Neonatal resuscitation and post-resuscitation stabilisation — branching viva

Opening (candidate)

My first move is to ventilate. The baby is term, apnoeic and bradycardic, which puts him straight onto the resuscitation pathway. I would start positive-pressure ventilation in air at 40 to 60 breaths per minute, ask the nurse to apply pre-ductal pulse oximetry and three-lead ECG, and call for senior neonatal help. I would watch for chest rise and recheck the heart rate at 30 seconds, running MR SOPA if ventilation is not effective. [1] [10]

Branch A — The algorithm and the heart-rate ladder

Examiner: Walk me through the escalation. The heart rate is now 44 after 30 seconds of effective ventilation. [1]

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

Branch B — Why ventilation first

Examiner: Why not compress immediately, as you would in an adult arrest? [10]

Candidate: Because the problem at birth is almost always the lung, not the heart. In fetal life the lungs are fluid-filled and the pulmonary vessels are constricted; the first breaths aerate the lung, drop pulmonary resistance and close the fetal shunts. When aeration fails the circuit stays fetal and the hypoxic newborn heart slows. Restoring ventilation re-opens the circuit, which is why the heart rate usually recovers without compressions. Inadequate ventilation is the commonest reason a newborn fails to transition, so I fix ventilation before I escalate. [2] [10]

Branch C — Oxygen and saturation targeting

Examiner: You started in air. What are you targeting, and when would you change the oxygen? [8]

Candidate: For a term infant I start in 21% oxygen and titrate against the pre-ductal saturation nomogram: about 60 to 65% at one minute, 80 to 85% at five minutes, 85 to 95% at ten minutes. I would not chase 100% too early, because excess oxygen causes oxidative injury, especially in the preterm. For a preterm infant under about 35 weeks I would start in 21 to 30% oxygen. When compressions begin I raise the oxygen toward 100% and wean it back as the heart rate recovers. [1] [8]

Branch D — Cord management and the preterm caveat

Examiner: The next delivery is a 26-week preterm. How do you manage the cord? [7]

Candidate: For a stable preterm I favour deferred cord clamping for 30 to 60 seconds, ideally with resuscitation possible at the bedside with the cord intact. I would not use intact cord milking under 28 weeks — Katheria's trial showed an excess of death or severe intraventricular haemorrhage with milking versus delayed clamping in this group. If the infant needs immediate resuscitation that cannot be provided with the cord intact, I clamp and cut and begin resuscitation. [7]

Branch E — The cooling clock

Examiner: The term infant recovers but at four hours is hypotonic with seizures. What now? [9]

Candidate: This is moderate or severe hypoxic-ischaemic encephalopathy in a term infant, so the cooling clock is running. Therapeutic hypothermia to 33.5 degrees for 72 hours reduces death and disability, and it must begin within six hours of birth. I would not start controlled cooling locally; I would maintain normothermia at 36.5 to 37.5 degrees, treat the seizures, check the glucose, and refer urgently to the regional cooling centre via the neonatal retrieval service. [9]

Close

Confirm the airway is secure and the heart rate recovered, hold normothermia and normoglycaemia, screen and treat for sepsis, watch for encephalopathy, and — for the eligible term infant — refer for cooling within six hours. Debrief the team and document the sequence, times, interventions and responses, and speak honestly and early with the family. [1] [9]