Paediatrics chapters
Transition at birth and newborn resuscitation
What happens to the lungs and circulation at birth, why ventilation is the key step in newborn resuscitation, and the step-by-step algorithm from drying and stimulation to bag-mask ventilation, chest compressions and adrenaline.
- At birth the lungs must fill with air, pulmonary vascular resistance falls and the foramen ovale and ductus close; most babies do this alone, a few need help.
- Ventilation of the lungs is the single most important action: start bag-mask PPV within the first minute (the golden minute) if the baby is apnoeic, gasping or has a heart rate below 100.
- Start chest compressions if the heart rate stays below 60 after 30 seconds of effective PPV (ratio 3:1); give adrenaline if it is still below 60 after compressions.
On this page
Overview
Most babies breathe on their own at birth. Some need help to start breathing, and only a few need full resuscitation. Nearly all who need help recover with good ventilation alone. Chest compressions and drugs are rarely needed when ventilation is done well.
Birth asphyxia is a leading cause of neonatal death in Pakistan, so every doctor who attends deliveries must know the steps by heart.
Transition at birth
Before birth the lungs are full of fluid, pulmonary vascular resistance is high and blood bypasses the lungs through the foramen ovale and ductus arteriosus. At birth:
- The baby gasps within seconds (on average about 6 seconds, most by 20 seconds) and breathes regularly within about 30-90 seconds.
- Air replaces lung fluid, which is absorbed into the lymphatics and blood.
- Lung expansion and oxygen make pulmonary vascular resistance fall, so pulmonary blood flow rises.
- More blood returns to the left atrium; its pressure rises and closes the foramen ovale.
- The ductus arteriosus constricts and closes as oxygen levels rise, ending the right-to-left shunt.
If the baby does not breathe, the lungs stay fluid-filled, resistance stays high and the fetal pattern of circulation continues, so the baby stays hypoxic.
Primary and secondary apnoea (the basis of resuscitation)
| Stage | What happens | Response |
|---|---|---|
| Primary apnoea | After a short burst of rapid breathing, breathing stops; heart rate starts to fall | Stimulation and oxygen restart breathing |
| Gasping | Deep irregular gasps; heart rate and BP keep falling | - |
| Secondary apnoea | Gasps stop; heart rate and BP low | Will not respond to stimulation; needs PPV; risk of brain damage |
Primary and secondary apnoea look the same at birth. Always assume a baby who is not breathing is in secondary apnoea and start ventilation without delay.
Preparation
- Anticipate: identify antenatal and intrapartum risk factors (prematurity, fetal distress, meconium, maternal diabetes, breech, prolonged labour).
- Team: at least one person trained in resuscitation for every delivery; brief the team.
- Equipment (check before every delivery): radiant warmer, warm towels and cap, suction (bulb and catheter), self-inflating bag with term and preterm masks, oxygen and blender if available, pulse oximeter, laryngoscope, endotracheal tubes from 2.5 to 4.0 mm, umbilical catheters, syringes, stopwatch.
- Drugs: adrenaline 1:10,000, normal saline, 10% dextrose.
Assessment at birth
Three quick questions:
- Is the baby term?
- Is there good muscle tone?
- Is the baby breathing or crying?
If yes to all, the baby stays with the mother for routine care: dry, skin-to-skin, keep warm, clear the airway only if needed, and keep watching.
If no to any, move to the radiant warmer for the initial steps.
The Apgar score is not used to decide when to start resuscitation. Decisions rest on breathing, heart rate and oxygen saturation (or colour). The Apgar score tells you afterwards how the baby responded.
The golden minute
The golden minute is the first 60 seconds after birth. In this time the initial steps should be completed, the baby re-assessed and, if needed, positive pressure ventilation started. Delay in ventilating a non-breathing baby increases the risk of death and brain injury.
Step 1: Initial steps (A: airway)
- Warm: place under a radiant warmer; preterm babies can go into a plastic bag with a cap.
- Dry thoroughly and remove the wet towel (drying also stimulates breathing).
- Position the head in the neutral or slightly extended ("sniffing") position; avoid over-flexion and over-extension, which both block the airway.
