Ashok K. Deorari
the Division of Neonatology, Department of Pediatrics, All India
Institute of Medical Sciences, New Delhi 110 029, India.
Correspondence to: Dr. Ashok K. Deorari,
Additional Professor, Division of Neonatology, Department of
Pediatrics, All India Institute of Medical Sciences, New Delhi 110
I read with interest the article on ‘Guidelines
2000 for Neonatal Resuscita-tion’(1) which was based on ‘International
Guidelines for Neonatal Resuscitation’(2). On 27th October 2000, the
American Academy of Pediatrics formally launched Neonatal Resuscitation
Programme (NRP) Provider Course and released a new ‘Textbook of
Neonatal Resuscitation, 4th Edition’ along with multimedia CD-Rom(3).
All of us, who are involved in the care of newborn
are curious to know the changes which will have a bearing on our
practice of newborn resuscitation. Given below are the important changes
in the revised NRP in a tabular form (Table I) to serve as a
Changes in the Revised NRP
delivery there should be at least one person with the skills
required to perform a complete resuscitation. When that
person is caring for the mother, another person capable of
initiating and assisting with resuscitation must be
primarily responsible for the infant, even when a normal,
healthy infant is expected.
initial steps baby is assessed for respirations, heart rate and
wet linen, position, suction, stimulate to breathe, if
respirations and intervene, if necessary.
heart rate and intervene, if necessary.
color and intervene, if necessary.
done in the sequential manner for respirations, heart rate and
of meconium stained liquor for oropharyngeal suction use 10 F or
larger suction catheter.
suctioning is indicated for all infants who are depressed and
have meconium and for any infant passing through thick
particulate meconium stained liquor.
suction should be repeated till returns are clear. If the baby
is severely depressed positive pressure ventilation may be
needed even if some meconium remains in the airway.
compressions are indicated when the heart rate, after 15-30
seconds of positive pressure ventilation with 100% oxygen, is
below 60 bpm or between 60 and 80 bpm and not increasing.
compressions are stopped if the heart rate >80/bpm
Lower third of
the sternum is located by imagining a line drawn between the
compressions, depress the sternum ½ to ¾ inch.
indicated when the heart rate remains below 80 bpm despite a
minimum of 30 seconds of adequate ventilation with 100% oxygen
and chest compression or if the heart is zero.
general instructions for epinephrine administration via
expanders include 5% albumin.
delivery, there should be at least one person whose primary
responsibility is the baby and who is capable of initiating
resucitation. Either that person or someone else who is
immediately available (not at home or in a remote hospital
location) should have the skills required to perform a
complete resuscitation, including endotracheal intubation
and administration of medications.
Assessment of the newborn begins
at the time of birth. The five questions clearly differentiate
the baby in need of assistance from the baby who can receive
routine care. If the answer to any of these initial assessment
questions is no, the baby requires the initial steps under the
radiant warmer. If all answer are yes, the baby can be
provided routine care:
1. Is the
amniotic fluid clear of meconium?
2. Is the baby
breathing or crying?
3. It there
good muscle tone?
4. Is the baby’s
5. Is the baby
Nearly 90% of
newborns are vigorous term babies with no risk factors and clear
amniotic fluid. They can be directly placed on mother’s chest,
dried and covered with dry linen. Warmth is maintained by direct
skin-to-skin contact with the mother. Clearing of the upper
airway can be provided as necessary by wiping the baby’s mouth
and nose. Ongoing observation of breathing, activity and color
should be carried out.
If deemed necessary:
clear airway, dry, remove wet linen, stimulate, reposition,
give oxygen as necessary.
Simultaneously, evaluate respirations, heart rate color during
the initial steps.
If the baby
is breathing and cyanotic or begins to breathe during the
initial steps and is cyanotic, administer free-flow oxygen.
After completion of the initial steps, base further
interventions on simultaneous assessment of respirations,
heart rate and color.
done simultaneously for respirations, heart rate and color
suction use 12 F or larger suction catheter.
The need to
suction the trachea for meconium is determined by whether or not
the baby is vigorous at birth. Vigor is defined by strong
respiratory effort as evidenced by cry, good muscle tone, and a
heart rate >100 bpm. If any of the criteria is not met, the
newborn requires tracheal suctioning. Thin or thick meconium
does not guide need for intubation.
If you recover
meconium with the first suction, check the heart rate. If the
baby does not have significant bradycardia, reintubate and
suction again. If the heart is low you may decide to administer
positive pressure ventilation without repeating the procedure.
compressions are indicated when the heart rate remains at <60
bpm despite 30 seconds of effective positive-pressure
compressions are stopped if the heart rate >60/bpm.
Lower third of
the sternum is located by running finger along the lower edge of
ribs till xiphoid. Area just above xiphoid is used for chest
sternum one-third of the anterior-posterior diameter of the
indicated when the heart rate remains below 60 bpm despite 30
seconds of assisted ventilation and another 30 seconds of
coordinated chest compressions and ventilation.
detailed instructions for epinephrine administration via
emergency umbilical venous catheter as well.
5% albumin has
been deleted from the list of volume expanders.
respiratory depression and a history of maternal narcotic
administration within the past 4 hours after 30 seconds of
positive-pressure ventilation has restored normal heart rate and
administration performance checklist evaluates the learner’s
ability to administer epinephrine via endotracheal tube and to
assist with placement of or place an emergency umbilical venous
catheter and administer volume expander and/or medication.
includes information on:
situations that may complicate resuscitation and cause ongoing
management of the baby who has required resuscitation.
principles apply to babies beyond the immediate newborn period
or outside the hospital delivery room?
- Ethical considerations about
starting, non-initiation and stopping resuscitation.
Gupta P. Guidelines 2000 for neonatal
resuscitation. Indian Pediatr 2000; 37: 1229-1233.
International Guidelines for Neonatal
Resuscitation. An excerpt from the Guidelines 2000 for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care: Inter-national
Consensus on Science. Pediatrics 2000; 106: e29.
- Kattwinkel J, Textbook of Neonatal Resus-citation, 4th Edition,
Elk Grove Village, Illinois, American Academy of Pediatrics and American
Heart Association, 2000.