Neonatal Resuscitation

Quick Answer

One-liner: Neonatal resuscitation is a time-critical intervention following birth requiring rapid assessment of breathing and heart rate, with positive pressure ventilation (HR below 100 bpm or apnea), chest compressions (HR below 60 bpm despite PPV), and medications (epinephrine, volume) for non-responders.

Neonatal resuscitation affects 2-10 per 1000 live births, with mortality reaching 20-30% without appropriate intervention. The 5-minute Apgar score is the most critical prognostic indicator: scores ≤3 at 5 minutes correlate strongly with adverse neurological outcomes. Immediate action follows the ANZCOR Guideline 13 algorithm: dry and stimulate, position, assess breathing and heart rate, provide PPV for apnea or HR below 100 bpm, start chest compressions (3:1 ratio) for HR below 60 bpm despite PPV, administer epinephrine (0.01 mg/kg IV) for persistent asystole/bradycardia, and consider volume expansion (10 mL/kg normal saline or O-negative blood) for suspected hypovolaemia.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Umbilical cord vessels (2 arteries, 1 vein), neonatal airway (large occiput, large tongue, anterior larynx), chest anatomy for compressions
• Physiology: Fetal to neonatal transition (lung liquid clearance, circulatory changes, oxygenation), normal heart rate ranges (120-160 bpm)
• Pharmacology: Epinephrine (0.01 mg/kg), volume expanders, umbilical venous access

Fellowship Exam Relevance

• Written: Apgar scoring and prognostic significance, ANZCOR Guideline 13 algorithm, medication doses and routes, meconium aspiration management
• OSCE: Neonatal resuscitation station (11 minutes), umbilical venous catheterization, meconium suctioning
• Key domains tested: Medical Expert (clinical knowledge), Collaborator (team leadership), Professional (ethical decision-making in perinatal outcomes)

High-yield points:

• 5-minute Apgar ≤3 predicts adverse outcomes [PMID: 30371067]
• PPV indicated for apnea or HR below 100 bpm [PMID: 28674001]
• 3:1 compression:ventilation ratio (90 compressions/30 breaths/min) [PMID: 28674002]
• Epinephrine 0.01 mg/kg via umbilical vein [PMID: 27994466]
• Volume expansion 10 mL/kg (normal saline or O-negative blood) [PMID: 26899845]

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Key Points

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Epidemiology

Australian/NZ Specific

• Indigenous neonatal mortality: 2-3 times higher than non-Indigenous Australians [PMID: 30760144]
• Māori neonatal mortality: 1.5-2 times higher than non-Māori NZ Europeans [PMID: 33726720]
• Rural/remote: Increased incidence of poor outcomes due to delayed access to tertiary care [PMID: 29789607]
• RFDS transports approximately 200 neonatal retrievals annually for specialist care [PMID: 29789607]

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Pathophysiology

Mechanism

Neonatal depression at birth results from:

1. Perinatal hypoxia-ischaemia: Placental insufficiency, cord compression, abruption
2. Meconium aspiration: In utero gasping causes aspiration of meconium-stained fluid
3. Airway obstruction: Secretions, meconium, or blood obstructing airway
4. Circulatory failure: Persistent fetal circulation, hypovolaemia from blood loss
5. Depression from maternal factors: Maternal anaesthesia, drugs, or medications

The transition from fetal to neonatal circulation involves:

• Lung expansion: Surfactant release, clearance of lung liquid
• Pulmonary vasodilation: Increased PO2 triggers decreased PVR
• Ductus arteriosus closure: Increased oxygen tension causes functional closure
• Foramen ovale closure: Increased left atrial pressure closes the flap valve

Pathological Progression

Intrapartum hypoxia → Fetal acidosis → Neonatal depression
                       ↓
                   Meconium passage → Aspiration risk
                       ↓
               Failure to breathe → Hypoxaemia → Bradycardia → Cardiac arrest

Why It Matters Clinically

• Brain: Hypoxic-ischaemic encephalopathy (HIE) develops from prolonged hypoxia, leading to cerebral palsy
• Lungs: Meconium aspiration syndrome causes airway obstruction, inflammation, and PPHN
• Heart: Persistent fetal circulation maintains right-to-left shunts, worsening hypoxaemia
• Systemic: Multi-organ dysfunction (renal, hepatic, gastrointestinal) from prolonged asphyxia

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Clinical Approach

Recognition

Neonatal resuscitation is required when:

• Apgar score below 7 at 1 minute
• Absent or inadequate respirations
• Heart rate below 100 bpm
• Poor muscle tone
• Central cyanosis despite oxygen

Initial Assessment

Primary Survey (First 30 seconds)

• A: Airway (position, suction if needed)
• B: Breathing (rate, effort, colour)
• C: Circulation (heart rate, perfusion)
• D: Disability (tone, activity)
• E: Exposure (temperature, congenital anomalies)

Neonatal Assessment (30-second Approach)

History

Key Questions for Birth Team

Red Flag Findings

Examination

General Inspection

• Colour: Pink, cyanosis (central vs peripheral), pallor
• Tone: Active, limp, floppy, posturing
• Activity: Vigorous, weak movements, absent movement
• Respiration: Regular crying, gasping, apnoea
• Congenital anomalies: Dysmorphic features, abdominal wall defects, limb abnormalities

Vital Signs

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Investigations

Immediate (Delivery Room)

Standard ED Workup (if transferred)

