The Textbook of Neonatal Cardiopulmonary Resuscitation

Based on the 2020 Guidelines of theJapan Resuscitation Council
Fourth Edition
Editor: Shigeharu Hosono

Chair, Committee on Neonatal Resuscitation
Japan Society of Perinatal and Neonatal Medicine

The instructions,adverse reactions,and administration schedules described inthis text may change.When handling drugs mentioned in this text,carefully
review the information provided by the manufacturer.

The Japan Society of Perinatal and Neonatal Medicine periodically updates its
information on neonatal cardiopulmonary resuscitation.
Visit the websites below for the latest information:

Japan Society of Perinatal and Neonatal Medicine:
https://www.jspnm.com/
The Japan Society of Perinatal and Neonatal Medicine
Neonatal Cardiopulmonary Resuscitation(NCPR) Project:https://www.ncpr.jp/

The Textbook of Neonatal Cardiopulmonary Resuscitation
Based on JRC Guidelines 2020
(ISBN978-4-7583-1998-0 C3047)

Editor: HOSONO Shigeharu
2021.4.1 4th ed.
©MEDICAL VIEW,2021
Printed and Bound in Japan

Medical View Co.,Ltd.

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The Textbook of Neonatal Cardiopulmonary Resuscitation
Based on the 2020 Guidelines of the Japan Resuscitation Council,4th Edition

Table of Contents
Chapter

1

What is Neonatal Cardiopulmonary Resuscitation?

The Neonatal Cardiopulmonary Resuscitation(NCPR)project . . ........................................... 8
Assessment of certainty of evidence and strength ofrecommendation using the GRADE approach ............................................................................ 15
Major revisions to the 2020 Japan Resuscitation Council Guidelines on
Neonatal Resuscitation based on Consensus 2020................................................................ 18
Chapter2

Basic Neonatal Resuscitation

Basic knowledge needed for neonatal resuscitation ............................................................ 36
Indications for neonatal resuscitation ........................................................................................ 43
NCPR algorithm ........................................................................................................................................ 44
Neonatal Resuscitation
STEP 0Team briefing...................................................................................................................... 52

STEP 1

Assess the neonate immediately after birth...................................................... 56

STEP 2

Provide routine care.. ....................................................................................................... 59

STEP 3

Perform initial steps of resuscitation.. .................................................................. 61

STEP 4

Assess effectiveness of initial steps.. .................................................................... 67

STEP 5

Provide ventilation........................................................................................................... 71

STEP 6
			Assess effectiveness of ventilation andproceed to next step (chest compressions)......................................................... 87

STEP 7

Medications.......................................................................................................................... 94

STEP 8

Stabilization of breathing.. ........................................................................................ 100

Post- resuscitation care................................................................................................................... 106
Chapter3

Advanced Neonatal Resuscitation

Endotracheal intubation.................................................................................................................... 116
Resuscitation of preterm infants................................................................................................ 130
Other recommendations regarding neonatal resuscitation. . .......................................... 133
Chapter

4

Better utilization of teamwork in neonatal resuscitation

Teamwork in neonatal resuscitation .......................................................................................... 138
Need for continuous learning and on-the-job training (OJT) in NCPR ..................... 142

3

List of authors■Editor
Shigeharu Hosono

Chair, Committee on Neonatal Resuscitation,
Japan Society of Perinatal and Neonatal Medicine■Author (in order of section written)
Shigeharu Hosono

Professor of Neonatal Division, Department of Perinatal and Neonatal Medicine,
Jichi Medical University Saitama Medical Center

Tetsuya Isayama

Head, Division of Neonatology, National Center for Child Health and Development

Isao Kusakawa

Professor of Clinical Pediatrics, St. Luke’s International University andChief of Pediatrics, Pediatric Health Center, St. Luke’s International Hospital

Takahiro Sugiura

Director, Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital

Takahide Yanagi

Senior Assistant Professor, Department of Pediatrics,
Shiga University of Medical Science

Takenori Kato

Director, Department of Pediatrics and Neonatology, Toyohashi Municipal Hospital

Hiroyuki Kitano

Chief, Department of Neonatology, Medical Center for Maternal and Child Health,Ishikawa Prefectural Central Hospital

