Resusciation of the Neonate from SIM

Credit: Drs Wu, A. Ogunniyi, R. Pedigo, R. Fleischman on 
OB Sim Day at Harbor-UCLA

Ill-appearing neonate

  • For babies
    born precipitously in ED, always ask: 1) Term? 2) Good tone? 3)
    Breathing or crying?

    • If yes to
      all 3Qs, consider delaying cord clamping and hand baby to mother
      for skin-to-skin contact while keeping baby warm and dry.

      • Clamping of
        cord should be delayed 30-60 sec unless child requires immediate

      • Associated
        with less IVH, NEC, better BPs and blood volume, but a/w more
        phototherapy requirement

    • If no to any
      of Qs, cut cord and begin resuscitation by:

      • Taking baby
        to warmer (make sure it’s on!, plastic bag from neck
        down) goal temp 36.5-37.5

      • Bulb
        syringe suction to clear secretions,

      • Dry,
        stimulate. Ventilate/oxygenate as needed.

      • Note time,
        document APGAR.

  • Cutaneous
    temp monitor on liver – largest organ provides most consistent
    measurement. Hypothermia increases risk of intraventricular
    hemorrhage, respiratory issues, hypoglycemia, and late onset sepsis.

  • Meconium
    aspiration no longer empirically intubated, treat similar to other
    babies with stimulation, suctioning, PPV as needed. Immediate
    intubation thought to delay resuscitation

Resuscitating a neonate: HR, RR, Pox

  • HR:
    Detecting HR difficult, 3 lead ECG best, umbilical cord stethoscope
    alternate but not as accurate

    • If
      bradycardic HR <60, start chest compressions, thumb encircling
      chest wall, 3:1.

    • If not
      already done, intubate baby

    • Epi 1:10,000
      concentration, dose 0.01 mg to 0.03 mg/kg IV, or 0.05 to 0.1 mg/kg
      via ETT

  • RR/Pulse
    – low oxygen sat is normal in first few minutes of life.
    Increases by 5% every minute of life. Place monitor on R palm/wrist
    for pre-ductal measurement, reflects blood that is going to the

    • Normal
      preductal (right hand) O2 Sat

    • Resuscitation
      with room air (FiO2 21%) initially

    • Give
      supplemental O2 – increase FiO2 if not achieving normal saturation
      or has a HR<100.

    • PPV using
      BVM to RR 40-60 for 30 sec, CPAP

    • If need for
      CPR, then intubated baby

  • Intubation:

ETT = [age/4+4]

Laryngoscope blade

<28 wks 2.5

Pre-term 0

28-34 wks 3.0

Term 1

34-38 wks 3.5

>38 wks 3.5 to 4


Depth 3xETT size to lip

  • Why does baby
    need resuscitation?

    • Shock? Blood
      or volume? Give transfusion or IVF bolus as indicated, 10ml/kg,
      repeat prn

    • Uterine
      rupture or abruption?

    • Accident
      with umbilical cord?

    • Hypoglycemic?
      2ml/kg of D10 as initial bolus, then D10W maintenance IVF at
      80ml/kg per day.

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