- Clear the airway only if needed (copious secretions, blood or meconium): suction the mouth first, then the nose. Routine suction of every baby is not needed and can cause bradycardia.
- Stimulate: rub the back or flick the soles once or twice.
Step 2: Breathing (B: positive pressure ventilation)
Indications for PPV:
- Apnoea or gasping, or
- Heart rate below 100/min despite the initial steps.
How to ventilate:
- Bag and mask covering the mouth and nose (not the eyes), with a good seal.
- Rate 40-60 breaths/min ("breathe, two, three").
- Akbar gives first breaths of about 25-30 cm H2O in term babies, then 15-20 cm H2O; use lower pressures in very small babies.
- Attach a pulse oximeter to the right hand or wrist (pre-ductal).
- Watch for chest movement and listen for a rising heart rate, which is the best sign that ventilation is working.
Ventilation corrective steps: MR SOPA
If the chest does not move or the heart rate does not rise:
| Letter | Action |
|---|---|
| M | Mask adjustment for a better seal (two-hand hold) |
| R | Reposition the head (sniffing position) |
| S | Suction mouth and nose |
| O | Open the mouth and lift the jaw forward |
| P | Pressure increase in small steps (up to about 40 cm H2O) |
| A | Alternative airway: endotracheal tube or laryngeal mask |
"Mister SOPA" fixes the leak, the head, the secretions, the mouth, the pressure and finally the airway.
When to intubate
- Bag-mask ventilation is ineffective or prolonged.
- Chest compressions are needed.
- Suspected diaphragmatic hernia (bagging fills the gut in the chest; intubate instead).
- Extremely preterm babies who will need ongoing ventilation, or surfactant.
- A non-vigorous baby with thick meconium blocking the trachea.
Tube size by weight: about 2.5 mm for the smallest preterm babies, 3.0-3.5 mm for most, and 3.5-4.0 mm for large term babies. Akbar's rule for depth at the lip is 6 + weight in kg (cm).
Pre-ductal oxygen saturation targets after birth
| Time after birth | Target SpO2 |
|---|---|
| 1 minute | 60-65% |
| 2 minutes | 65-70% |
| 3 minutes | 70-75% |
| 4 minutes | 75-80% |
| 5 minutes | 80-85% |
| 10 minutes | 85-95% |
Healthy babies take several minutes to reach normal saturation, so a low reading in the first minutes is expected. Give supplementary oxygen only to keep the saturation in the target range.
Step 3: Circulation (C: chest compressions)
Indication: heart rate below 60/min after 30 seconds of effective PPV (with chest movement).
- Intubate if not done, and increase oxygen to 100%.
- Use the two-thumb technique (thumbs on the sternum, hands encircling the chest) or two fingers placed at right angles to the chest.
- Compress the lower third of the sternum (just below the nipple line) to one-third of the chest depth.
- Ratio 3 compressions to 1 breath: one cycle every 2 seconds, giving 90 compressions and 30 breaths per minute.
- Recheck heart rate after about 60 seconds; stop compressions when it is above 60 and rising.
One cycle = 3 compressions + 1 breath = 4 events every 2 seconds
Cycles per minute = 60 ÷ 2 = 30
Compressions = 30 × 3 = 90; breaths = 30 × 1 = 30; total = 120 events per minute
Step 4: Drugs
| Drug | Indication | Dose and route |
|---|---|---|
| Adrenaline (epinephrine) 1:10,000 | Heart rate below 60 despite effective ventilation and compressions (after about 45-60 seconds of compressions) | 0.1-0.3 mL/kg IV (umbilical venous catheter preferred), repeat every 3-5 minutes; the endotracheal dose is higher and less reliable |
| Volume expander (normal saline or O-negative blood) | Suspected blood loss: pallor, weak pulses despite good heart rate, poor response | 10 mL/kg IV over 5-10 minutes |
| Naloxone | Rarely; mother given opioids in the last 4 hours and baby not breathing after good ventilation | Ventilate first; never instead of PPV |
| Sodium bicarbonate | Not recommended in routine resuscitation | - |
Strength: 1:10,000 (1 mg in 10 mL, i.e. 0.1 mg/mL)
Volume: 0.1-0.3 mL/kg × 3 kg = 0.3-0.9 mL IV
Drug given: 0.03-0.09 mg (0.01-0.03 mg/kg)
The adrenaline for newborn resuscitation is 1:10,000, not 1:1000. Make it by diluting 1 mL of 1:1000 with 9 mL of water or saline.