Hiroshi Mizumoto

Chief, Division of Neonatology, Department of Pediatrics,
Tazuke Kofukai Medical Research Institute, Kitano Hospital

Rinshu Shimabukuro

Assistant head physician, Department of Pediatrics, St. Luke’s International Hospital

Takuya Tokuhisa

Chief, Department of Neonatology, Imakiire General Hospital

Jun Shibasaki

Chief, Department of Neonatology, Kanagawa Children’s Medical Center

Hagane Shimaoka

Deputy Director, Lecturer, Department of Pediatrics,
International University of Health and Welfare Shioya Hospital4

Third Edition Editor and authors■Editor

Shigeharu Hosono■Authors Shigeharu Hosono, Masanori Tamura, Takahiro Sugiura,
Isao Kusakawa, Takahide Yanagi, Takenori Kato,

Takaharu Yamada, Kenji Shirai, Hiroyuki Kitano,

Masahiko Murase, Masahiko Murase, Toshihiko Nishida,
Takuya Tokuhisa, Jun Shibasaki, Reiji Nakano,
Hagane Shimaoka, Masaki Wada

Second Edition Editor and authors■EditorMasanori Tamura■Authors Masanori Tamura, Hisanori Sobajima, Masaki Wada,
Takahiro Sugiura, Toshihiko Nishida, Atsuko Taki,
Keiji Goishi, Isao Kusakawa, Shigeharu Hosono,
Naoki Masaoka, Toshiki Takeuchi

First Edition Editor and authors■EditorMasanori Tamura■Authors Masanori Tamura, Hisanori Sobajima,
Tomoo Nakamura, Yoshio Sakurai■Collaborators Tetsuya kunikata, Takehiko Hiroma, Kenji Shimizu,
Kikuko Oku, Masaki Wada, Masatoshi Sugiura

5

NCPR2020 Algorithm
STEP 2
STEP 0Team briefing,
PPE, and Equipment check

Team briefing

Birth

STEP 1
Assess the neonate
immediately
after birth• Preterm?
• Weak respiration?
• Weak tone?

★

STEP 3
Perform
initial steps ofresuscitation

Assesseffectiveness of
initial steps

Provideventilation

STEP 6
Assess effectivenessof ventilation andproceed to next step
(chest compressions)★

• Check ventilation (b)• Consider intubation★

60/min≤HR<100/min.

★

YES• SpO2 monitoring• CPAP or O2 asneeded

ImprovingLabored breathing or
cyanosis (low SpO 2)

HR<60/min.

HR≥ 60/min.

HR

HR<60/min.
Consider IV adrenalineHRNOcyanosis (low SpO 2)• PPV (a)• SpO 2 monitoring• Consider ECG monitoring

STEP 7

HR≥ 60/min.
HR<60/min.

PPV + Chest compression and…..
• Normal saline for suspected hypovolemia• Searching for the cause of cardiac arrest
After ROSC (HR ≥ 60/min.)Stop chest compression and continue PPV

6Routine Care(stay with mother)• Provide warmth• Open airway• Dry
Ongoing evaluation

Apnea /Gasping or
HR <100/min.

HR

Stabilization ofbreathing

Spontaneous breathingandHR≥ 100/min.
Labored breathing or

Breathing • HR

HR≥100/min.

STEP 8NO

PPV(+O2) + Chest compression (1:3) (c)Medications

SpO2 (%)
≥60
≥70
≥80
≥90

Warm,
open airway (positioning, etc.),
dry, and stimulate(Consider SpO2
monitoring)

Maintain temperature

STEP 5

Target SpO2
Time
1min.
3min.
5min.
10min.

YES

Within60 seconds

STEP 4

Provideroutine care

★

NO

Not
Improving• Search for the cause
and…

• Consider PPV if laboredbreathing and low SpO2
continues.
• Check congenital heartdisease if low SpO2
continues without laboredbreathing.

Post
Resuscitationcare• Carefulobservation
on respiration(a) Add or increase supplemental oxygen if HR
or SpO2 are not improved.
(b) If the ventilation is not optimal,
focus on improving ventilation before
proceeding to the chest compressions.
(c) PPV 30/min. and chest compression 90/min

Consider endotracheal intubation
at the time points marked with the ★

Chapter1

What is Neonatal
Cardiopulmonary Resuscitation?

