Introduction-

Ninety per cent of new-borns make the transition from intrauterine to extrauterine life and require little or no assistance to begin spontaneous and regular breathing. About 10% of new-borns will need some assistance to start breathing at birth, and only about 1% may need extensive CPR to survive. Asphyxia at birth is a leading cause of neonatal mortality and morbidity, accounting for one-fifth of all neonatal deaths in India. These deaths can be averted with proper prenatal and intrapartum care, the right technique, and the steps of neonatal resuscitation.

The basic New-born resuscitation within the one golden minute is sequential activities performed to stimulate and assist breathing in babies who do not cry (Breathing) spontaneously at birth which can reduce neonatal mortality.    

Objective-

The Objective of the Resuscitation is to establish and maintain a clear airway to ensure effective circulation to correct acidosis and prevent hypothermia, hypoglycaemia and haemorrhage. Careful intrapartum fetal heart rate assessment can alert the midwife to the probable need for new-born resuscitation.

The fetus undergoes Prolong period of Birth asphyxia and may make gasping attempts followed by apnoea in utero (Primary Apnoea). At Birth, Weaker Gasping may be followed by the last Gasp and a Secondary Period of aponia. The heart rate falls Dramatically and without intervention, neonates may die.

By the end of this exercise, the participant will be able to resuscitate a new-born baby.

Basic resuscitation if performed correctly, will help most infants to survive even in resource-limited settings.

Key Points of successful Resuscitation
1.	Anticipation
2.	Preparation
3.	Call for help when needed
4.	Be able to work quickly in coordination (with the helper or the Team)
5.	Communicate effectively
6.	Be gentle but quick during the Procedure
7.	Provide Warmth during the Procedure
8.	Maintain Infection Prevention Practices During Procedure
9.	Documentation/ Record

Get Ready with

1. A draught-free, warm room with a temperature of 26°C- 28°C.
2. Neonatal resuscitation bag (Bag and Mask) 250-500 ml with oxygen reservoir
3. Face masks, For term size 1 and for pre-term/LBW Size 0.
4. Mucus extractor (Sterile and Single use) or Suction devices & catheters, No. 12FG, 14 FG oral suction.
5. Shoulder Roll (A folded piece of cloth, 1/2 to 1 inch thick to position the baby)
6. Gloves
7. Two clean, warm towels/clothes
8. Radiant warmer
9. Oxygen source with flow meter and tubing
10. Pulse oximeter
11. Digital Clock with second hand
12. Cord clamp/ sterile thread
13. Scissor
14. Cap, Gloves and Socks
15. Medications: Epinephrine, normal saline
16. Identification Tag
17. Identify the Helper to support in the New-born Resuscitation process

Make sure these are in a functional condition-

• Bag and mask
• Radiant warmer
• Oxygen source
• Clock with a second-hand

Procedure Steps:-

Steps		Rationale	Score	Participants
				1	2	3	4	5
1.	Arrange all the necessary equipment		1
2.	Ensure radiant warmer on 20-30 minutes before delivery		1
3.	Rapid assessment of newly born who do not require resuscitation can generally be identified by the following four characteristics: 1. Was the infant born after a full-term gestation? 2. Is the amniotic fluid clear of meconium and evidence of infection? 3. Is the Newborn breathing or crying? 4. Does the Newborn have good muscle tone?		2
4.	If the answer to all four of these questions is ‘YES,’ go for routine care	The new-born does not need resuscitation and should not be separated from the mother.  New-born can be dried, placed directly on the mother’s chest and covered with dry linen, to maintain temperature. Observation of breathing, activity and colour should be ongoing.	2
5.	If anyone of the above component is NO- Call for helpClamp and cut the cord immediately and shift the New-born to a Radiant warmer.		2
6.	In the Radiant warmer perform the initial steps of New-born Resuscitation PSDSR (Within first 30 second of life)   1. Place the baby on its back and position the head so that neck is slightly extended (to open the airway) by placing a shoulder roll under the baby’s shoulder to help maintain this Position.	Shoulder roll should not be too thick or thin, this may cause overextension or flexion which will close the airway	2
	2. If there is thick meconium and the baby is unresponsive, suction should be carried out before drying the baby.   If there is no meconium, there is no need to do suction.	Suction first the mouth and then the nose (Remember ‘M’ comes before ‘N’)Do this by gently introducing a suction tube 5 cm into the baby’s mouth until the ‘5 cm’ mark is at the baby’s lips. Use suction while withdrawing the tube Next introduce the suction tube up to 1-2 cm into each nostril Use suction while withdrawing the tube Repeat suction if there is a lot of mucus, amniotic fluid or meconium but not more than two times or for a duration exceeding 20 seconds	2
	3. Dry the baby thoroughly under the radiant warmer and remove the wet linen.	Drying will stimulate the Newborn and prevent hypothermia.	1
	4. Provide Tactile Stimulation to the Newborn by Flanking on the Sole or Gently Rubbing the back, trunk and extremities of the baby by using Two finger	Any form of stimulation will initiate breathing if the baby is in primary apnoea. Therefore 1 or 2 flicks on the sole or gently rubbing the back once or twice is sufficient.	1
	5. Reposition the Newborn and Assess the Breathing and heart rate for 6 second	Make sure shoulder roll placed appropriately	1
7.	If the Newborn is not Breathing go for ventilation (next 30 second of life ) Apply an appropriately sized mask (0 for preterm and 1 for term baby) correctly covering the mouth and nose up to the chin		2
8.	Start providing positive pressure ventilation (PPV) or bagging (calling out ‘2, 3, squeeze’). Start with 5 prolonged inflation breaths (lasting 2-3 seconds) make sure the chest raises bilaterally with each ventilation.	When chest rise is seen, this indicates a good ventilation technique	1
9.	If the chest does not rise, check for the correct position, look for leaks from the face mask/seal and give a further 5 inflation breaths		1
10.	After 30 seconds of the bag and mask ventilation, Reassess the breathing and heart rate (Umbilical Pulse) for 6 seconds. If available, apply a pulse oximeter probe and connect it to the machine.	Umbilical Pulsation felt in 6 seconds * 10 = Heart rate	1
11.	If the newborn is breathing well and HR >100/Minutes, Bean of the bag and mask Ventilation and refer for observational care, fill in the details of resuscitation.   If the newborn is not breathing well /or HR between 60-100/Minutes, continue PPV (bagging) for 30 seconds at a rate of 40–60 breaths/ min and connect Oxygen.   If the Heart Rate is < 60 / minute continue PPV (Bag and mask) with Oxygen and start Chest Compression and administer Medication (Only under the supervision of a paediatrician)	The rate of oxygen for newborns is 0.5-1 litre / Minute. For newborns, give the amount of oxygen which is needed to reach an oxygen saturation of between 90 to 95 %. Administering too much oxygen to a newborn, particularly a preterm, can cause serious damage to the retina and blindness.	2
12.	At any point, if the New-born start breathing spontaneously and is seen chest raising bilaterally bean off the bag and mask ventilation and give post-resuscitation care, stabilize the New-born and refer a higher centre for further observation and care.		1
13.	If no improvement, continue bag and mask ventilation Maximum for 20 Minutes and prepare to refer to the appropriate centre.	The Referral unit will be nearest to NBSU or SNCU.	2
Total			25