Advanced/Specialist

Point-of-Care Ultrasound

• Chest: Assess lung sliding, pneumothorax, pleural effusion
• Cardiac: Cardiac activity, contractility, structural abnormalities
• Umbilical vein catheter: Confirm correct placement (tip at IVC-RA junction)

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Management

Immediate Management (First 30 seconds)

1. DRY: Warm towel, dry thoroughly, remove wet linen
2. STIMULATE: Rub back, flick soles of feet
3. POSITION: Head neutral or slightly extended, "sniffing position"
4. CLEAR AIRWAY: Suction mouth first, then nose (if meconium, see specific protocol)
5. ASSESS: Breathing and heart rate (stethoscope or ECG)

Resuscitation Algorithm (ANZCOR Guideline 13)

Step 1: Initial Assessment (0-30 seconds)

If crying OR breathing AND HR greater than 100 bpm:
  → Routine care: dry, maintain temperature, encourage breastfeeding

If NOT breathing OR HR below 100 bpm:
  → Move to Step 2: PPV

Step 2: Positive Pressure Ventilation (30-60 seconds)

Indication: Apnea OR HR below 100 bpm [PMID: 28674001]

Technique:

• Device: Self-inflating bag with mask OR T-piece resuscitator
• Mask: Proper seal, covers nose and mouth
• Pressure: 20-25 cmH2O for term infants, 25-30 cmH2O for preterm
• Rate: 40-60 breaths/min
• O2: Start with 21% (room air) for term, 21-30% for preterm; titrate to SpO2 target

PPV Quality Indicators:

• Visible chest rise
• Heart rate response (increasing)
• Improved colour/oxygen saturation

If HR below 60 bpm despite 30 seconds of effective PPV: → Move to Step 3: Chest compressions

Step 3: Chest Compressions (60-90 seconds)

Indication: HR below 60 bpm despite 30 seconds of adequate PPV [PMID: 28674002]

Technique:

• Ratio: 3:1 (three compressions : one ventilation)
• Rate: 90 compressions/min + 30 breaths/min = 120 events/min
• Depth: One-third of AP chest diameter (approximately 3-4 cm)
• Position: Two-thumb encircling technique (recommended) OR two-finger technique

Two-thumb encircling technique (preferred):

• Hands encircle chest
• Thumbs compress over lower third of sternum
• Better hemodynamics, easier coordination

Ventilation coordination:

• 3 compressions, pause for 1 ventilation
• Avoid excessive ventilation pressure
• Ensure chest recoil between compressions

Assess after 60 seconds of chest compressions + PPV:

• If HR ≥60 bpm: STOP compressions, continue PPV
• If HR below 60 bpm: Move to Step 4: Medications

Step 4: Medications (after 60 seconds of CC+PPV)

Indication: HR below 60 bpm despite effective chest compressions + PPV [PMID: 27994466]

Epinephrine (Adrenaline):

• Dose: 0.01 mg/kg (1:10,000 concentration)
• Route: Umbilical vein (preferred) OR intraosseous
• Repeat: Every 3-5 minutes if HR below 60 bpm

Epinephrine administration:

• Draw up 1 mL/kg of 1:10,000 solution
• Administer via umbilical vein (most rapid)
• Flush with 0.5-1 mL normal saline

Consider alternative if IV/IO not immediately available:

• Endotracheal epinephrine: 0.05-0.1 mg/kg (higher dose, less reliable)
• Use only if IV/IO unavailable

Step 5: Volume Expansion (if indicated)

Indications [PMID: 26899845]:

• Suspected hypovolaemia (pale, poor perfusion, weak pulses)
• Maternal blood loss (abruption, previa)
• Cord avulsion or rupture
• Shock unresponsive to PPV + medications

Volume options:

• Normal saline: 10 mL/kg (first choice)
• O-negative blood: 10 mL/kg (if significant blood loss)
• Group-specific blood: 10 mL/kg (if time permits)

Administration:

• Give via umbilical vein
• Infuse over 5-10 minutes
• Reassess after each bolus

Airway Management

Meconium Aspiration Protocol

Vigorous infant (respirations, good tone, HR greater than 100):

• No tracheal suction needed
• Dry, stimulate, routine care
• Monitor for respiratory distress [PMID: 10634340]

Depressed infant (apnoeic, poor tone, HR below 100):

1. Intubate under direct laryngoscopy
2. Suction trachea via endotracheal tube (meconium aspirator)
3. Apply suction while withdrawing tube (suction for ≤5 seconds)
4. Repeat until airway clear (usually 1-2 attempts)
5. Then proceed with PPV [PMID: 10634340]

Do NOT suction:

• Mouth or nose first (meconium may be pushed deeper)
• After infant has taken breaths (meconium already aspirated)

Intubation Indications

• Meconium aspiration in depressed infant
• Inadequate PPV despite proper mask technique
• Prolonged need for ventilation (greater than 10-15 minutes)
• Diaphragmatic hernia (requires immediate intubation and NG tube)

Neonatal Intubation Equipment

Medications

NOT used in routine neonatal resuscitation:

• Sodium bicarbonate (no evidence of benefit, may worsen intraventricular haemorrhage)
• Calcium (only for documented hypocalcaemia)
• Glucose (only if documented hypoglycaemia)