Chap.1

The Neonatal Cardiopulmonary
Resuscitation (NCPR) project
Shigeharu Hosono

Chair, Committee on Neonatal Resuscitation Japan Society of Perinatal and Neonatal Medicine
Neonatal Life Support Task Force, International Liaison Committee on Resuscitation
Director, Neonatal Division, Japan Resuscitation Council

I

Characteristics of neonatal asphyxia and neonatal
cardiopulmonary resuscitation (CPR)

1 Percentage of neonates in need of resuscitation at birthWith advances in obstetrics management, especially the widespread use of fetal heart ratemonitoring, it has become possible to assess the well-being of fetuses, and systems have been
put in place for general and regional perinatal medical centers to manage and carry out high-risk
deliveries. A growing number of facilities, including general and some regional perinatal medical
centers, can perform emergency cesarean sections at any time of day within 30 min after making
the decision to perform surgery. The immediate transportation of pregnant women to general or regional perinatal medical centers after the confirmation of non-reassuring fetal status(NRFS) at a local obstetrics clinic and the allocation of appropriate staff for advanced neonatal
resuscitation at facilities where cesarean sections are performed has substantially contributed
to improving the prognosis of neonates. Nevertheless, even when fetal heart rate monitoring
findings are normal immediately before delivery following an uneventful course of pregnancy
and delivery, neonatal asphyxia is a common complication.
After delivery, as soon as the fluids that fill the airway, including the alveoli, are replaced by
air upon the cessation of placental circulation by clamping and cutting of the umbilical cord,
the fetus must make a drastic transition to neonatal respiration and hemodynamics to adapt
to extrauterine life. Approximately 85% of term neonates start breathing within 10-30 s after
birth 1). Approximately 10% of neonates start breathing in response to drying and stimulation 2).
Approximately 5% start breathing spontaneously after receiving positive pressure ventilation(PPV), including intubation. Approximately 2%, 0.1%, and 0.05% require respiratory support withendotracheal intubation, chest compressions, and adrenaline administration plus ventilation andchest compressions, respectively 3-6). When spontaneous breathing does not occur in neonates,
appropriate and timely interventions are required to hinder the progression of hypoxia and ischemia, thereby preventing the onset of hypoxic-ischemic encephalopathy. Given that the numberof births was 865,239 in 2019 7), the figures cited above mean that slightly fewer than 130,000
neonates (approximately 1 every 4 min) required some kind of support to stabilize respirationand circulation at birth. Preterm infants accounted for 5.6% of all births in 2014 8), and many ofthem were likely delivered with a pediatrician in attendance at a general or regional perinatal
medical center.
8

What is Neonatal Cardiopulmonary Resuscitation?

2 Asphyxiated neonates can be resuscitation with relatively
simple procedures

Chap.

1

Term neonates who require some sort of procedure account for approximately 15% of all deliveries. Two-thirds of these neonates (approximately 10% of all deliveries) start beathing spontaneously after being dried and stimulated, and the remaining one-third (approximately 5% of alldeliveries) start breathing spontaneously after receiving PPV, including endotracheal intubation.
Only approximately 0.1% of term neonates require chest compressions or further treatment. In
other words, even though some neonates do not spontaneously breathe at birth, approximately
90% of them start breathing spontaneously after intervention with drying and stimulation andbag-mask ventilation. When endotracheal intubation and chest compressions are included in theinterventions, approximately 99% of neonates can be resuscitated; medication (i.e., adrenaline)
and normal saline must be ready for use, but an automated external defibrillator (AED), which iscommonly used for older children and adults, is not necessary for neonatal resuscitation.

