1) Newborns requiring resuscitation should be kept warm through drying, warming blankets/towels, and a pre-warmed heat source like an open bed warmer. Continuous temperature monitoring is important, especially for preterm infants who may need plastic wrap. 2) Bradycardia below 100bpm requires positive pressure ventilation and pulse oximetry. Chest compressions should be initiated if the heart rate remains below 60bpm after 30 seconds of effective PPV. 3) Intubation may be needed if the heart rate remains low despite ventilation and chest compressions. Umbilical vein catheterization can provide vascular access for medications like adrenaline.

1. Code Pink
What to think about when running up
to Delivery Suite
A summary of the Australian
Resuscitation Council Guidelines
For Newborn Resuscitation

2. Australian Resuscitation Council
Guidelines
http://www.resus.org.au

4. The transition from fetus to
newborn requires intervention by a
skilled individual or team in
approximately 10% of all deliveries.

5. Keep warm
Hypothermia on admission to the neonatal unit
has been shown to be associated with an
increased mortality. It is essential to prevent
excessive heat loss in the delivery room and
throughout stabilization and transport to the
neonatal unit.

6. Keep Warm
Hypothermia can increase oxygen
consumption and impede
effective resuscitation

7. Axillary Temperatures in Infants
Weighing Less Than 1500 gm
Ranges Temperature Action Needed
Normal 36.5-37.5o C Continue
Potential cold stress 36-36.5o C Cause for concern
Moderate hypothermia 32-36o C Danger; immediate
warming of baby needed
Severe hypothermia < 32o C Outlook grave; skilled
care urgently needed

8. Keep Warm
• Newborns should be dried with pre-warmed
blankets or towels and placed on a pre-warmed
heat source. Open bed warmers, which use
radiant heat, are used in most delivery rooms.
They provide warmth during resuscitation and for
any subsequent invasive procedures. It is
important to keep in mind that this source of
heat does not protect the infant from evaporative
heat loss but, instead, encourages evaporative
heat losses.

9. Keep Warm
• Continuous monitoring of temperature should
occur as soon as possible after the delivery.
Premature infants (< 1500 g) should be
covered in plastic wrap (polyethylene) to
prevent excessive heat loss. A full
resuscitation, including line placement, can
and should be performed with the plastic
wrap in place. A woolen head cap should be
used.

10. Keep Warm
• Another common source of heat loss in the
neonate undergoing resuscitation is the use of
unheated non-humidified oxygen sources for
the bag-valve-mask device. The inspired gases
sent to the lungs are subsequently heated and
humidified by the infant; this results in
massive heat exchange from evaporative heat
loss and insensible water loss. Whenever
possible, warmed and humidified gases should
be provided in the resuscitation area.

11. Airway management
• Once in a heated environment, the infant
should be positioned so as to open the airway,
and the mouth and nose should be suctioned.
• Should suction involve larynx
and Trachea?

12. Easy answer is no!!
• Infants have a vagal reflex response to sensory
stimulation of the larynx, which may induce
apnea, bradycardia, hypotension, and
laryngospasm.
• Suctioning the posterior oral airway or the
trachea with a catheter because of extremely
thick or meconium-stained fluids may cause
profound central apnea, potentially profound
bradycardia, and laryngospasm

13. Suctioning
• Instillation of saline into the trachea also has
been shown to stimulate the afferent sensory
neurons leading to apnea, bradycardia,
hypotension, and laryngospasm.
• Suctioning the posterior oral airway or the
trachea consequently has no place in the
immediate resuscitation period.
• Lung inflation has been shown to reverse the
effects of vagal stimulation.

14. Code Pink
If called to Delivery suite
Heart Rate is the critical sign.
>100 is crucial

15. Bradycardia is Bad
• Normal Newborn HR is 100-160
• HR below 100 requires Positive Pressure
Ventilation and Pulse Oximetry
• This is irrespective of normal or abnormal
Respiratory effort

16. Why is Bradycardia bad?
• A fetus or newborn that is subjected to
asphyxia initiates a "diving" reflex in an
attempt to maintain perfusion and oxygen
delivery to vital organs. Hypoxia and acidosis
lead to pulmonary arteriolar vasoconstriction.
Pulmonary vascular resistance increases,
leading to decreased pulmonary blood flow
and increased blood flow directly to the left
atrium.

17. Why is Bradycardia bad?
• Systemic cardiac output is redistributed, with
increased flow to the heart, brain, and adrenal
glands and decreased flow to the rest of the
body. Early in the course of asphyxia, systemic
blood pressure increases.
• With ongoing hypoxia and acidosis, however, the
myocardium fails and bradycardia occurs; this
causes a decrease in blood pressure and tissue
perfusion, leading to eventual tissue ischemia
and hypoxia.

18. • With prolonged asphyxial insult
and failure of compensatory
mechanisms, cerebral blood flow
falls, leading to ischemic brain
injury

19. What about Oximetry?
•Is a cyanosed Newborn
normal?

20. Targeted pre-ductal SpO2 after birth
• 1min 60-70%
• 2min 65-85%
• 3min 70-90%
• 4min 75-90%
• 5min 80-90%
• 10min 85-90%

21. Changes in circulation after birth

22. Reversal of right to left shunting
• Clamping of the umbilical cord removes the low-resistance
placental vascular circuit and thereby raises total systemic
vascular resistance, with a resultant increase in left
ventricular and aortic pressures. The increased systemic
vascular resistance, combined with the decreased
pulmonary vascular resistance, reverses the shunt through
the ductus arteriosus (from right-to-left shunting to left-to-
right shunting) until the ductus closes completely.
• All of these events result in closure of the other fetal
shunts. With the decrease in right atrial pressure and the
increase in left atrial pressure, the 1-way "flap-valve"
foramen ovale is pushed closed against the atrial septum.
This functional closure at birth is followed by anatomic
closure, which usually occurs at several months of age.