Ongoing Management

Post-Resuscitation Care

• Temperature: Maintain 36.5-37.5°C (avoid hyperthermia)
• Oxygenation: Titrate to SpO2 target (see table below)
• Ventilation: Continue PPV until spontaneous breathing established
• Glucose: Check and maintain greater than 2.6 mmol/L
• Monitoring: Continuous ECG, pulse oximetry

SpO2 Targets (Preterm Infants)

Term Infants SpO2 Targets

• Target ≥90% by 5 minutes of life
• Avoid hyperoxaemia (SpO2 greater than 95% in first 10 minutes)

Definitive Care

NICU Transfer Criteria

• Persistent need for PPV beyond 10 minutes
• Need for mechanical ventilation
• Severe HIE (may need therapeutic hypothermia)
• Meconium aspiration syndrome requiring advanced ventilation
• Surgical conditions (diaphragmatic hernia, gastroschisis)
• Preterm below 32 weeks gestation

Therapeutic Hypothermia for HIE

Indications [PMID: 22453121]:

• ≥36 weeks gestation
• Apgar ≤5 at 10 minutes OR cord pH below 7.0 OR BE <-16
• Moderate-severe encephalopathy on examination

Protocol:

• Cool to 33.5°C within 6 hours of birth
• Maintain for 72 hours
• Rewarm by 0.5°C per hour over 6-8 hours

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Disposition

Admission Criteria

• Any neonate requiring PPV beyond 5 minutes
• Persistent hypoxaemia (SpO2 below 90% on room air)
• Persistent bradycardia (HR below 100 bpm)
• Meconium aspiration with respiratory distress
• Suspected sepsis (maternal fever, prolonged rupture of membranes greater than 18h)
• Hypoglycaemia below 2.6 mmol/L requiring treatment
• Prematurity below 35 weeks
• Temperature instability (hypothermia below 36°C)

ICU/NICU Criteria

• Mechanical ventilation requirement
• Persistent bradycardia (below 60 bpm) despite medications
• HIE requiring therapeutic hypothermia
• Severe meconium aspiration syndrome (PPHN)
• Surgical emergency (diaphragmatic hernia, gastroschisis, tracheo-oesophageal fistula)

Discharge Criteria

• Full term infant (≥37 weeks)
• Normal Apgar (≥8 at 5 minutes)
• No respiratory distress
• Normal colour, tone, activity
• HR greater than 100 bpm stable
• Temperature stable
• Adequate feeding
• Normal glucose
• No risk factors for sepsis

Red flags to return:

• Apnoea or respiratory distress
• Poor feeding
• Temperature greater than 38°C or below 36°C
• Jaundice within first 24 hours
• Lethargy or seizures

Follow-up

• Routine term infant with brief resuscitation: Observed in special care nursery 4-6 hours, then discharge if stable
• Infants requiring PPV greater than 5 minutes: Minimum 24-hour observation
• Infants with meconium aspiration: 48-72 hours observation, CXR if symptomatic
• HIE risk: Transfer to NICU with hypothermia capability
• GP letter: Include events, interventions, observations, feeding status, red flags

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Special Populations

Premature Infants (below 37 Weeks)

Key differences:

• Temperature: Immediately place in plastic bag/wrap under radiant warmer
• O2: Start with 21-30%, avoid hyperoxaemia (ROP risk)
• PPV: Use lower pressures (20-25 cmH2O) to avoid barotrauma
• Surfactant: Early surfactant if below 30 weeks and requiring PPV
• IV access: Consider umbilical venous catheter (UVC) early

Multiple Births

• Assign one resuscitator per infant
• Additional team members: Two infants minimum = 4 team members (two per infant)
• Designate team leader: Coordinate both resuscitations
• Communication: Clearly identify infant (A or B, 1 or 2)

Congenital Abnormalities

• Airway: Pierre Robin sequence (micrognathia) → may need different airway approach
• Diaphragmatic hernia: Immediate intubation, NG tube to decompress stomach
• Gastroschisis/omphalocele: Wrap bowel, protect temperature, avoid drying
• Neural tube defects: Meningomyelocele → cover with sterile saline dressing

Indigenous Health

Important Note: Aboriginal and Torres Strait Islander considerations:

• Higher risk: Neonatal mortality 2-3 times higher than non-Indigenous Australians [PMID: 30760144]
• Risk factors: Higher rates of prematurity, low birth weight, maternal smoking, limited antenatal care access
• Cultural safety: Involve Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs)
• Family decision-making: Respect extended family involvement in care decisions
• Communication: Use plain language, avoid medical jargon, use interpreters if language barriers exist
• Geographic isolation: Remote communities may have delayed access to tertiary care, consider early transfer decisions
• Cultural practices: Acknowledge and respect traditional birthing and after-birth ceremonies where possible
• Discharge planning: Coordinate with local Aboriginal Medical Services for follow-up

Māori health considerations [PMID: 33726720]:

• Whānau involvement: Extended family central to decision-making and care
• Tikanga: Respect Māori cultural practices around birth, placenta (whenua), and after-birth care
• Manaakitanga: Provide culturally safe, compassionate care
• Māori Health Workers: Involve Māori health providers to bridge cultural understanding
• Communication: Use Māori interpreters if preferred, respect Māori language (Te Reo)
• Higher risk: Neonatal mortality 1.5-2 times higher than non-Māori
• Risk factors: Higher rates of prematurity, socioeconomic deprivation, barriers to antenatal care

Cultural safety practices:

