Newborn Resuscitation

Quick Answer

Critical: Most newborns (85%) transition spontaneously. The single most important intervention in newborn resuscitation is effective ventilation. Use room air (21% O2) initially for term infants, give 5 inflation breaths, use 3:1 compression:ventilation ratio, and give adrenaline 10-30 mcg/kg IV/IO if HR remains below 60 bpm despite effective CPR. Follow ANZCOR Guidelines 13.1-13.10.

The Golden Minute: Initial steps (warmth, dry, stimulate, assess) should be completed within the first 60 seconds of life. Positive pressure ventilation (PPV) should begin by 60 seconds if the newborn remains apnoeic or has HR below 100 bpm.

Australian Guidelines: This topic follows ARC/ANZCOR Guidelines - NOT AHA or ERC algorithms.

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ACEM Exam Focus

Primary Exam Relevance

Fellowship OSCE

Core Station Type: Resuscitation Leadership / Team-based Resuscitation

Key Competencies Assessed:

• Team leadership and closed-loop communication
• Systematic ANZCOR algorithm adherence
• Recognition of the primacy of ventilation
• Correct SpO2 targets and oxygen titration
• Adrenaline dosing and timing decisions
• Post-resuscitation care and cooling criteria

Fellowship Written (SAQ)

Common question stems:

• Management of meconium-stained liquor
• Preterm infant thermoregulation and oxygen targets
• Therapeutic hypothermia eligibility criteria
• Delayed cord clamping evidence and contraindications

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Key Points

Critical Point: Ventilation is the cornerstone: The single most important and effective action in newborn resuscitation is achieving adequate lung inflation. Heart rate almost always improves with effective positive pressure ventilation (PPV). [PMID: 33081527]

1. 85% of term newborns transition spontaneously within 10-30 seconds of birth; only 10% require any assistance; under 1% require advanced resuscitation [PMID: 33081527]

2. Room air (21% FiO2) initially for term infants - titrate to preductal SpO2 targets; 100% oxygen is NOT routinely recommended [PMID: 11242466]

3. SpO2 targets rise gradually: 60-70% at 1 min, 65-85% at 2 min, 80-90% at 5 min, 85-90% at 10 min [PMID: 20516373]

4. 5 inflation breaths at 30 cmH2O (term) or 20-25 cmH2O (preterm) with PEEP 5 cmH2O if available [PMID: 33081527]

5. 3:1 compression:ventilation ratio (90 compressions + 30 breaths per minute) - different from paediatric (15:2) because neonatal arrest is almost always hypoxic [PMID: 26477422]

6. Adrenaline dose: 10-30 mcg/kg (0.1-0.3 mL/kg of 1:10,000) IV/IO preferred; 50-100 mcg/kg if ETT route [PMID: 32975136]

7. Delayed cord clamping: At least 60 seconds for vigorous term infants; at least 30 seconds for preterm below 34 weeks [PMID: 33605427]

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Epidemiology

Need for Resuscitation Interventions

Australian Context

• Approximately 310,000 births per year in Australia [AIHW 2023]
• Birth asphyxia accounts for 23% of neonatal deaths worldwide (~650,000 annually) [PMID: 27839855]
• Aboriginal and Torres Strait Islander infants have higher rates of low birthweight (12.5% vs 6.1%) and preterm birth (15.6% vs 8.2%), increasing resuscitation risk [AIHW]

Risk Factors Requiring Preparation

Antepartum Factors:

Intrapartum Factors:

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Pathophysiology

Normal Fetal-to-Neonatal Transition

The transition from intrauterine to extrauterine life involves profound cardiopulmonary changes:

Pulmonary Adaptation [PMID: 25883119]:

1. Lung liquid clearance: Approximately 30 mL/kg of fetal lung liquid is absorbed via sodium channels in alveolar epithelium, driven by catecholamine surge during labour
2. Functional residual capacity (FRC): First breaths generate negative intrathoracic pressures of -40 to -100 cmH2O to inflate fluid-filled alveoli
3. Surfactant activation: Surface tension reduction permits alveolar stability

Circulatory Adaptation [PMID: 26092932]:

1. Pulmonary vasodilation: Oxygen and mechanical lung expansion trigger dramatic decrease in pulmonary vascular resistance (PVR) - pulmonary blood flow increases 5-6 fold
2. Increased SVR: Cord clamping removes low-resistance placental circulation
3. Foramen ovale functional closure: Left atrial pressure exceeds right atrial pressure
4. Ductus arteriosus constriction: Oxygen exposure and prostaglandin withdrawal trigger ductal closure

Pathophysiology of Failed Transition

Primary Apnoea:

• Initial gasping followed by cessation of breathing
• Heart rate decreases but typically remains above 60 bpm
• Responds to stimulation and PPV
• Usually reversible with basic intervention

Secondary Apnoea:

• Follows unrelieved primary apnoea
• Progressive bradycardia (below 60 bpm)
• Hypotension and poor perfusion
• Does NOT respond to stimulation alone
• Requires PPV and potentially compressions and adrenaline

Exam Detail: The Apnoea-Bradycardia-Hypoxia Cycle:

Failed lung inflation → Hypoxaemia → Pulmonary vasoconstriction → Persistent fetal circulation → Right-to-left shunting → Worsening hypoxaemia → Myocardial hypoxia → Bradycardia → Decreased cardiac output → Multi-organ hypoxic injury

Key principle: Establishing lung inflation breaks the cascade. This is why VENTILATION is the single most important intervention.

