Neonatal resuscitation and post-resuscitation stabilisation — formative SAQs

SAQ 1 — The first-minute algorithm and escalation (10 marks)

A term infant is born apnoeic and limp after an emergency caesarean for fetal bradycardia. After warmth, drying and stimulation there is still no breathing, and the heart rate is 70 beats per minute. [1] [10]

Questions

1. State the three first-minute assessment questions and the action each "no" triggers. (3 marks) [1]
2. Describe your ventilation technique: rate, starting pressure, and starting oxygen for this term infant. (3 marks) [1]
3. The heart rate falls to 44 despite 30 seconds of effective ventilation with visible chest rise. State the next steps, including the compression-to-ventilation ratio and the adrenaline dose. (4 marks) [1] [4]

Model answer

First-minute triage (3). The three questions are: is the baby term, is there good tone, and is the baby breathing or crying? A "no" to any, or apnoea or gasping, moves the infant onto the resuscitation pathway. This infant is term but limp and apnoeic, so the pathway begins with positive-pressure ventilation. [1]

Ventilation (3). Begin positive-pressure ventilation at 40 to 60 breaths per minute using the lowest pressure that gives gentle chest rise (about 20 to 25 cm of water in most term infants), starting in air (21% oxygen) for a term infant. Titrate the inspired oxygen against the pre-ductal saturation nomogram. [1]

Escalation (4). Because the heart rate is under 60 despite at least 30 seconds of effective ventilation, add chest compressions coordinated with ventilation in a 3:1 ratio (about 120 events per minute) using the two-thumb encircling technique, and raise the inspired oxygen toward 100%. If the heart rate remains under 60, give adrenaline 0.01 to 0.03 mg per kilogram intravenously (0.1 to 0.3 mL per kilogram of the 1:10,000 concentration) via an umbilical venous catheter, repeated every three to five minutes. Reassess the heart rate every 60 seconds. [1] [4]

SAQ 2 — Post-resuscitation stabilisation and cord management (10 marks)

A 26-week gestation infant is being resuscitated. The team is debating cord management, and a separate term infant who needed advanced resuscitation is now four hours old and encephalopathic. [2] [7] [9]

Questions

1. Discuss deferred cord clamping versus intact cord milking for this 26-week infant, citing the evidence on milking at this gestation. (4 marks) [6] [7]
2. Outline the post-resuscitation stabilisation bundle for any resuscitated newborn, covering temperature, glucose and surveillance. (3 marks) [1] [2]
3. State the criteria and the time window for therapeutic hypothermia for the encephalopathic term infant, and what the delivering unit should do. (3 marks) [9]

Model answer

Cord management (4). Deferred cord clamping (30 to 60 seconds) is supported for stable preterm infants who do not need immediate resuscitation. Intact cord milking is not recommended under 28 weeks: Katheria's randomised trial showed an excess of death or severe intraventricular haemorrhage with milking versus delayed clamping in this group. If the 26-week infant needs immediate resuscitation that cannot be provided with the cord intact, clamp and cut the cord and begin resuscitation; if a bedside set-up allows resuscitation with the cord intact, deferred clamping may be considered for a stable infant. [7]

Post-resuscitation bundle (3). Maintain normothermia at 36.5 to 37.5 degrees (avoid both hypothermia and hyperthermia), check and maintain blood glucose to avoid hypoglycaemia, admit to a neonatal unit for monitoring, and observe for encephalopathy, seizures, feeding difficulty and respiratory distress. Screen for sepsis and treat empirically when indicated. [1] [2]

Cooling (3). An infant of 36 weeks gestation or more with moderate or severe hypoxic-ischaemic encephalopathy is referred to a cooling centre within six hours of birth, because therapeutic hypothermia to 33.5 degrees for 72 hours reduces death and disability (TOBY). The delivering unit does not start controlled cooling; it maintains normothermia, treats seizures, and transfers urgently with the regional neonatal retrieval service. [9]