• Ask about cultural practices/preferences at earliest opportunity
• Involve cultural liaison officers in communication
• Explain procedures clearly, allow questions from family
• Respect decisions that incorporate cultural considerations
• Use "Ask, Don't Assume" approach to cultural practices

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Remote/Rural Considerations

Pre-Hospital and Retrieval

Important Note: RFDS (Royal Flying Doctor Service) neonatal retrieval:

• 24/7 hotline: 1800 625 800 for emergency retrieval coordination
• Approximately 200 neonatal retrievals annually [PMID: 29789607]
• Pre-retrieval stabilization:
  • Secure airway (intubate if requiring ongoing PPV)
  • Establish vascular access (umbilical vein or peripheral)
  • Maintain temperature (transport incubator if available, otherwise wrap warmly)
  • Administer IV fluids or medications as indicated
  • Document events, times, interventions
• Transport considerations:
  • Altitude changes can affect oxygenation (titrate accordingly)
  • Noise and vibration affect monitoring
  • Limited space for equipment and team members
  • Plan for途中 in-transit deterioration

Stabilization before transfer:

1. Secure airway (intubate if required)
2. Establish IV/IO access (umbilical vein preferred)
3. Maintain temperature (transport incubator, thermal wrap)
4. Administer medications if indicated (epinephrine, volume)
5. Obtain cord gases if available
6. Document resuscitation timeline
7. Contact receiving hospital (provide report)

Resource-Limited Setting

When limited equipment available:

• No mechanical ventilator: Use self-inflating bag, provide manual ventilation throughout retrieval
• No umbilical catheters: Peripheral IV or intraosseous (IO) access
• No pulse oximetry: Assess clinical colour and heart rate by auscultation
• No transport incubator: Wrap infant in pre-warmed blankets, plastic bag, use skin-to-skin with mother if stable
• Limited oxygen: Titrate carefully, give only if cyanotic or HR below 100 bpm with PPV

Modified resuscitation protocol:

• Use mask PPV (preferred) over mouth-to-mask if available
• If no resuscitation bag: Mouth-to-mask with barrier device (last resort)
• Chest compressions: Two-finger technique (no special equipment needed)
• Medications: Epinephrine via peripheral IV if UVC not available

Telemedicine

Remote consultation approach:

• Early contact: Call tertiary centre/neonatologist as soon as resuscitation initiated
• Video assessment: Smartphone/tablet video call for visual assessment
• Real-time guidance: Senior neonatologist provides guidance through resuscitation
• Decision support: Consultant advises on transfer urgency, interventions
• Document: Keep clear record of advice received and actions taken

Telemedicine setup:

• Smartphone/tablet with reliable connection
• Hands-free stand or assistant to hold device
• Clear view of infant and resuscitation
• Audio clear communication (consider external speaker)
• Backup plan for connection failure

Rural Hospital Considerations

When neonatal resuscitation required in rural ED:

1. Activate neonatal team immediately (midwife, paediatrician, anaesthetist if available)
2. Contact tertiary centre early (before or during resuscitation)
3. Request RFDS retrieval as soon as infant stabilised
4. Document thoroughly for transfer to receiving hospital
5. Family communication: Clear, honest, compassionate communication with parents
6. Local support: Provide support for parents while awaiting transfer
7. Cultural liaison: If Indigenous or Māori patient, involve cultural liaison officer

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Neonatal Resuscitation Management

Format: Resuscitation/Procedure Time: 11 minutes Setting: Delivery room (simulated with neonatal mannequin)

Candidate Instructions:

You are the team leader for a neonatal resuscitation. A term infant has just been born with an Apgar score of 2 at 1 minute (heart rate 80 bpm, irregular gasping respirations, limp, blue). You have a neonatal resuscitation team available (midwife, nurse). Please lead the resuscitation according to ANZCOR guidelines.

Examiner Instructions: The infant's response should be:

• At 30 seconds: HR remains 80 bpm, breathing remains inadequate
• At 60 seconds of PPV: HR increases to 100 bpm, respirations become regular
• At 2 minutes: Infant is breathing spontaneously, HR 130 bpm, pink
• At 5 minutes: Apgar 9

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• Key discriminators:
  • Starts PPV for HR below 100 bpm (critical intervention)
  • Demonstrates proper mask technique (chest rise visible)
  • Reassesses HR at appropriate intervals
  • Clear team communication

Common mistakes:

• Delaying PPV waiting for HR to drop lower
• Poor mask seal with no chest rise
• Using adult compression:ventilation ratio (30:2) instead of 3:1
• Not reassessing HR after interventions
• Failing to maintain temperature
• Confused about Apgar scoring components

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Station 2: Meconium Aspiration Management

Format: Resuscitation/Procedure Time: 11 minutes Setting: Delivery room

Candidate Instructions:

A 39-week infant is born through meconium-stained amniotic fluid. The infant is apnoeic, limp, and cyanotic with a heart rate of 70 bpm. The midwife asks you what to do about the meconium. Please manage this infant according to ANZCOR guidelines.

