Neonatal resuscitation

Basic Algorithm and Step A (Airways)

The regulatory framework for resuscitation measures is the methodological letter of the Russian Ministry of Health and Social Development (2010). A key indication for the immediate start of resuscitation is an Apgar score (Apgar score) of less than 6 points at birth.

The first step (Airways) aims to restore airway patency and prevent hypothermia. 30 seconds are allocated for its completion. The algorithm includes:

• Drying: the infant's skin is wiped thoroughly dry, and the wet blanket is removed to preserve heat.
• Positioning: the head is placed in a slight extension position (tilt angle of about 15°) to straighten the airways.
• Suctioning: performed using an electric aspirator strictly according to indications (absence of breathing in the first 10 seconds or excessive secretions). Clean the mouth first, then the nose. The procedure lasts no more than 10 seconds.

Deep pharyngeal suction is strictly prohibited. Irritation of the posterior pharyngeal wall triggers a vagus nerve reflex, provoking severe bradycardia, bronchospasm, or laryngospasm. At the end of this step, the head is turned to the side for mucus drainage, and tactile stimulation is performed (patting the soles, rubbing the back for 10–15 seconds).

Step B (Breathing) — Ventilation

If initial measures are ineffective and the infant exhibits apnea, gasping respirations (gasping), or the heart rate drops below 100 beats per minute, proceed to artificial pulmonary ventilation (mechanical ventilation).

An Ambu bag with a face mask is used for ventilation. A critical anatomical feature of newborns is that their tongue occupies the entire oral cavity. Therefore, ventilation must be performed through the nose and mouth simultaneously. The mask is applied in a rolling motion from the bridge of the nose to the chin; the left hand secures it, while the right hand squeezes the bag.

The first mechanical or spontaneous breaths establish the functional residual capacity (FRC) of the lungs, after which their mechanical properties improve. If mask ventilation continues for longer than 3–5 minutes, a gastric tube is inserted to prevent gastric distension. The insertion depth is measured from the corner of the mouth to the tragus of the ear and down to the lower edge of the xiphoid process.

Step C (Circulation) — Chest Compressions

The main condition for initiating chest compressions is persistent bradycardia (heart rate less than 60 beats per minute) that does not resolve despite properly performed mechanical ventilation.

The ratio of chest compressions to artificial breaths is strictly 3:1. The two-handed encircling technique is the preferred method:

1. The clinician places their hands under the infant's back, creating a firm support.
2. The tips of the thumbs are placed overlapping (one on top of the other) in the lower third of the sternum.
3. Pressure is applied vertically downward by 1/3 of the anteroposterior diameter of the chest.
4. 3 compressions are performed, then the assistant delivers 1 breath.

Lateral compression of the ribs is unacceptable—this can lead to fractures and pneumothorax. An alternative is the two-finger method (index and middle fingers) of one hand. The pulse is monitored every 30 seconds (pausing for 6 seconds to count, and multiplying the result by 10).

Medication Stage, Transport, and Termination of CPR

If the heart rate remains below 60 beats per minute after adequate ventilation and compressions, continue chest compressions and proceed to step D (Drugs) — administration of medications.

The target indicators of successful resuscitation are the restoration of spontaneous breathing and stabilization of the pulse above 100 beats per minute. Afterward, the newborn is transferred to the intensive care unit (ICU). If the distance exceeds 15–30 meters, a transport incubator with continuous mechanical ventilation is used. Dynamic condition assessment using the Apgar score is performed every 5 minutes.

Criteria for Resuscitation Termination:

• Absence of cardiac activity for 10 minutes from the start of CPR in the delivery room.
• Persistence of total cyanosis and asystole for 15–20 minutes (in case of overall ineffectiveness).
• If at least a temporary response is observed, resuscitation is continued as long as there is an effect.

Class and exam questions

What else to study on this topic

• Step D (Drugs): Drug Selection, Dosages, and Routes of Administration
• Features of Cardiopulmonary Resuscitation in Extreme Prematurity
• Dynamic Apgar Scoring and Post-Resuscitation Monitoring
• Setting Up Mechanical Ventilation and Oxygen Therapy Parameters After Successful Tracheal Intubation

Other topics in "Chapter 13. Main syndromes requiring emergency care"

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