After 5 cycles of PPV (Bag and mask ventilation) if the chest is not raised check the following

	Problem	Need to be check
M	Inadequate seal	Adjust the mask to ensure an airtight seal
R	Inappropriate position	Reposition the Head in the sniffing Position (Flexion of the neck and extension of the head) by using shoulder roll.
S O	Blocked Airway	Perform suction if needed or open the Newborns mouth and ventilate
P	Inadequate Pressure	squeezing the bag with more pressure till the chest is start raising
A	No Improvement after following the above steps	Now go for an alternate option such as endotracheal intubation

Key points to remember:

• Anticipate and prepare for resuscitation immediately in the Labour room New-born care corner/ Area (NBCC/NBCA)
• Organize the Labour room as per the Delivery load.
• Call for help if the newborn is not crying spontaneously or Breathing at any point after Birth.
• Suction of the mouth and nose in new-born babies can cause injury and should only be carried out if there is meconium.
• Routine suction is not recommended if the new-born is crying even if the liquor is meconium stained.
• Do not Perform postural drainage, or squeeze the chest to remove secretion from the airway.
• Do not stimulate the new-born by slapping.
• Ensure that the bag and mask are functional and ready for use.
• The masks are available in sizes 0 and 1 for preterm and term babies
• Normal new-born respiration is 40–60 breaths/min.
•  For new-born oxygen should be given to reach an oxygen saturation of between 90- 95%.
• To administer a fixed flow of oxygen without checking can cause serious damage to the retina and cause blindness.
• Ensure the chest is raised while ventilating with a bag and mask
• Babies who require positive pressure ventilation for more than one minute or need further resuscitation with chest compressions and/or drugs are at risk of deterioration and at high risk for developing subsequent complications. These babies should be referred to a higher centre for supervised medical care.

Observational care with Mother-

• Place the baby in a prone position between the mother’s breasts.
• Cover baby and mother together.
• Initiate breastfeeding.
• Monitor neonate (temperature, heart rate, breathing and colour, every 15 minutes in the first hour and then every 30 minutes in the next hour).

Points to remember during observational care-

• Keep the mother and baby together in skin-to-skin contact to keep the baby warm.
• NEVER leave the mother and newborn alone. Monitor the duo every 15 minutes during the first hour.
• Check breathing, temperature and colour. Watch for complications & refer immediately, if present.
• Encourage the mother to breastfeed her baby as soon as she is ready. This will help prevent hypoglycaemia (low blood sugar).
• Assess the baby’s attachment at the breast, and help the mother breastfeed if needed. Good suckling is a sign of recovery. If the baby cannot suck effectively, help the mother express colostrum.
• Record the sequence of events during resuscitation and explain them to the mother and family. Keeping records of events that occur at the time of delivery and in the immediate period can be vital. The information is important if a baby needs to be referred or becomes sick in the next few days.