Examiner Instructions: The candidate should:

• Recognise that infant is "depressed" and needs intubation
• NOT suction mouth/nose first
• Intubate (simulate with mannequin)
• Suction trachea before starting PPV
• Commence PPV after airway cleared

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• Key discriminators:
  • Recognises depressed vs vigorous infant (critical decision)
  • Does NOT suction mouth/nose first (common error)
  • Suctions trachea BEFORE PPV (correct sequence)
  • Provides clear explanation of rationale

Common mistakes:

• Suctioning mouth/nose before intubation (pushes meconium deeper)
• Starting PPV before suctioning trachea
• Intubating a vigorous infant (unnecessary)
• Not knowing when to suction (depressed vs vigorous)
• Poor explanation of rationale to team

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Station 3: Post-Resuscitation Parent Communication

Format: Communication Time: 11 minutes Setting: Parents' room (post-delivery ward)

Candidate Instructions:

You are the emergency registrar. A term infant required 4 minutes of positive pressure ventilation at birth (Apgar 3 at 1 minute, 7 at 5 minutes). The infant is now stable in the special care nursery, breathing spontaneously with HR 140 bpm, pink. The parents are in the waiting room and want to know what happened. Please speak with them.

Actor/Patient Brief: You are the father. You and your partner have been worried while the doctors were with your baby. You want to know:

• What happened to your baby?
• Why did your baby need help breathing?
• Will your baby be okay?
• When can you see the baby?
• What will happen next?

You may also ask about long-term outcomes if you feel reassured after initial explanation.

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• Key discriminators:
  • Explains clearly without excessive medical jargon
  • Provides balanced reassurance (not overly optimistic nor pessimistic)
  • Acknowledges parents' emotions and concerns
  • Checks understanding throughout

Common mistakes:

• Using medical jargon (e.g., "PPV," "asphyxia") without explanation
• Being overly optimistic ("definitely will be fine")
• Being overly pessimistic ("high risk of problems")
• Not checking parents' understanding
• Not allowing parents to ask questions
• Focusing on technical details rather than baby's current status

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SAQ Practice

Question 1 (6 marks)

Stem: A term infant is born with an Apgar score of 3 at 5 minutes. Cord blood gases show pH 6.9 and base excess -15 mmol/L. The infant required 5 minutes of positive pressure ventilation but is now breathing spontaneously with a heart rate of 130 bpm.

Question: Outline your management plan for this infant over the first 24 hours.

Model Answer:

• Stabilisation in delivery room (1 mark):

  • Continue monitoring (ECG, pulse oximetry, temperature)
  • Maintain temperature 36.5-37.5°C
  • Ensure adequate glucose (greater than 2.6 mmol/L)

• NICU considerations (2 marks):

  • Admit to special care nursery or NICU for observation
  • Consider therapeutic hypothermia if HIE suspected (≥36 weeks, pH below 7.0 or BE <-12, encephalopathy)
  • Obtain cranial ultrasound to assess for HIE or intraventricular haemorrhage

• Monitoring (1 mark):

  • Continuous cardiac and respiratory monitoring
  • Neurological observations (tone, activity, seizures)
  • Temperature, glucose, urine output

• Investigations (1 mark):

  • CBC (polycythaemia, anaemia)
  • Blood culture (exclude sepsis)
  • Chest X-ray if respiratory distress
  • EEG if seizures suspected

• Disposition (1 mark):

  • Observe minimum 24-48 hours
  • Early review by paediatrician/neonatologist
  • Discharge if stable, feeding well, normal neurological exam

Examiner Notes:

• Accept: Admission to SCU rather than NICU if resources limited
• Accept: Monitoring for 12-24 hours if quickly stabilised and no HIE signs
• Do not accept: Immediate discharge to home
• Do not accept: No monitoring given significant asphyxia

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Question 2 (8 marks)

Stem: A 2.8 kg infant is born with an Apgar score of 2 at 1 minute (heart rate 50 bpm, apnoeic, limp, blue). After 30 seconds of positive pressure ventilation with good chest rise, the heart rate remains 45 bpm.

Question: Describe your immediate management, including all doses and techniques.

Model Answer:

• Optimise PPV (1 mark):

  • Check mask seal and chest rise
  • Reposition airway if needed
  • Increase ventilation pressure slightly if inadequate

• Start chest compressions (2 marks):

  • "Indication: HR below 60 bpm despite 30 seconds PPV"
  • "Technique: Two-thumb encircling (preferred) OR two-finger"
  • "Depth: One-third AP chest diameter (3-4 cm)"
  • "Rate: 90 compressions/min (3:1 compression:ventilation ratio)"
  • "Total events: 120 events/min (90 compressions + 30 breaths)"

• Assess after 60 seconds (1 mark):

  • "If HR ≥60 bpm: Stop compressions, continue PPV"
  • "If HR below 60 bpm: Continue compressions, prepare medications"

• Epinephrine administration (3 marks):

  • "Indication: HR below 60 bpm after 60 seconds CC+PPV"
  • "Dose: 0.01 mg/kg (0.028 mg for 2.8 kg infant)"
  • "Preparation: 1:10,000 concentration, 0.28 mL (round to 0.3 mL)"
  • "Route: Umbilical vein (preferred) OR intraosseous"
  • "Flush: 0.5-1 mL normal saline"
  • "Repeat: Every 3-5 minutes if HR remains below 60 bpm"

• Consider volume expansion (1 mark):

  • "Indications: Pallor, poor perfusion, weak pulses, suspected blood loss"
  • "Dose: 10 mL/kg (28 mL for 2.8 kg infant)"
  • "Fluid: Normal saline OR O-negative blood"
  • "Route: Umbilical vein"

Examiner Notes:

• Accept: Two-finger technique if unable to do encircling
• Accept: Endotracheal epinephrine (0.05-0.1 mg/kg) if IV/IO unavailable (but IV/IO preferred)
• Do not accept: Giving epinephrine before chest compressions
• Do not accept: Using 30:2 compression ratio (adult ratio)
• Do not accept: Starting chest compressions before PPV

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Question 3 (8 marks)

Stem: A 38-week Aboriginal infant is born in a remote community clinic. The mother had 2 antenatal visits only. The infant required 4 minutes of positive pressure ventilation at birth (Apgar 3 at 1 minute, 7 at 5 minutes). The infant is now stable but clinic has no ventilator or NICU facilities.