Molecular Mechanisms of Hypoxic Injury

Prolonged hypoxia-ischaemia triggers a cascade of cellular injury:

1. Energy failure: ATP depletion from anaerobic metabolism
2. Excitotoxicity: Glutamate accumulation and NMDA receptor activation
3. Calcium influx: Activation of destructive enzymes (proteases, lipases, endonucleases)
4. Free radical generation: Oxidative stress (particularly during reperfusion)
5. Inflammatory response: Microglial activation and cytokine release
6. Apoptosis/Necrosis: Programmed and unprogrammed cell death

This understanding underpins the rationale for therapeutic hypothermia, which attenuates multiple steps in this cascade. [PMID: 19797281]

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ANZCOR Newborn Life Support Algorithm

┌─────────────────────────────────────────────────────────────┐
│                    NEWBORN ASSESSMENT                        │
│                                                              │
│  • Term gestation?     • Good muscle tone?                  │
│  • Breathing or crying?                                      │
└─────────────────────────────────────────────────────────────┘
                              │
              ┌───────────────┴───────────────┐
              │ YES to all                    │ NO to any
              ▼                               ▼
┌─────────────────────────┐    ┌─────────────────────────────┐
│   ROUTINE CARE          │    │      INITIAL STEPS          │
│ • Skin-to-skin          │    │ • Dry, warm, stimulate      │
│ • Delayed cord clamp    │    │ • Clear airway if needed    │
│ • Keep warm             │    │ • Position (neutral/sniff)  │
│ • Ongoing assessment    │    │                             │
└─────────────────────────┘    └─────────────────────────────┘
                                              │
                               ASSESS breathing and HR at 60 sec
                                              │
              ┌───────────────────────────────┴───────────────┐
              │ HR ≥100, breathing                            │
              │ normally                                       │
              ▼                                               ▼
┌─────────────────────────┐    ┌─────────────────────────────┐
│   Continue care         │    │  HR below 100 or apnoea/gasping  │
│   Monitor               │    │                             │
│   Consider CPAP if      │    │  → START PPV               │
│   distressed            │    │    5 inflation breaths      │
└─────────────────────────┘    │    40-60/min thereafter     │
                               │    SpO2 monitor             │
                               └─────────────────────────────┘
                                              │
                               ASSESS HR after 30 sec effective PPV
                                              │
              ┌───────────────────────────────┴───────────────┐
              │ HR ≥60 and rising                             │
              ▼                                               ▼
┌─────────────────────────┐    ┌─────────────────────────────┐
│   Continue PPV          │    │      HR STILL below 60           │
│   Wean as tolerated     │    │                             │
│   Consider intubation   │    │  CHECK ventilation effective│
│   if prolonged          │    │  (chest rise visible?)      │
└─────────────────────────┘    │                             │
                               │  → START COMPRESSIONS       │
                               │    3:1 ratio                 │
                               │    Lower sternum, 1/3 depth  │
                               │  → Prepare adrenaline/UVC    │
                               └─────────────────────────────┘
                                              │
                               ASSESS HR after 60 sec CPR
                                              │
              ┌───────────────────────────────┴───────────────┐
              │ HR ≥60                                        │
              ▼                                               ▼
┌─────────────────────────┐    ┌─────────────────────────────┐
│   Cease compressions    │    │      HR STILL below 60           │
│   Continue PPV          │    │                             │
│   Post-resus care       │    │  → ADRENALINE               │
│                         │    │    10-30 mcg/kg IV/IO       │
└─────────────────────────┘    │    (50-100 mcg/kg if ETT)   │
                               │    q3-5 min                  │
                               │                             │
                               │  → Consider:                │
                               │    - Volume 10 mL/kg        │
                               │    - Reversible causes      │
                               │    - Equipment check        │
                               └─────────────────────────────┘

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Clinical Approach

Initial Assessment Questions (30 seconds)

Heart Rate Decision Thresholds

Assessment of Heart Rate

Methods (in order of accuracy):

1. 3-lead ECG - most accurate for continuous monitoring [PMID: 24189866]
2. Auscultation - gold standard for initial rapid assessment (left chest/apex)
3. Pulse oximetry - may have 60-90 second delay in signal acquisition
4. Umbilical cord palpation - least accurate, underestimates HR

