1 person whose only responsibility is the baby and who is capable of
initiating resuscitation. Either that person or someone else who is immediately available should have the skills
required to perform a complete resuscitation. When resuscitation is anticipated, additional personnel should
be present in the delivery room before the delivery occurs.
9. Resuscitation should proceed rapidly.
? You have approximately 30 seconds to achieve a response from one step before deciding whether you
need to go on to the next.
? Evaluation and decision making are based primarily on respirations, heart rate, and color.
10. The steps of neonatal resuscitation are as follows:
A. Initial steps
? Provide warmth.
? Position head and clear airway as necessary.*
? Dry and stimulate the baby to breathe.
? Evaluate respirations, heart rate, and color.
B. Provide positive-pressure ventilation with a resuscitation bag and supplemental oxygen.*
C. Provide chest compressions as you continue assisted ventilation.*
D. Administer epinephrine as you continue assisted ventilation and chest compressions.*
*Consider intubation of the trachea at these points.
Key Points - Lesson 2
1. If meconium is present and the newborn is not vigorous, suction the baby’s trachea before proceeding with
any other steps. If the newborn is vigorous, suction the mouth and nose only, and proceed with resuscitation as
2. ―Vigorous‖ is defined as a newborn who has strong respiratory efforts, good muscle tone, and a heart rate
greater than 100 beats per minute.
3. Open the airway by positioning the newborn in a ―sniffing‖ position. 4. Appropriate forms of tactile stimulation are
? Slapping or flicking the soles of the feet
? Gently rubbing the back
5. Continued use of tactile stimulation in an apneic newborn wastes valuable time. For persistent apnea, begin
positive-pressure ventilation promptly.
6. Free-flow oxygen is indicated for central cyanosis. Acceptable methods for administering free-flow oxygen
? Oxygen mask held firmly over the baby’s face
? Mask from the flow-inflating bag or T-piece resuscitator held closely over the baby’s mouth and nose
? Oxygen tubing cupped closely over the baby’s mouth and nose
7. Free-flow oxygen cannot be given reliably by a mask attached to a self-inflating bag.
8. Decisions and actions during newborn resuscitation are based on the newborn’s
• Respirations • Heart rate • Color
9. Determine a newborn’s heart rate by counting how many beats are in 6 seconds, then multiply by 10. For
example, if you count 8 beats in 6 seconds, announce the baby’s heart rate as 80 beats per minute.
Key Points - Lesson 3
1. Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation
of the compromised infant.
2. Indications for positive-pressure ventilation are
? Heart rate less than 100 beats per minute even if breathing
? Persistent central cyanosis despite 100% free-flow oxygen
3. Self-inflating bags
? Fill spontaneously after they are squeezed, pulling oxygen or air into the bag
? Remain inflated at all times
? Must have a tight face-mask seal to inflate the lungs
? Can deliver positive-pressure ventilation without a compressed gas source; user must be certain the
bag is connected to an oxygen source for the purpose of neonatal resuscitation
? Require attachment of an oxygen reservoir to deliver 90% to 100% oxygen
? Cannot be used to administer free-flow oxygen reliably through the mask
4. Flow-inflating bags
? Fill only when gas from a compressed source flows into them
? Depend on a compressed gas source
? Must have a tight face-mask seal to inflate
? Use a flow-control valve to regulate pressure/ inflation
? Look like a deflated balloon when not in use
? Can be used to administer free-flow oxygen 5. The flow-inflating bag will not work if
? The mask is not properly sealed over the newborn’s nose and mouth.
? There is a hole in the bag.
? The flow-control valve is open too far.
? The pressure gauge is missing or the port is not occluded.
6. T-piece resuscitators
? Depend on a compressed gas source.
? Must have a tight face-mask seal to inflate the lungs.
? Operator sets maximum circuit pressure, peak inspiratory pressure, and positive end-expiratory
? Peak inspiratory pressure must be adjusted during resuscitation to achieve physiologic improvement,
audible breath sounds, and perceptible chest movements.
? Positive pressure is provided by alternately occluding and releasing the hole in the PEEP cap.