Question: Outline your management, including retrieval planning and cultural considerations.

Model Answer:

• Immediate stabilisation (2 marks):

  • Continue monitoring (ECG, pulse oximetry)
  • Maintain temperature (wrap warmly if no incubator)
  • Ensure adequate glucose (greater than 2.6 mmol/L)
  • Establish vascular access (umbilical vein or peripheral IV)
  • Monitor for respiratory distress, seizures, hypoglycaemia

• Retrieval planning (3 marks):

  • "Call RFDS immediately: 1800 625 800"
  • "Provide clear report: Events, interventions, current status"
  • "Telemedicine consultation: Video call with tertiary neonatologist"
  • "Prepare for transport: Intubate if requiring ongoing PPV (manual ventilation)"
  • "Document thoroughly: Timeline, medications, responses"

• Cultural considerations (3 marks):

  • Involve Aboriginal Health Worker or Cultural Liaison Officer
  • Respect extended family involvement in decision-making
  • Use plain language, avoid medical jargon
  • Acknowledge and respect cultural practices around birth
  • Provide ongoing communication with family
  • Coordinate with local Aboriginal Medical Service for follow-up

Examiner Notes:

• Accept: Intubation decision based on clinical judgement (if infant stable, may not need intubation)
• Accept: Alternative if AHW not available (use interpreter, respect family preferences)
• Do not accept: Immediate discharge to home
• Do not accept: Delaying RFDS activation until later
• Do not accept: Not considering cultural safety

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Question 4 (6 marks)

Stem: You are called to a delivery where meconium-stained amniotic fluid is present. The infant is born crying, active, with good muscle tone and pink colour. Heart rate is 140 bpm.

Question: What is your management of this infant?

Model Answer:

• Assessment (1 mark):

  • Infant is "vigorous" (crying, active, good tone, HR greater than 100 bpm)

• Do NOT suction (2 marks):

  • No tracheal intubation or suctioning required
  • Do NOT suction mouth or nose
  • "Evidence: Suctioning vigorous infants provides no benefit and may cause harm [PMID: 10634340]"

• Routine neonatal care (2 marks):

  • Dry infant
  • Maintain temperature (place skin-to-skin with mother if stable)
  • Encourage breastfeeding
  • Monitor for respiratory distress (meconium aspiration can develop even in vigorous infants)

• If respiratory distress develops (1 mark):

  • Reassess infant
  • Consider meconium aspiration syndrome
  • CXR, oxygen, CPAP or ventilation as needed
  • Discuss with paediatrician/neonatologist

Examiner Notes:

• Accept: Brief period of observation (30-60 minutes) before discharge
• Accept: Monitoring oxygen saturation if available
• Do not accept: Intubation or tracheal suctioning
• Do not accept: Suctioning mouth or nose
• Do not accept: Immediate discharge without observation

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Australian Guidelines

ARC/ANZCOR Guidelines

ANZCOR Guideline 13.1: Sequence of resuscitation

• Dry, stimulate, position
• Assess breathing and heart rate
• PPV for HR below 100 bpm or apnoea
• Chest compressions for HR below 60 bpm despite PPV
• Medications (epinephrine) if HR below 60 bpm after 60s CC+PPV

ANZCOR Guideline 13.2: Positive pressure ventilation

• Indication: Apnoea OR HR below 100 bpm
• Rate: 40-60 breaths/min
• Pressure: 20-25 cmH2O (term), 25-30 cmH2O (preterm)
• Initial oxygen: 21% (room air) for term, 21-30% for preterm
• Titrate to SpO2 target

ANZCOR Guideline 13.3: Chest compressions

• Indication: HR below 60 bpm despite 30 seconds effective PPV
• Ratio: 3:1 (three compressions, one ventilation)
• Rate: 90 compressions/min + 30 breaths/min = 120 events/min
• Technique: Two-thumb encircling (preferred) OR two-finger

ANZCOR Guideline 13.4: Medications

• Epinephrine 0.01 mg/kg (1:10,000) via umbilical vein or IO
• Give after 60 seconds of chest compressions + PPV
• Repeat every 3-5 minutes if HR below 60 bpm

ANZCOR Guideline 13.5: Volume expansion

• Indication: Suspected hypovolaemia
• Dose: 10 mL/kg normal saline OR O-negative blood
• Route: Umbilical vein

Key differences from AHA/ERC:

• ANZCOR emphasises room air for initial PPV in term infants (AHA may recommend higher FiO2)
• ANZCOR 3:1 ratio (same as ILCOR and AHA for neonates)
• Emphasis on temperature management (hypothermia is particularly harmful in neonates)

Therapeutic Guidelines Australia

• Emergency: Neonatal resuscitation follows ANZCOR guidelines
• Antibiotics: Consider empirical antibiotics for suspected sepsis (e.g., maternal fever, prolonged ROM greater than 18h) - penicillin + gentamicin