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Preparation and Equipment

Team Composition for High-Risk Delivery

Equipment Checklist (ANZCOR 13.1)

Thermoregulation:

• Radiant warmer (preheated)
• Warm blankets/towels
• Polyethylene bag/wrap for below 32 weeks
• Temperature probe and thermometer

Airway:

Medications:

Vascular Access:

• Umbilical catheterisation tray
• UVC catheters (3.5F, 5F)
• Intraosseous needle (backup)

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Thermoregulation

Importance

Cold stress increases oxygen consumption and metabolic acidosis, worsening outcomes. Admission temperature is a predictor of outcome and should be recorded. [PMID: 25911227]

Target temperature: 36.5-37.5°C for all non-asphyxiated newborns

Term Infants

• Radiant warmer (preheated)
• Dry thoroughly with warm towels
• Remove wet linens immediately
• Place skin-to-skin with mother if vigorous

Preterm Infants (Below 32 weeks)

• Polyethylene bag/wrap without drying (except head)
• Increase delivery room temperature to 23-26°C
• Consider chemical thermal mattress
• Avoid excessive handling

Clinical Pearl: Preterm infants lose heat rapidly due to high surface area-to-volume ratio, thin skin, and minimal subcutaneous fat. The polyethylene wrap technique reduces evaporative heat loss by up to 90% and is evidence-based practice. [PMID: 29405037]

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Delayed Cord Clamping

ANZCOR Recommendations

Benefits of Delayed Cord Clamping

Placental Transfusion Effects [PMID: 33605427]:

• Transfer of 25-35 mL/kg blood volume
• 30-50 mg/kg iron stores (prevents deficiency for 6-8 months)
• Higher haemoglobin at birth

Preterm-Specific Benefits [PMID: 29054196]:

• Reduced intraventricular haemorrhage (IVH)
• Reduced need for blood transfusion
• Improved transitional circulation
• Lower necrotising enterocolitis (NEC) incidence

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Airway Management and Ventilation

Positioning

• Supine with head in neutral "sniffing" position
• Slight neck extension (avoid hyperextension or flexion)
• Small shoulder roll (1-2 cm) may help in preterm infants with prominent occiput

Airway Suctioning

Critical Point: Routine suctioning is NOT recommended - even for meconium-stained amniotic fluid in vigorous infants. Aggressive suctioning causes vagal bradycardia, mucosal injury, and delays ventilation initiation. [PMID: 33081527]

When to suction:

• Obvious airway obstruction
• Visible secretions/meconium blocking airway
• Required to visualise vocal cords during intubation

Technique:

• Mouth before nose (prevents aspiration during gasping)
• Limit to 10 seconds
• Suction pressure 80-100 mmHg

Positive Pressure Ventilation

Indications for PPV:

• Apnoea or gasping after initial steps
• Heart rate below 100 bpm despite stimulation

Ventilation Parameters (ANZCOR 13.4):

Device Preference:

• ANZCOR suggests T-piece resuscitator over self-inflating bag (consistent pressure, PEEP delivery) [PMID: 33081527]
• Self-inflating bag must always be available as backup

MR SOPA - Corrective Ventilation Steps

If no chest rise or heart rate not improving:

Clinical Pearl: Two-Person Mask Ventilation: When single-operator mask ventilation is challenging, one person applies the mask using both hands (E-C technique with jaw thrust) while a second person squeezes the bag/operates T-piece. This dramatically improves mask seal and airway patency. [PMID: 21156637]

Endotracheal Intubation

Indications:

• Ineffective bag-mask ventilation despite MR SOPA
• Need for chest compressions
• Prolonged PPV anticipated
• Congenital diaphragmatic hernia
• Surfactant administration
• Extreme prematurity

ETT Size Selection (ANZCOR 13.5):

Confirmation:

1. CO2 detection (colorimetric/capnography) - MOST RELIABLE
2. Clinical: Visible chest rise, bilateral breath sounds, improving HR
3. CXR: Tip at T1-T2 (should not delay resuscitation)

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Oxygen Management

Rationale for Room Air Initiation

Evidence: Randomised trials and meta-analyses demonstrate no survival benefit from 100% oxygen for term newborn resuscitation, with potential harm from oxidative stress. Room air (21%) is as effective as 100% oxygen. [PMID: 11242466, PMID: 30593099]

Target Preductal SpO2 by Minute of Life (ANZCOR 13.4)

Key Principles:

1. Apply pulse oximeter to right hand/wrist (preductal)
2. Start at 21% for term, 21-30% for preterm below 35 weeks
3. Increase FiO2 if not meeting lower target
4. Decrease FiO2 if exceeding 90%
5. First priority is always effective ventilation - then adjust FiO2

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Chest Compressions

Indications (ANZCOR 13.6)

Critical Point: Chest compressions are indicated when heart rate remains below 60 bpm after 30 seconds of effective PPV with visible chest movement. Ensure ventilation is effective BEFORE starting compressions - most neonates with bradycardia respond to ventilation alone.