? Can be used to deliver free-flow oxygen.
7. Every resuscitation bag must have
? A pressure release (pop-off) valve
? A pressure gauge and a flow-control valve
8. An oxygen reservoir must be attached to deliver high concentrations of oxygen using a self inflating bag.
Without the reservoir, the bag delivers only about 40% oxygen, which may be insufficient for neonatal
9. If there is no physiologic improvement and no perceptible chest expansion during assisted ventilation,
? Reapply mask to face using light downward pressure and lifting the mandible up toward the mask.
? Reposition the head.
? Check for secretions; suction mouth and nose.
? Ventilate with the baby’s mouth slightly open.
? Increase pressure of ventilations.
? Recheck or replace the resuscitation bag.
? After reasonable attempts fail, intubate the baby.
10. Improvement during positive-pressure ventilation with a mask is indicated by a rapid increase in heart rate
and subsequent improvement in
? Color and oxygen saturation
? Muscle tone
? Spontaneous breathing
11. Current evidence is insufficient to resolve all questions regarding supplemental oxygen use for
positive-pressure ventilation during neonatal resuscitation.
? The Neonatal Resuscitation Program recommends use of 100% supplemental oxygen when
positive-pressure ventilation is required during neonatal resuscitation.
? However, research suggests that resuscitation with something less than 100% may be just as
? If resuscitation is started with room air, supplemental oxygen, up to 100%, should be administered if
there is no appreciable improvement within 90 seconds following birth.
? If supplemental oxygen is unavailable, use room air to deliver positive-pressure ventilation.
Key Points - Lesson 4
1. Chest compressions are indicated when the heart rate remains less than 60 beats per minute despite 30 seconds
of effective positive-pressure ventilation.
2. Chest compressions
? Compress the heart against the spine.
? Increase intrathoracic pressure.
? Circulate blood to the vital organs, including the brain.
3. There are 2 acceptable techniques for chest compressions—the thumb technique and the 2-finger
technique—but the thumb technique usually is preferred. 4. Locate the correct area for compressions by running your fingers along the lower edge of the rib cage until you
locate the xyphoid. Then place your thumbs or fingers on the sternum, above the xyphoid and on a line
connecting the nipples.
5. To ensure proper rate of chest compressions and ventilation, the compressor repeats
6. During chest compressions, the breathing rate is 30 breaths per minute and the compression rate is 90
compressions per minute. This equals 120 ―events‖ per minute. One cycle of 3 compressions and 1 breath
takes 2 seconds.
7. During chest compressions, ensure that
? Chest movement is adequate during ventilation.
? Supplemental oxygen is being used.
? Compression depth is one third the diameter of the chest.
? Pressure is released fully to permit chest recoil during relaxation phase of chest compression.
? Thumbs or fingers remain in contact with the chest at all times.
? Chest compressions and ventilation are well coordinated. ? Duration of the downward stroke of the compression is shorter than duration of the release.
8. After 30 seconds of chest compressions and ventilation, check the heart rate. If the heart rate is
? Greater than 60 beats per minute, discontinue compressions and continue ventilation at 40 to 60
breaths per minute.
? Greater than 100 beats per minute, discontinue compressions, and gradually discontinue ventilation if
the newborn is breathing spontaneously.
? Less than 60 beats per minute, intubate the newborn, if not already done, and give epinephrine.
Intubation provides a more reliable method of continuing ventilation.
Key Points - Lesson 5
1. A person experienced in endotracheal intubation should be available to assist at every delivery.
2. Indications for endotracheal intubation include the following:
? To suction trachea in presence of meconium when the newborn is not vigorous
? To improve efficacy of ventilation after several minutes of bag-and-mask ventilation or ineffective
? To facilitate coordination of chest compressions and ventilation and to maximize the efficiency of each
? To administer epinephrine if required to stimulate the heart while intravenous access is being
3. The laryngoscope is always held in the operator’s left hand.
4. The correct-sized laryngoscope blade for a term newborn is No. 1. The correct-sized blade for a preterm
newborn is No. 0.