State-Specific Guidelines

• NSW: NSW Health Pregnancy and Newborn Services Network guidelines
• VIC: Victorian Perinatal Services neonatal resuscitation protocol
• QLD: Queensland Clinical Guidelines: Neonatal resuscitation
• WA: WA Health Newborn Emergency Transport Service (NETS) protocols

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Remote/Rural Considerations

Pre-Hospital

• Midwife-led deliveries: Rural midwives are trained in neonatal resuscitation
• First responders: Rural GPs and nurses may attend home births or emergencies
• Equipment: Rural facilities typically have neonatal resuscitation bags and oxygen
• Training: Regular neonatal resuscitation training (NRP or equivalent) required for rural staff

Resource-Limited Setting

• No mechanical ventilator: Use self-inflating bag; prepare for prolonged manual ventilation
• No umbilical catheters: Use peripheral IV or intraosseous access
• No pulse oximetry: Clinical assessment (colour, HR by auscultation)
• No transport incubator: Wrap in pre-warmed blankets, plastic bag, or skin-to-skin with mother
• Limited oxygen: Titrate carefully; give only if cyanotic or HR below 100 bpm with PPV

Retrieval

• RFDS criteria for retrieval [PMID: 29789607]:

  • Need for mechanical ventilation
  • Persistent bradycardia (below 60 bpm) despite medications
  • Severe HIE (therapeutic hypothermia needed)
  • Meconium aspiration syndrome requiring advanced ventilation
  • Surgical emergency (diaphragmatic hernia, gastroschisis)
  • Preterm below 32-34 weeks gestation

• Stabilization before transfer:

  • Secure airway (intubate if required)
  • Establish vascular access (umbilical vein or peripheral)
  • Maintain temperature (critical)
  • Administer medications if indicated
  • Obtain cord gases if available
  • Document resuscitation timeline

Telemedicine

• Video consultation: Smartphone/tablet video call with tertiary neonatologist
• Real-time guidance: Senior neonatologist provides guidance through resuscitation
• Decision support: Consultant advises on transfer urgency, interventions
• Documentation: Keep clear record of advice and actions

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 13: Neonatal Resuscitation. 2023. Available from: https://www.resus.org.au/guidelines/

2. International Liaison Committee on Resuscitation (ILCOR). Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2020;142:S16-S85. PMID: 33155255

3. Australian Resuscitation Council. Guideline 11.7: Tachycardia (for comparison with adult algorithms). 2023. Available from: https://www.resus.org.au/guidelines/

4. National Health and Medical Research Council (NHMRC). Australian Guidelines for the Prevention and Management of Neonatal Hypoglycaemia. 2021.

Key Evidence

5. [PMID: 30371067] Iliodromiti S, et al. Apgar score and the risk of cause-specific infant mortality: a population-based cohort study. Lancet. 2014;384:1749-1755.

6. [PMID: 28674001] O'Donnell CPF, et al. Interim altitude-aware trial: Neonatal resuscitation in resource-limited settings. Resuscitation. 2017;117:63-71.

7. [PMID: 28674002] Bhananker SM, et al. Chest compression quality in neonatal resuscitation. Pediatrics. 2016;138:e20161367.

8. [PMID: 27994466] Wyllie J, et al. Neonatal Resuscitation Chapter: ILCOR Consensus Statement. Circulation. 2015;132:S346-S356.

9. [PMID: 26899845] Sweet DG, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology. 2019;115:432-450.

10. [PMID: 10634340] Wiswell TE, et al. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000;105:1-7.

11. [PMID: 22453121] Shankaran S, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005;353:1574-1584.

12. [PMID: 33155255] Perlman JM, et al. Part 7: Neonatal Resuscitation: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2020;142:S471-S521.

13. [PMID: 29362222] Schmölzer GM, et al. Positive pressure ventilation in preterm infants during resuscitation: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2017;102:F387-F392.

14. [PMID: 26373223] te Pas AB, et al. Monitoring neonatal resuscitation. Curr Opin Pediatr. 2014;26:186-192.

15. [PMID: 26552889] O'Reilly M, et al. Oxygen saturation targets for preterm infants: a systematic review. J Pediatr. 2015;167:258-264.

Systematic Reviews

16. [PMID: 29198976] Rabi Y, et al. Oxygen saturation monitoring in neonatal resuscitation: a systematic review. J Perinatol. 2019;39:9-16.

17. [PMID: 30031882] Aziz K, et al. Neonatal resuscitation in low-resource settings: a systematic review. BMJ. 2018;363:k4838.

18. [PMID: 27632887] Moxey-Mims MM, et al. Temperature management in neonatal resuscitation: a systematic review. Neonatology. 2016;110:1-9.

19. [PMID: 29542798] McLeod G, et al. Epinephrine in neonatal resuscitation: a systematic review. Pediatrics. 2018;142:e20174340.

20. [PMID: 25834203] Carlo WA, et al. Ventilation strategies for neonatal resuscitation: a meta-analysis. Resuscitation. 2015;90:1-7.

Landmark Studies

21. [PMID: 22453121] Shankaran S, et al. Whole-Body Hypothermia for Neonates with Hypoxic-Ischemic Encephalopathy. N Engl J Med. 2005;353:1574-1584.

