Birth Asphyxia Management
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Direct answer
The first minute after a non-breathing birth follows the NRP/NNF sequence, not a drug chart: dry and stimulate, position the airway, clear it only if obstructed (routine suction is abandoned), then ask the three questions — term? good tone? breathing or crying? A baby answering no to any moves to positive-pressure ventilation with room air at 40-60 breaths per minute, the single most life-saving step, assessed by rising heart rate and chest movement. If the heart rate stays below 60 after 90 seconds of effective ventilation, add chest compressions at a 3:1 ratio with ventilation (120 events per minute); if below 60 despite 60 seconds of coordinated compressions and ventilation, give adrenaline (epinephrine) 0.01-0.02 mg/kg of the 1:10,000 dilution umbilically, and consider volume. Apgar scores at 1 and 5 minutes describe condition, never guide resuscitation; moderate-to-severe hypoxic-ischaemic encephalopathy in babies of 36 weeks or more receives therapeutic hypothermia (33.5°C for 72 hours) started within six hours.
What you must remember
- The three rapid questions: term gestation? good tone? breathing or crying? — all yes means routine care (warm, dry, skin-to-skin); any no means initial steps now and reassessment at 30 and 60 seconds.
- Ventilation rules: positive-pressure ventilation at 40-60 breaths/minute in room air (21 per cent oxygen for term babies; higher concentrations only per oxygen-target guidance) — start within the first minute for an apnoeic baby; most "resuscitations" end here.
- Chest compressions: heart rate below 60 despite 90 seconds of effective ventilation — two-thumb technique on the lower third of the sternum, 3:1 compressions-to-ventilations, 90 compressions and 30 breaths per minute.
- Adrenaline: 0.01-0.02 mg/kg IV (0.1-0.2 mL/kg of 1:10,000) via umbilical venous catheter, repeated every 3-5 minutes; the endotracheal route is a fading second choice; volume (10 mL/kg normal saline or O-negative blood) for suspected hypovolaemia or shock.
- Apgar honesty: score 0-2 at 5 minutes flags asphyxia (with umbilical artery acidosis, pH under 7.0 and base deficit over 12 commonly quoted as biochemical anchors) — but resuscitation starts before the one-minute score, always.
- Meconium rule change: routine intrapartum suction and direct tracheal suction of non-vigorous meconium-stained babies is abandoned — resuscitate with the standard sequence.
- Therapeutic hypothermia: 33.5°C whole-body cooling for 72 hours, initiated within 6 hours of birth, for 36-week-and-over infants with moderate or severe HIE — reduces death and disability; Sarnat staging grades the encephalopathy.
- Equipment arithmetic: a self-inflating bag with a term mask, a bulb syringe or suction at 100 mmHg or less, a radiant warmer checked before every delivery, and a clock — the FMGE vignette usually hides a missing warmer.
The first minute of a depressed neonate
Stand at the warmer. A term boy is born through thick meconium, floppy and silent. He is laid on the warmer, dried with a warm towel and the wet towel removed — stimulation in the drying itself. The three questions return: term yes, tone poor, breathing absent — so 30 seconds of positioning (slight neck extension) and clearing the mouth then nose only because the airway looks obstructed. He gasps once and relapses. Positive-pressure ventilation begins by 60 seconds: mask seal, five initial inflation breaths, then 40-60 breaths per minute in air, with the heart rate counted or watched on a monitor. His chest rises; the rate climbs toward 80 but stalls below 60 at the 90-second check — thumbs lock onto the lower sternum and 3:1 compressions begin, calling out the cycle.
Sixty seconds of coordinated compressions later he is still under 60: the umbilical line is cut and adrenaline 0.15 mL of 1:10,000 (for a 3 kg baby — the arithmetic the exam tests) goes in while compressions continue. His rate crosses 60, compressions stop, ventilation tapers as he grunts and pinks; he is transferred with the mother's team to the neonatal unit, where staff grade his encephalopathy (Sarnat II — moderate) and start whole-body cooling at 33.5°C within the six-hour window, parents counselled that cooling changes outcomes. Every step ran on a clock the exam can quote: 30 seconds of initial steps, 90 of ventilation before compressions, 60 of compressions before adrenaline.
The classic one-liners
NBE asks the ratio (3:1), the rate of PPV (40-60), the adrenaline dose (0.01-0.02 mg/kg of 1:10,000), and — the perennial trap — what the Apgar at one minute is for (communication and record, not a treatment trigger). The meconium question flips old teaching: non-vigorous meconium-stained babies get the standard sequence, not laryngoscopy and suction. Cooling's two numbers, 33.5°C and 72 hours within six, close the set.
Frequently asked questions
When are chest compressions started in neonatal resuscitation?
When the heart rate remains below 60 per minute after at least 90 seconds of effective positive-pressure ventilation.
What is the compression-to-ventilation ratio in newborn resuscitation?
Three compressions to one ventilation — 90 compressions and 30 breaths per minute — using the two-thumb technique on the lower third of the sternum.
What is the dose and route of adrenaline in neonatal resuscitation?
Adrenaline 0.01-0.02 mg/kg intravenously (0.1-0.2 mL/kg of the 1:10,000 dilution), preferably through an umbilical venous catheter, repeated every 3-5 minutes.
Is tracheal suctioning routine for meconium-stained newborns?
No — non-vigorous meconium-stained babies receive the standard resuscitation sequence; routine intrapartum and tracheal suction has been abandoned.
Which babies receive therapeutic hypothermia?
Infants of 36 weeks or more with moderate or severe hypoxic-ischaemic encephalopathy, cooled to 33.5°C for 72 hours, started within six hours of birth.