5. Choice of proper endotracheal tube size is based on weight.
Tube size (mm) Weight Gestational Age (Inside (g) (wks) diameter)
2.5 Below 1,000 Below 28 3.0 1,000–2,000 28–34 3.5 2,000–3,000 34–38 3.5–4.0 Above 3,000 Above 38 6. The intubation procedure ideally should be completed within 20 seconds.
7. The steps for intubating a newborn are as follows:
? Stabilize the newborn’s head in the ―sniffing‖ position. Deliver free-flow oxygen during the
? Slide the laryngoscope over the right side of the tongue, pushing the tongue to the left side of the mouth,
and advancing the blade until the tip lies just beyond the base of the tongue.
? Lift the blade slightly. Raise the entire blade, not just the tip.
? Look for landmarks. Vocal cords should appear as vertical stripes on each side of the glottis or as an
inverted letter ―V‖.
? Suction, if necessary, for visualization.
? Insert the tube into the right side of the mouth with the curve of the tube lying in the horizontal plane.
? If the cords are closed, wait for them to open. Insert the tip of the endotracheal tube until the vocal cord ? Hold the tube firmly against the baby’s palate while removing the laryngoscope. Hold the tube in place guide is at the level of the cords. while removing the stylet if one was used.
8. Correct placement of the endotracheal tube is indicated by
? Improved vital signs (heart rate, color, activity)
? Presence of exhaled CO2 as determined by a CO2 detector
? Breath sounds over both lung fields but decreased or absent over the stomach
? No gastric distention with ventilation
? Vapor in the tube during exhalation
? Chest movement with each breath
? Tip-to-lip measurement: add 6 to newborn’s weight in kilograms
? Chest x-ray confirmation if the tube is to remain in place past initial resuscitation
? Direct visualization of the tube passing between the vocal cords
Key Points - Lesson 6
1. Epinephrine, a cardiac stimulant, is indicated when the heart rate remains below 60 beats per minute, despite
30 seconds of assisted ventilation followed by another 30 seconds of coordinated chest compressions and
2. Recommended epinephrine
? Concentration: 1:10,000 (0.1 mg/mL).
? Route: Intravenously. Endotracheal administration may be considered while intravenous access is
? Dose: 0.1 to 0.3 mL/kg (consider higher does, 0.3 to 1 mL/kg, for endotracheal route only)
? Preparation: 1:10,000 solution
? Rate: Rapidly—as quickly as possible
3. Epinephrine should be given by umbilical vein. The endotracheal route is often faster and more accessible
than placing an umbilical catheter, but is associated with unreliable absorption and may not be effective at the
4. Indications for volume expansion during resuscitation include
? Baby is not responding to resuscitation
? Baby appears in shock (pale color, weak pulses, persistently low heart rate, no improvement in
circulatory status despite resuscitation efforts)
? There is a history of condition associated with fetal blood loss (eg, extensive vaginal bleeding, abruptio
placentae, placenta previa, twin-to-twin transfusion, etc).
5. Recommended volume expander
? Solution: Normal saline, Ringer’s lactate, or O Rh-negative blood
? Dose: 10 mL/kg
? Route: Umbilical vein
? Preparation: Correct volume drawn into large syringe
? Rate: Over 5 to 10 minutes
Key Points - Lesson 7
1. The appropriate action for a baby who fails torespond to resuscitation will depend on the presentation—failure
to ventilate, persistent cyanosis or bradycardia, or failure to initiate spontaneous breathing.
2. Symptoms from choanal atresia can be helped by placing an oral airway.
3. Airway obstruction from Robin syndrome can be helped by inserting a nasopharyngeal tube and placing the
4. In an emergency, a pneumothorax can be detected by transillumination and treated byinserting a needle in the
5. If diaphragmatic hernia is suspected, avoid positive-pressure ventilation by mask. Immediately intubate the
trachea and insert an orogastric tube.
6. Persistent cyanosis and bradycardia are rarely caused by congenital heart disease. More commonly, the
persistent cyanosis and bradycardia are caused by inadequate ventilation.