3 Asphyxia at medical facilities during deliverysimple procedures
In Japan, 99.9% of deliveries take place at medical facilities 9). Therefore, it is possible to achieve
efficient training effects by providing appropriate resuscitation supplies and regularly training limited medical staff in limited procedures such as bag and mask ventilation and chest compressions.

features of the Japanese system
II Distinguishingfor delivery
In North America, most deliveries take place at a general hospital with a pediatrician in attendance.
In Japan, with the improvement of the perinatal medical care system in recent years, a system is
becoming established in which pregnant women are transported to a general or regional perinatal
medical center to deliver their babies with a pediatrician in attendance when a high-risk delivery
or high-risk neonate is anticipated. However, it is impossible to predict all deliveries of high-risk
neonates, and it is not uncommon for neonates to suddenly develop problems with adaptation to
extrauterine life, even when the course of pregnancy and delivery was completely uneventful.
Furthermore, in Japan in 2018, only 55.1% of deliveries took place at hospitals, and 44.3% and0.5% took place at obstetric clinics and midwifery centers, respectively 9). The remaining 0.1%
took place at home and at other locations. This means that, if high-risk deliveries and/or fetal
abnormalities are not predicted, most deliveries take place without a pediatrician in attendance.
On the other hand, there are a certain number of miscarried deliveries, such as home deliveries and deliveries in cars, in which obstetricians and midwives are not involved, and emergency
teams, including paramedics, respond to deliveries and newborn.

importance of training perinatal care
III Theproviders in standard neonatal resuscitation
For the reasons described above, it is important that not only pediatricians but all obstetricians, midwives, and nurses who are involved in delivery have mastered the theory, techniques,9and attitudes of standard neonatal resuscitation in order to appropriately treat neonates who
cannot smoothly make the transition to the extrauterine environment, thereby avoiding unnecessary problems for their parents. Also, many medical professionals have had the alarming
experience where a neonate who appeared healthy soon after birth fell into respiratory arrestor bradycardia during early skin-to-skin contact or after having a bath, being fed, or crying. To
respond appropriately to such situation, it is desirable that doctors and nurses who work in thepediatric ward including the neonatal unit, neonatal intensive care unit (NICU), and pediatricintensive care unit (PICU) have mastered standard neonatal resuscitation.
Against this background, the guidelines introduced here are intended to be used at obstetricclinics and midwifery centers, rather than unmodified guidelines based on the assumption thatdeliveries are carried out with a pediatrician in attendance at a general hospital as in the UnitedStates. Meanwhile, the person in charge in the clinical setting must strive to establish a systemand provide training opportunities for relevant staff, so that safer and more effective resuscitation can be provided in accordance with international standards.

IV The ultimate goal of the NCPR project
The American Heart Association (AHA) International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (AHA2000) 10) recommend that “at least one person skilled in initiating neonatal resuscitation should be present at every delivery. An additional
skilled person capable of performing a complete resuscitation, including the administration of
medications and endotracheal intubation, should be immediately available to provide help. Morethan one dedicated staff member must attend an anticipated high-risk delivery solely for careof the neonate”. This was again emphasized in the Consensus on Science with Treatment Recommendations (CoSTR) 2005 11) published by the International Liaison Committee on Resuscitation(ILCOR) in 2005.
Thus, the ultimate goal of the NCPR project is to establish a system in which all personnel
involved in perinatal medical care master standard neonatal resuscitation by attending practical training sessions, and dedicated staff skilled in the initiation of neonatal resuscitation areavailable at every delivery.
The NCPR project estimates that the number of personnel involved in perinatal medical care is
75,000. From the beginning of the training project in 2007 to the end of December 2015, thetotal number of participants was 174,167 (97,856 for the A course, 48,650 for the B course),
and 67,643 were registered as holding a certificate of completion. 12)

significance of neonatal cardiopulmonary
V The
resuscitation training by simulation in small-group
Knowledge acquisition alone is not sufficient to allow medical professionals to perform resuscitation procedures calmly and adequately when they encounter a neonate with unanticipated asphyxia. Practical training for individual skills in neonatal cardiopulmonary resuscitation(NCPR) using manikins and real equipment is necessary, as is gaining an understanding of theory
10

What is Neonatal Cardiopulmonary Resuscitation?

and techniques through audiovisual aids such as slides and videos.
Furthermore, small-group courses, in which participants’ abilities to make decisions and implement practical procedures are formatively evaluated through simulation exercises using scenarios based on asphyxia situations that frequently occur in the real world, were shown to increase
the effectiveness of training 13-17).