Technique

Two-Thumb Encircling Technique (preferred):

• Thumbs on lower third of sternum (just below nipple line)
• Fingers encircle chest, supporting back
• Compress to 1/3 anterior-posterior diameter of chest
• Allow full chest recoil between compressions

Two-Finger Technique (alternative):

• Two fingers on lower third of sternum
• Other hand supports back
• Only when single resuscitator or UVC being placed

Compression-to-Ventilation Ratio

Exam Detail: 3:1 ratio for newborns (different from paediatric 15:2 or adult 30:2)

Rationale: Neonatal cardiac arrest is almost always due to respiratory failure (hypoxic arrest) rather than primary cardiac arrhythmia. Therefore, ventilation is prioritised over compressions. The 3:1 ratio optimises oxygen delivery while maintaining cardiac output.

Rhythm: "One-and-Two-and-Three-and-Breathe"

• 90 compressions + 30 ventilations = 120 events/minute

Exception: If suspected primary cardiac aetiology (known CHD, arrhythmia), consider 15:2 ratio.

Coordination

• Intubation strongly recommended before/during compressions
• Pause compressions briefly for ventilation (synchronised, not continuous)
• Assess heart rate every 60 seconds
• Discontinue compressions when HR ≥60 bpm
• When compressions start, increase FiO2 to 100%; wean after ROSC

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Medications

Adrenaline (Epinephrine)

Mechanism: Alpha-adrenergic vasoconstriction increases diastolic BP and coronary perfusion pressure during CPR; beta-adrenergic effects increase HR and contractility.

Indication: Heart rate remains below 60 bpm after at least 60 seconds of effective ventilation AND chest compressions.

Dosing (ANZCOR 13.7):

Administration:

• IV via umbilical venous catheter is fastest and most reliable
• Flush with 0.5-1 mL normal saline
• May repeat every 3-5 minutes if HR remains below 60

Critical Point: IV/IO is the preferred route because tracheal absorption is unpredictable and achieves lower plasma levels. The 2020 ANZCOR guidelines emphasise establishing vascular access promptly if anticipating need for adrenaline. [PMID: 32975136]

Umbilical Venous Catheter Insertion

Emergency Technique:

1. Clean umbilical stump with antiseptic
2. Place sterile tie loosely around base of cord
3. Cut cord 1-2 cm from skin with sterile blade
4. Identify vessels: 1 large, thin-walled vein (12 o'clock); 2 smaller, thick-walled arteries
5. Insert catheter (3.5-5F) into umbilical vein
6. Advance just until blood return (2-4 cm) - shallow insertion for emergency
7. Aspirate to confirm blood return
8. Flush and secure

Volume Expansion

Indications:

• Suspected blood loss (abruption, praevia, cord avulsion, fetomaternal haemorrhage)
• Signs of shock: pallor, weak pulses, poor perfusion
• Not responding to resuscitation despite effective CPR

Fluids:

• First-line: Normal saline 0.9%
• Severe blood loss: O-negative packed red blood cells

Dose: 10 mL/kg IV push over several minutes; may repeat

Medications NOT Routinely Used

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Meconium-Stained Amniotic Fluid

Current Approach (ANZCOR 13.4)

Critical Point: Routine tracheal suctioning is NO LONGER recommended for non-vigorous infants born through meconium-stained fluid. Emphasis is on initiating ventilation rapidly. [PMID: 33081527]

Management Algorithm

Vigorous Newborn (breathing/crying, good tone, HR above 100):

• NO routine suctioning
• Standard initial steps (dry, warm, stimulate)
• Observation for respiratory distress
• Routine care if remains well

Non-Vigorous Newborn (depressed tone, apnoeic/gasping, HR below 100):

• Standard initial steps
• Begin PPV if apnoeic or HR below 100
• Do NOT delay PPV for suctioning
• If airway obstruction suspected (no chest rise despite corrective steps) → Consider intubation and tracheal suctioning

Evidence Base

The 2015 and 2020 guidelines moved away from routine intubation and tracheal suctioning:

• No improvement in mortality or morbidity with routine suctioning [PMID: 32078962]
• Delayed initiation of ventilation with suctioning protocol
• Tracheal suctioning does not prevent meconium aspiration syndrome (MAS) if already aspirated in utero

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Special Populations

Preterm Infants (Below 32 Weeks)

Thermoregulation:

• Polyethylene bag/wrap without drying (except head)
• Increase room temperature to 25-26°C
• Chemical thermal mattress
• Target temperature 36.5-37.5°C

Respiratory Support:

• Start with lower FiO2 (21-30%)
• T-piece resuscitator preferred for consistent PEEP
• Consider CPAP for spontaneously breathing infants with distress
• Lower threshold for intubation and surfactant

Specific Risks:

• Intraventricular haemorrhage (avoid BP swings, hypercarbia)
• Retinopathy of prematurity (avoid hyperoxia)
• Bronchopulmonary dysplasia (avoid excessive pressures/volumes)

Congenital Diaphragmatic Hernia

Recognition: Scaphoid abdomen, respiratory distress, bowel sounds in chest

Key Modifications:

• Immediate intubation - avoid bag-mask ventilation (gastric distension)
• Low ventilation pressures
• Insert orogastric tube for decompression
• Prepare for ECMO consideration

Suspected Blood Loss

Signs: Pallor, weak pulses, poor perfusion, no response to resuscitation

Management:

• Urgent IV access
• Volume resuscitation: Normal saline 10 mL/kg initially
• O-negative blood if severe haemorrhage
• May need higher volumes (up to 30-40 mL/kg)

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Post-Resuscitation Care

Immediate Monitoring

Laboratory Assessment

Immediate:

• Blood gas (arterial/capillary) - pH, pCO2, base deficit, lactate
• Blood glucose
• Complete blood count

Within First Hours:

• Electrolytes, urea, creatinine
• Liver function tests
• Coagulation studies (if prolonged resuscitation/bleeding)

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Therapeutic Hypothermia for HIE

Eligibility Criteria (ANZCOR 13.9)

Criteria A - Evidence of Perinatal Asphyxia (any of):

• Apgar score ≤5 at 10 minutes
• Continued need for resuscitation at 10 minutes
• Cord or early arterial pH below 7.0
• Base deficit ≥16 mEq/L

Criteria B - Evidence of Moderate-Severe Encephalopathy:

• Altered level of consciousness (lethargy, stupor, coma)
• Abnormal tone (hypotonia or extensor posturing)
• Abnormal reflexes (weak/absent suck, Moro)
• Clinical seizures
• Abnormal aEEG (if available)

Additional Requirements:

• Gestational age ≥36 weeks
• Age ≤6 hours at initiation of cooling
• No congenital anomalies or alternative diagnoses

Cooling Protocol

• Target: 33.5°C ± 0.5°C (whole body) for 72 hours
• Rewarming: Slow over 6-12 hours (0.2-0.5°C/hour)
• Passive cooling can be initiated immediately (turn off warmer, remove blankets)

Critical Point: Time Is Brain: Therapeutic hypothermia must be initiated within 6 hours of birth for maximum benefit. If criteria met, begin passive cooling and arrange urgent transfer to a cooling centre. Do NOT delay transfer for investigations. [PMID: 19797281]

Outcomes with Therapeutic Hypothermia

Evidence from landmark trials (CoolCap, NICHD, TOBY, ICE):

• Reduction in death or major disability: NNT = 7-9
• Absolute risk reduction in mortality: ~10%
• Benefits sustained to school age [PMID: 19797281]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Higher Risk Factors:

• Higher rates of preterm birth (15.6% vs 8.2% non-Indigenous)
• Higher rates of low birthweight (12.5% vs 6.1%)
• Higher rates of maternal smoking, gestational diabetes
• Rural/remote location with delayed access to care

Cultural Considerations:

• Involve Aboriginal Health Workers/Liaison Officers
• Respect traditional practices where safe
• Allow family presence during resuscitation if possible
• Clear, culturally appropriate communication with family
• Document interpreter use

Maori Health (New Zealand)

• Whanau-centred care approach
• Cultural support from kaumatua if requested
• Awareness of higher rates of preterm birth and low birthweight
• Connection with Maori health providers

Remote/Rural Considerations

• Royal Flying Doctor Service retrieval protocols
• Telemedicine consultation for complex decisions
• Ensure equipment regularly checked and maintained
• Staff training and simulation critical
• Clear escalation pathways

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Discontinuation of Resuscitation

When to Consider Stopping

Consider Discontinuation When:

• No heart rate detected after 20 minutes of optimal resuscitation
• Gestational age or birth weight at threshold of viability without response
• Lethal congenital anomaly confirmed

Factors to Consider:

• Gestational age and presumed prognosis
• Underlying aetiology (reversible vs irreversible)
• Response to resuscitation (any heart rate present)
• Time elapsed since birth
• Quality of resuscitation efforts
• Parental wishes (prenatal counselling)

Critical Point: Apgar score of 0 at 10 minutes is associated with greater than 95% mortality and severe disability in survivors. However, individual cases with good outcomes have been reported. The decision to stop should involve the whole team and, when possible, the family. [PMID: 20008421]

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Apgar Scoring

Components

Timing

• Score at 1 minute and 5 minutes
• If 5-minute score below 7, continue every 5 minutes until 20 minutes or stable

Important: Apgar scores are for documentation - NOT to guide resuscitation decisions. Do not delay resuscitation to assign an Apgar score.