7. A baby who has required resuscitation must have close monitoring and management ofoxygenation, infection,
blood pressure, fluids,apnea, blood sugar, feeding, and temperature.
8. Be careful not to overheat the baby during or following resuscitation.
9. If a mother has recently received narcotics and her baby fails to breathe, first assist ventilation with positive
pressure, then consider giving naloxone to the baby.
10. Restoring adequate ventilation remains the priority when resuscitating babies at birth in the delivery room or
later in the nursery or other location.
11. Some alternative techniques for resuscitation outside of the delivery room include the following:
? Maintain temperature by placing the baby skin-to-skin with the mother and raising the environmental
? Clear airway with a bulb syringe or cloth on your finger.
? Consider mouth-to-mouth-and-nose for administering positive pressure.
? Cannulation of a peripheral vein or intraosseous space can be used for vascular access.
Key Points - Lesson 8
1. Preterm babies are at additional risk for requiring resuscitation because of their
? Excessive heat loss
? Vulnerability to hyperoxic injury
? Immature lungs and diminished respiratory drive
? Immature brains that are prone to bleeding
? Vulnerability to infection
? Low blood volume, increasing the implications of blood loss
2. Additional resources needed to prepare for an anticipated preterm birth include
? Additional trained personnel, including intubation expertise
? Additional strategies for maintaining temperature
? Compressed air
? Oxygen blender
? Pulse oximetry
3. Premature babies are more vulnerable to hyperoxia; use an oximeter and blender to gradually achieve
oxyhemoglobin saturations in the 85% to 95% range during and immediately following resuscitation.
4. When assisting ventilation in preterm babies,
? Follow the same criteria for initiating positive-pressure ventilation as with term babies.
? Use the lowest inflation pressure to achieve an adequate response.
? Consider using CPAP if the baby is breathing spontaneously and has a heart rate above 100 bpm, but is ? Consider giving prophylactic surfactant. having difficulty such as labored respiration, persistent cyanosis, or low oxygen saturation. 5. Decrease the risk of brain injury by
? Handling the baby gently
? Avoiding the Trendelenburg position
? Avoiding high airway pressures when possible
? Adjusting ventilation gradually, based on physical examination, oximetry, and blood gases
? Avoiding rapid intravenous fluid boluses and hypertonic solutions 6. After resuscitation of a preterm baby,
? Monitor and control blood sugar.
? Monitor for apnea, bradycardia, or oxygen desaturations and intervene promptly.
? Monitor and control oxygenation and ventilation.
? Consider delaying feeding if perinatal compromise was significant.
? Increase your suspicion for infection.
Key Points - Lesson 9
1. The ethical principles regarding the resuscitation of a newborn should be no different from those followed in
resuscitating an older child or adult.
2. Ethical and current national legal principles do not mandate attempted resuscitation in all circumstances, and
withdrawal of critical care interventions and institution of comfort care are considered acceptable if there is
agreement by health professionals and the parents that further resuscitation efforts would be futile, would
merely prolong dying, or would not offer sufficient benefit to justify the burdens imposed.
3. Parents are considered to be the appropriate surrogate decision makers for their own infants. For parents to
fulfill this role responsibly, they must be given relevant and accurate information about the risks and benefits
of each treatment option.
4. Where gestation, birth weight, and/or congenital anomalies are associated with almost certain early death, or
unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated, although
exceptions may be reasonable to comply with parental wishes.
5. In conditions associated with uncertain prognosis, where there is borderline survival and a high rate of
morbidity, and where the burden to the child is high, parental desires regarding initiation of resuscitation
should be supported.
6. Unless conception occurred via in vitro fertilization, techniques used for obstetrical dating are accurate only to
? 1 to 2 weeks. When counseling parents about the births of babies born at the extremes of prematurity, advise
them that decisions made about neonatal management before birth may need to be modified in the delivery
room, depending on the condition of the baby at birth and the postnatal gestational age assessment. 7. Discontinuation of resuscitation efforts may be appropriate after 10 minutes of absent heart rate following
complete and adequate resuscitation efforts.