23. • Functional closure of the ductus arteriosus
generally occurs within 72 hours of life, with
anatomic closure by age 1-2 weeks.
• Functional postnatal circulation generally is
established within 60 seconds; however,
completion of the transformation can take up
to 6 weeks.

24. How to correct Bradycardia
• PPV using Neopuff
• 5cm PEEP (Positive End Expiratory Pressure)
• 30cm PIP (Peak Inspiratory pressure)
• Settings should already be made on resus
trolley

25. PPV
• Ventilatory rates of 40-60 breaths/min should
be provided initially, with proportionally fewer
assisted breaths provided if the infant's
spontaneous respiratory efforts increase.

26. NEOPUFF

27. NEOPUFF

28. What to do if HR< 60
• Commence Chest compressions
• 100% O2
• Intubation or LMA

29. HR< 60
Chest compressions should be initiated after
only 30 seconds of effective PPV if the heart
rate remains below 60 beats/min.

30. Chest Compressions

31. Chest Compressions
• Pressure should be applied to the lower portion
of the sternum, depressing it to a depth of about
one third of the anterior-posterior diameter. The
chest should fully re-expand during relaxation.
One ventilation should be interposed after every
3 chest compressions.
• An overall rate of 120 compression/ventilation
events per minute is recommended; with the 3:1
compression-to-ventilation ratio, this equates to
90 compressions and 30 breaths each minute.

32. Chest Compressions
• Evaluate heart rate and color every 30
seconds. Infants who fail to respond may not
be receiving effective ventilatory support;
thus, constantly evaluating ventilation is
imperative. Chest compressions should be
discontinued when the heart rate is 60
beats/min or higher.

33. Intubation
• If things still not going well
then intubation required

34. Intubation
Blade size 0 or 1 should be chosen in accordance with the size of
the infant. Premature infants may be more easily intubated with a
size 0 blade, and term infants require a size 1 blade.
Endotracheal tube should be chosen in accordance with the weight
of the infant .
• Table 3. Endotracheal Tube Size and Measurement at Lip According
to Infant Weight
• Infant Weight Endotracheal Tube Size Endotracheal
Tube Measurement at Lip
• < 1000 g 2.5 7 cm
• 1000-2000 g 2.5-3 8 cm
• 2000-3000 g 3-3.5 9 cm
• > 3000 g 3.5-4 10 cm

35. Intubation
• Another way of estimating correct placement
of the ET tube is to take the weight of the
infant in kilograms and add 6 to yield the
number of centimeters at which the tube
should be secured at the lip.

36. Intubation
• Assessment for equal bilateral breath sounds
with maintenance of oxygenation.
• An increase in the heart rate within 5-15
seconds is an excellent indicator of adequate
ventilation and appropriate ET tube
placement.

37. Intravenous Access
• Needed for Volume expansion
• Administration of Adrenaline

38. Intravenous Access
• Peripheral Venous access
• Umbilical Vein Catheterisation
• Intraosseous access generally not
recommended (Too small intramedullary
space and fragile bones)

39. Intravenous Access
• Umbilical vein catheterization may be a life-
saving procedure in neonates who require
vascular access and resuscitation.
• The umbilical vein remains patent and viable
for cannulation until approximately 1 week
after birth

40. Umbilical Vein Catheterisation

41. Umbilical Vein Catheterisation
• Advance the catheter only 1-2 cm beyond the
point at which good blood return is obtained.
This is approximately 4-5 cm in a full-term
neonate.

42. Umbilical Vein Catheterisation
• Secure the catheter with a suture through the
cord, marker tape, and a tape bridge.
• The position of the catheter must be
confirmed radiographically. A properly placed
umbilical vein catheter appears to travel
cephalad until it passes through the ductus
venosus

43. Adrenaline
• The recommended dose is 0.01-0.03 mg/kg
(0.1-0.3 mL of the 1:10,000 solution),
preferably administered intravenously (IV).
Higher IV doses are not recommended

44. Adrenaline
• If you are too overwhelmed and can’t think
• Easy tip to remember is that average newborn
in size will need
1ml of 1:10,000
Adrenaline

45. Adrenaline
• If vascular access cannot be obtained,
Adrenaline may be given via the ET tube
• The dose should be increased to 3 times the IV
dose. Followed with infusion of 0.5-1 mL of
saline to ensure that the drug is delivered to
the lung, where it is absorbed and delivered to
the heart.

46. Volume Expansion
• Suspected Blood loss
• Pale poor perfusion or weak pulse
• Not responded to other resuscitative
measures
10ml/kg IV push over
few minutes

47. Anything else?
• “DEFG” Don’t ever forget Glucose
If glucose low, administer 5ml/kg 10%
Dextrose and recheck

48. What Next?
•Get as much help as
possible locally
•NETS retrieval to NICU