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Pitfalls and Pearls

Common Pitfalls

1. Delaying ventilation to suction - ventilation takes priority
2. Starting compressions before effective ventilation - ensure chest rise first
3. Wrong adrenaline concentration - always use 1:10,000 (NOT 1:1,000)
4. Hyperoxia in preterm infants - use SpO2 targets, start low FiO2
5. Excessive ETT depth - shallow for emergency UVC
6. Hyperthermia - as harmful as hypothermia in HIE
7. Missing cooling window - must initiate within 6 hours

Clinical Pearls

Clinical Pearl: Heart rate is the primary indicator of successful resuscitation. An improving heart rate indicates effective ventilation and oxygenation. Failure of heart rate to improve suggests inadequate ventilation - troubleshoot with MR SOPA before escalating.

Clinical Pearl: Adrenaline is rarely needed (0.01-0.03% of deliveries). If reaching for adrenaline, ensure ventilation is truly effective first. Most HR below 60 will resolve with optimised PPV.

Clinical Pearl: Delayed cord clamping benefits almost everyone - unless immediate resuscitation on the warmer is essential, wait at least 30-60 seconds. The blood volume and iron transfer have lasting benefits.

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Viva Practice

Viva Scenario 1: Term Infant with Meconium

Viva Scenario 2: Extreme Preterm Infant

Viva Scenario 3: Resuscitation Decision-Making

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OSCE Scenarios

OSCE Station 1: Newborn Resuscitation Leadership

Format: Resuscitation Leadership Time: 11 minutes Setting: ED resuscitation bay / Delivery room

Candidate Instructions:

A term infant has just been delivered and is not breathing. The midwife has called for help. You are the team leader. Lead the resuscitation.

Resources Available:

• 2 nurses, 1 registrar
• Full neonatal resuscitation equipment
• T-piece resuscitator

Expected Actions:

1. Assume team leader role and allocate tasks
2. Direct initial steps (warm, dry, stimulate)
3. Assess breathing and heart rate
4. Direct commencement of PPV at 60 seconds if indicated
5. Apply pulse oximetry and monitor SpO2
6. Direct MR SOPA if no chest rise
7. Direct compressions if HR below 60 after 30s effective PPV
8. Order adrenaline if HR below 60 after 60s CPR
9. Demonstrate closed-loop communication throughout

Marking Criteria:

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OSCE Station 2: Meconium Management Discussion

Format: Communication/Clinical Reasoning Time: 8 minutes Setting: Delivery suite

Candidate Instructions:

A 28-year-old woman is in labour at 41 weeks. Thick meconium is noted at amniotomy. The obstetric registrar asks you to attend the delivery and explain your management approach.

Expected Discussion Points:

1. All infants born through meconium are at risk of MAS
2. Vigorous infant: No routine suctioning required; standard care
3. Non-vigorous infant: Do NOT delay PPV for suctioning; intubate and suction only if airway obstruction prevents effective ventilation
4. Equipment preparation including intubation kit
5. Post-delivery monitoring for MAS signs
6. Therapeutic hypothermia consideration if HIE criteria met

Marking Criteria:

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SAQ Practice

SAQ 1 (8 marks)

A term newborn requires resuscitation at birth. Heart rate remains below 60 bpm despite 30 seconds of PPV with visible chest rise.

a) What is the correct compression-to-ventilation ratio in newborn resuscitation? (1 mark)

Model Answer: 3:1 (3 compressions to 1 ventilation)

b) Explain the physiological rationale for this ratio differing from paediatric resuscitation. (2 marks)

Model Answer:

• Neonatal cardiac arrest is almost always due to respiratory failure (hypoxic arrest) rather than primary cardiac causes (1)
• Therefore, ventilation is prioritised over compressions to reverse hypoxia (1)

c) Describe the correct technique for chest compressions in the newborn. (3 marks)

Model Answer:

• Two-thumb encircling technique preferred (1)
• Thumbs on lower third of sternum, just below nipple line (1)
• Compress to 1/3 of anterior-posterior chest diameter (1)
• Allow full chest recoil between compressions

d) After 60 seconds of compressions, HR remains below 60 bpm. What is the next step and the correct dose? (2 marks)

Model Answer:

• Administer adrenaline (epinephrine) (1)
• Dose: 10-30 mcg/kg (0.1-0.3 mL/kg of 1:10,000 solution) IV/IO (1)

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SAQ 2 (6 marks)

List the target preductal oxygen saturations for a term newborn during resuscitation at the following time points:

What is the recommended starting FiO2 for resuscitation of a term infant? (1 mark)

Model Answer: 21% (room air)

What is the recommended starting FiO2 for resuscitation of a preterm infant below 35 weeks? (1 mark)

Model Answer: 21-30%

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SAQ 3 (6 marks)

A term infant requires extensive resuscitation including adrenaline. ROSC is achieved at 8 minutes. Cord pH was 6.85 with base deficit -18. The infant is now lethargic with poor tone and weak suck.

a) What diagnosis should be considered? (1 mark)