The umbilical venous catheter is the preferred route for adrenaline and fluids in the delivery room.
If the heart rate stays low despite all steps, think of hypovolaemia and pneumothorax, and check tube position.
Meconium-stained liquor
- Vigorous baby (good breathing, good tone, heart rate above 100): routine care; clear the mouth and nose only if needed. Do not intubate to suction.
- Non-vigorous baby: do the initial steps and start PPV. Akbar advises tracheal suction through an endotracheal tube only if there is no air entry or no improvement with bagging (airway blocked by meconium).
- Suction before delivery of the shoulders is no longer recommended.
Routine tracheal suction of every meconium-stained baby is not recommended; ventilation comes first in a non-breathing baby.
When to stop
Akbar advises stopping if there is no heart rate and no breathing after 10 minutes of effective resuscitation. Decisions should involve a senior and the family.
Post-resuscitation care
Babies who needed PPV or more are at risk of the effects of asphyxia and need close monitoring in the neonatal unit:
- Temperature: avoid both cooling and overheating; consider therapeutic hypothermia for moderate or severe encephalopathy (start within 6 hours of birth).
- Blood glucose: check early; treat hypoglycaemia.
- Breathing: watch for apnoea, pneumothorax and pulmonary hypertension.
- Circulation: BP, perfusion, urine output; avoid fluid overload.
- Seizures: watch and treat (phenobarbitone first-line).
- Infection: look for sepsis.
- Documentation and debrief: record times, Apgar scores and actions; explain to the parents.
Full details of organ damage after asphyxia are in the birth asphyxia and HIE chapter.
Expect: transition at birth with fall in pulmonary vascular resistance and closure of the foramen ovale and ductus; primary versus secondary apnoea and why to assume secondary apnoea; the golden minute; the three questions at birth; ventilation as the most important step; PPV for apnoea, gasping or heart rate below 100 at 40-60/min; heart rate as the best indicator of success; MR SOPA; compressions when heart rate is below 60 after 30 seconds of effective PPV, two-thumb technique, 3:1 ratio; adrenaline 1:10,000 at 0.1-0.3 mL/kg IV; volume 10 mL/kg; no routine bicarbonate; management of meconium-stained babies; Apgar score not used to start resuscitation.
Quick revision
- Three questions: term? tone? breathing or crying?
- Initial steps: warm, dry, position (sniffing), clear airway if needed, stimulate.
- Golden minute: PPV started within 60 seconds if needed.
- PPV for apnoea, gasping or HR below 100; rate 40-60/min; rising HR = success.
- MR SOPA for poor chest movement.
- Compressions: HR below 60 after 30 s effective PPV; two thumbs; lower third of sternum; 3:1; 100% oxygen.
- Adrenaline 1:10,000, 0.1-0.3 mL/kg IV, repeat 3-5 min; saline 10 mL/kg for hypovolaemia.
- No bicarbonate; naloxone rarely.
- Vigorous meconium baby: routine care; non-vigorous: PPV first.
- Stop after 10 minutes with no heart rate.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics).
FAQ
What is the most important step in newborn resuscitation?
Effective ventilation of the lungs; most babies who need help recover with bag-mask ventilation alone.
When do you start chest compressions in a newborn?
When the heart rate is below 60 per minute after 30 seconds of ventilation that moves the chest.
What is the compression to breath ratio in newborns?
Three compressions to one breath, giving 90 compressions and 30 breaths every minute.
Should a baby born through meconium-stained liquor be intubated and suctioned?
Not if vigorous; a non-vigorous baby should get PPV first, with tracheal suction only if the airway is blocked.
Is the Apgar score used to decide when to resuscitate?
No; the decision is based on breathing, heart rate and oxygen saturation, while the Apgar score records the response.