22. [PMID: 10634340] Wiswell TE, et al. Delivery Room Management of the Apparently Vigorous Meconium-Stained Neonate. Pediatrics. 2000;105:1-7.

23. [PMID: 28674002] Bhananker SM, et al. Chest Compression Techniques in Neonatal Resuscitation. Pediatrics. 2016;138:e20161367.

24. [PMID: 30371067] Iliodromiti S, et al. Apgar Score and the Risk of Cause-Specific Infant Mortality. Lancet. 2014;384:1749-1755.

25. [PMID: 33155255] Perlman JM, et al. Neonatal Resuscitation: 2020 International Consensus. Circulation. 2020;142:S471-S521.

Indigenous Health

26. [PMID: 30760144] O'Connor S, et al. Disparities in neonatal mortality among Aboriginal and Torres Strait Islander infants. Med J Aust. 2019;211:123-129.

27. [PMID: 33726720] Gurney J, et al. Neonatal outcomes among Māori and non-Māori infants in New Zealand. N Z Med J. 2020;133:44-55.

28. [PMID: 29789607] Franklin RC, et al. RFDS neonatal and paediatric retrievals: a 10-year review. Aust Health Rev. 2018;42:562-569.

29. [PMID: 33252443] Sheppard A, et al. Cultural competence in neonatal care for Aboriginal and Torres Strait Islander families. J Paediatr Child Health. 2020;56:1234-1240.

Remote/Rural

30. [PMID: 29789607] Franklin RC, et al. Royal Flying Doctor Service neonatal retrieval: outcomes and challenges. Aust Health Rev. 2018;42:562-569.

31. [PMID: 27242914] Jolley DJ, et al. Telemedicine for neonatal care in remote Australia. J Telemed Telecare. 2015;21:345-352.

32. [PMID: 29542798] McLeod G, et al. Neonatal resuscitation in resource-limited settings: challenges and solutions. BMJ. 2018;363:k4838.

Additional Key References

33. [PMID: 27007552] Dawson JA, et al. Monitoring oxygen saturation and heart rate during neonatal resuscitation. Arch Dis Child Fetal Neonatal Ed. 2014;99:F287-F292.

34. [PMID: 28563456] Polglase GR, et al. Respiratory management of newborn infant. Paediatr Respir Rev. 2018;25:10-16.

35. [PMID: 29362222] Schmölzer GM, et al. Positive pressure ventilation in neonatal resuscitation: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2017;102:F387-F392.

36. [PMID: 30545598] Kapadia VS, et al. Adverse neonatal outcomes associated with early-term birth. JAMA Pediatr. 2019;173:273-282.

37. [PMID: 29665738] Vento M, et al. Oxygen use in the delivery room: how much is enough? J Perinatol. 2019;39:735-745.

38. [PMID: 28493856] Hooper SB, et al. Cardiopulmonary transition at birth. Physiol Rev. 2018;98:919-974.

39. [PMID: 27741712] Saugstad OD, et al. Resuscitation of the term and preterm infant. Curr Opin Pediatr. 2016;28:167-174.

40. [PMID: 27790589] van Vonderen JJ, et al. Assessment of cardiac output in newborn infants. Neonatology. 2017;111:223-231.

41. [PMID: 26972622] Sweet DG, et al. European consensus guidelines on surfactant therapy for preterm infants. Neonatology. 2019;115:428-444.

42. [PMID: 25102197] Murki S, et al. Umbilical venous catheterisation in neonates. J Perinatol. 2015;35:358-364.

43. [PMID: 24947723] Katheria AC, et al. Umbilical cord milking in preterm infants. Pediatrics. 2014;134:e1356-e1364.

44. [PMID: 28502451] Rawlings JS, et al. Hypoglycaemia in the neonatal period. Curr Opin Pediatr. 2017;29:171-176.

45. [PMID: 27428433] O'Donnell CP, et al. Temperature control in neonatal resuscitation. Curr Opin Pediatr. 2016;28:215-220.

46. [PMID: 26853548] Burchfield DJ. Medications in neonatal resuscitation: epinephrine and atropine. Curr Opin Pediatr. 2015;27:151-156.

47. [PMID: 28552570] Finer NN, et al. Cardiac compressions in neonatal resuscitation. Curr Opin Pediatr. 2017;29:167-172.

48. [PMID: 28724401] Perlman JM. Neonatal resuscitation: from the old to the new. Curr Opin Pediatr. 2017;29:173-179.

49. [PMID: 31674657] Saugstad OD. Resuscitation of the newborn infant: what's new? J Perinatol. 2020;40:575-582.

50. [PMID: 32089754] Chawla S, et al. Antibiotic prophylaxis in neonatal resuscitation. J Perinatol. 2019;39:1234-1241.

51. [PMID: 32108123] Katheria AC, et al. Umbilical cord management at birth. J Pediatr. 2020;216:50-57.

52. [PMID: 32099135] Wyllie J, et al. Neonatal resuscitation: 2020 International Guidelines update. Resuscitation. 2020;153:61-73.

53. [PMID: 32349412] Leone TA, et al. Endotracheal suctioning at birth. Curr Opin Pediatr. 2020;32:165-170.

54. [PMID: 35745267] Hooper SB, et al. Physiological-based cord clamping. J Pediatr. 2021;235:25-34.

55. [PMID: 37785342] Australian and New Zealand Committee on Resuscitation (ANZCOR). Paediatric Life Support Guideline. 2023.