Model Answer: Hypoxic-ischaemic encephalopathy (HIE)

b) List 4 criteria (from Criteria A or B) that would make this infant eligible for therapeutic hypothermia. (4 marks)

Model Answer (any 4):

Criteria A:

• Cord pH below 7.0 (this infant 6.85) ✓
• Base deficit ≥16 (this infant -18) ✓
• Apgar ≤5 at 10 minutes
• Need for resuscitation at 10 minutes

Criteria B:

• Altered level of consciousness (lethargy) ✓
• Abnormal tone (poor tone) ✓
• Abnormal reflexes (weak suck) ✓
• Clinical seizures

c) What is the maximum age at which therapeutic hypothermia should be initiated? (1 mark)

Model Answer: 6 hours from birth

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Key Differences from Other Guidelines

ANZCOR vs AHA vs ERC

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References

ANZCOR Guidelines (Primary Sources)

1. ANZCOR. Guideline 13.1 - Introduction to Resuscitation of the Newborn. 2021.
2. ANZCOR. Guideline 13.2 - Planning for Newborn Resuscitation. 2021.
3. ANZCOR. Guideline 13.3 - Assessment of the Newborn. 2021.
4. ANZCOR. Guideline 13.4 - Airway Management and Mask Ventilation of the Newborn. 2021.
5. ANZCOR. Guideline 13.5 - Tracheal Intubation and Ventilation of the Newborn. 2021.
6. ANZCOR. Guideline 13.6 - Chest Compressions during Resuscitation of the Newborn. 2021.
7. ANZCOR. Guideline 13.7 - Medication or Fluids for the Resuscitation of the Newborn. 2021.
8. ANZCOR. Guideline 13.8 - The Resuscitation of the Newborn in Special Circumstances. 2021.
9. ANZCOR. Guideline 13.9 - After the Resuscitation of a Newborn. 2021.
10. ANZCOR. Guideline 13.10 - Ethical Issues in Resuscitation of the Newborn. 2021.

PubMed Citations

11. Wyckoff MH, Wyllie J, Aziz K, et al. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020;156:A156-A187. PMID: 33081527
12. Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S524-S550. PMID: 33081529
13. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7: Neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015;95:e169-201. PMID: 26477422
14. Vento M, Asensi M, Sastre J, et al. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates. Pediatrics. 2001;107(4):642-647. PMID: 11242466
15. Dawson JA, Kamlin CO, Vento M, et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics. 2010;125(6):e1340-1347. PMID: 20516373
16. Isayama T, Mildenhall L, Schmölzer GM, et al. The Route, Dose, and Interval of Epinephrine for Neonatal Resuscitation: A Systematic Review. Pediatrics. 2020;146(4):e20200586. PMID: 32975136
17. Hooper SB, Te Pas AB, Kitchen MJ. Respiratory transition in the newborn: a three-phase process. Arch Dis Child Fetal Neonatal Ed. 2016;101(3):F266-271. PMID: 25883119
18. Hooper SB, Polglase GR, Roehr CC. Cardiopulmonary changes with aeration of the newborn lung. Paediatr Respir Rev. 2015;16(3):147-150. PMID: 26092932
19. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries. Resuscitation. 2012;83(7):869-873. PMID: 22801476
20. Kapadia P, Hurst C, Harley D, et al. Trends in neonatal resuscitation patterns in Queensland, Australia. Resuscitation. 2020;157:126-132. PMID: 32767696
21. Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5 mortality in 2000-15. Lancet. 2016;388(10063):3027-3035. PMID: 27839855
22. Azzopardi DV, Strohm B, Edwards AD, et al. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med. 2009;361(14):1349-1358. PMID: 19797281
23. Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005;353(15):1574-1584. PMID: 16221780
24. Jacobs SE, Berg M, Hunt R, et al. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev. 2013;(1):CD003311. PMID: 23440789
25. Fogarty M, Osborn DA, Askie L, et al. Delayed vs early umbilical cord clamping for preterm infants. Am J Obstet Gynecol. 2018;218(1):1-18. PMID: 29097178
26. Gomersall J, Berber S, Middleton P, et al. Umbilical Cord Management at Term and Late Preterm Birth: A Meta-analysis. Pediatrics. 2021;147(3):e2020015404. PMID: 33605427
27. Seidler AL, Gyte GML, Rabe H, et al. Umbilical Cord Management for Newborns Below 34 Weeks' Gestation: A Meta-analysis. Pediatrics. 2021;147(3):e2020015404. PMID: 29054196
28. McCall EM, Alderdice F, Halliday HL, et al. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2018;2(2):CD004210. PMID: 29405037
29. Lyu Y, Shah PS, Ye XY, et al. Association between admission temperature and mortality and major morbidity in preterm infants. JAMA Pediatr. 2015;169(4):e150277. PMID: 25911227
30. Welsford M, Nishiyama C, Shortt C, et al. Room air for initiating term newborn resuscitation: a systematic review with meta-analysis. Pediatrics. 2019;143(1):e20181825. PMID: 30593099
31. Trevisanuto D, Strand ML, Kawakami MD, et al. Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis. Resuscitation. 2020;149:117-126. PMID: 32078962
32. Dawson JA, Kamlin CO, Wong C, et al. Changes in heart rate in the first minutes after birth. Arch Dis Child Fetal Neonatal Ed. 2010;95(3):F177-181. PMID: 19897787
33. Katheria A, Rich W, Finer N. Electrocardiogram provides a continuous heart rate faster than oximetry during neonatal resuscitation. Pediatrics. 2012;130(5):e1177-1181. PMID: 24189866
34. Niles DE, Cines C, Insley E, et al. Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital. Resuscitation. 2017;115:102-109. PMID: 28697869
35. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med. 1995;149(1):20-25. PMID: 7827654
36. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation. Pediatrics. 2006;118(3):1028-1034. PMID: 16908774
37. Halling C, Sparks JE, Christie L, Wyckoff MH. Efficacy of intravenous and endotracheal epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. J Pediatr. 2017;185:232-236. PMID: 28854171
38. Tracy MB, Klimek J, Coughtrey H, et al. Mask leak in one-person mask ventilation compared to two-person in newborn infant manikin study. Arch Dis Child Fetal Neonatal Ed. 2011;96(3):F195-200. PMID: 21156637
39. Laptook AR, Shankaran S, Ambalavanan N, et al. Outcome of term infants using Apgar scores at 10 minutes following hypoxic-ischemic encephalopathy. Pediatrics. 2009;124(6):1619-1626. PMID: 20008421
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42. Australian Institute of Health and Welfare. Australia's mothers and babies. 2023. Available at: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies

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Summary Card

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Documentation Requirements

Required Elements for Resuscitation Record

Communication Handover Structure (ISBAR)

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Quality Improvement Metrics

Performance Targets (ANZCOR)

Team Training Requirements

• Neonatal resuscitation certification for all staff attending deliveries
• Simulation training: Regular practice improves team performance
• Debriefing: Post-event debriefing identifies areas for improvement
• Mock codes: Regular drills maintain readiness and identify equipment/system issues

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Remote and Rural Considerations

RFDS/Retrieval Considerations

Pre-Retrieval Stabilisation:

• Ensure temperature 36.5-37.5°C
• Secure airway if ongoing respiratory support needed
• Establish IV access (UVC or peripheral)
• Check blood glucose and treat hypoglycaemia
• Document all interventions thoroughly

Telemedicine Consultation:

• Video consultation with neonatologist if available
• Clear communication of clinical status
• Guidance on cooling initiation if indicated
• Retrieval team contact and ETA

Equipment Considerations:

• Regular equipment checks essential in remote areas
• Backup equipment must be available
• Self-inflating bag does not require gas source
• Consider battery backup for monitors

Delayed Access to NICU

If transfer will be prolonged and cooling indicated:

• Begin passive cooling immediately (turn off radiant warmer, remove blankets)
• Target temperature 33-35°C rectal/oesophageal
• Monitor temperature continuously
• Avoid overcooling (below 32°C) and hyperthermia
• Document time of cooling initiation

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Exam Tips and Common Mistakes

OSCE Tips

1. Announce your role: "I am the team leader for this resuscitation"
2. Think aloud: Verbalise your assessment and decision-making
3. Use closed-loop communication: Confirm instructions are heard and completed
4. Follow the algorithm: ANZCOR algorithm adherence is marked
5. Prioritise ventilation: Say "Effective ventilation is the single most important intervention"
6. Time awareness: Note time intervals (30 seconds PPV → compressions; 60 seconds CPR → adrenaline)

Common Viva Mistakes

1. Using AHA terminology instead of ANZCOR - Know Australian guidelines
2. Wrong adrenaline concentration - Always 1:10,000 for neonates
3. Wrong adrenaline dose - 10-30 mcg/kg IV (NOT 0.1 mg/kg like adults)
4. Starting compressions before effective ventilation - Ensure chest rise first
5. Forgetting cooling eligibility - Must assess for HIE after any significant resuscitation
6. Not addressing preterm-specific needs - Polyethylene wrap, lower starting FiO2, SpO2 targets

SAQ Common Errors

1. Listing wrong SpO2 targets - Learn the minute-by-minute targets
2. Forgetting IV is preferred over ETT for adrenaline - Always mention route preference
3. Missing cooling time window - Must state 6 hours from birth
4. Incomplete cooling criteria - Need both Criteria A AND Criteria B

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Related Topics

• Paediatric Resuscitation
• Hypoxic-Ischaemic Encephalopathy
• Meconium Aspiration Syndrome
• Neonatal Sepsis
• Neonatal Respiratory Distress Syndrome
• Persistent Pulmonary Hypertension of the Newborn

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