for teaching standards in
VI Criteria
neonatal resuscitation courses(1) Compliance with evidence-based international standards and feasible in actual practice in Japan.
(2) Universally applicable to all professionals who are likely to be involved in NCPR.
(3) Able to be completed by individuals who are already working as health care professionals, aswell as recent graduates.
(4) Acceptable time and financial costs to allow the courses to be completed by all medical professionals who may attend a delivery.
(5) Able to be widely implemented to avoid disparities among regions and institutions.
(6) Compatible with other professional training programs and certification systems.

effects of training all perinatal care providers
VII Anticipatedin standard neonatal cardiopulmonary resuscitation(1) The standardization of NCPR will be promoted.
(2) Skills of individuals, including pediatricians, obstetricians, gynecologists, obstetric anesthetists, midwives, nurses, and ambulance crews, will be improved.
(3) Promotion of team medicine: The shared use of a standard algorithm will facilitate cooperation among staff and enable team members who do not initiate resuscitation to provide
appropriate assistance and preparation. This is important for improving the success rate ofresuscitation, a situation in which a slight delay makes a critical difference.
(4) The responsibilities of medical professionals will become clearer in cases in which both themother and the neonate require emergency treatment.
(5) Midwives and nurses will improve their neonatal resuscitation skills, allowing them to complement the shortage of pediatricians, obstetricians, and gynecologists, which is considered
the primary factor in a perinatal care crisis.
(6) The quality of emergency medical care in neonatal units, pediatric wards, and emergency andoutpatient departments will be improved.
(7) Such training will contribute to the quality assurance of certification and specialist programs related to perinatal medicine.
(8) A system will be implemented in which every delivery is attended by a designated person
capable of initiating neonatal resuscitation.

11

Chap.

1

VIII

Practical skills courses and a registration system for training
perinatal care providers across Japan in standard neonatal
cardiopulmonary resuscitation 12)

Against this background, in 2017, the Japan Society of Perinatal and Neonatal Medicine initiated a nationwide project in which courses are provided to those who are involved in perinatal
care so that they can learn the NCPR guidelines that are in compliance with international standards. In terms of practical courses for those involved in neonatal medical care across Japan,
the society has accredited a course on prehospital neonatal resuscitation since April 2020, in
addition to two existing courses for new participants in neonatal resuscitation within hospitals.
Additionally, courses for recipients of completion certificates were initiated in April 2015.
(1) Advanced Neonatal Resuscitation Course (Course A)
Main targets: Obstetricians, gynecologists, pediatricians, anesthetists, emergency medicine doctors, doctors in other perinatal medical facilities, nurse specialists andmidwives, paramedics, and others.
Contents: Advanced neonatal resuscitation techniques, including medications and endotracheal intubation.
(2) Basic Neonatal Resuscitation Course (Course B)
Main targets: General practitioners, nurses and midwives, early-stage interns, paramedics,
medical students, students in the nursing or midwifery department, and others.
Contents: Basic neonatal resuscitation techniques, with an emphasis on bag-mask ventilation and chest compressions.
The main targets of and participants in Course B are advised to participate in Course A for
further improvement of their knowledge and skills.
(3) Prehospital Neonatal Resuscitation (Course P)
Main targets: Paramedics, ambulance crew members, firefighters, and others.
Contents: Neonatal resuscitation in cases of delivery outside a medical facility.
(4) Skill training course (Course S)
Main targets: Recipients of certificates of completion of Course A and Course B.
Contents: A review course comprising lectures, skill practice, and scenario-based practicefor maintaining the quality of resuscitation techniques.
Recipients of a Course A certificate can become qualified instructors of Course B (J instructors) after learning necessary teaching methods ranging from how to prepare the course to how
to conduct the final assessment. These methods are learned through participation in at least
one society-accredited course as an assistant instructor and obtaining the recommendation ofa practicing instructor.
To become a qualified instructor of Course A, recipients of a Course A certificate must participate in at least two society-accredited courses (at least one course must be Course A) as
an assistant instructor, receive a recommendation from a practicing instructor to participate
in the training courses for becoming a Course A instructor (Course I), and complete Course I toobtain a Course I certificate.
It is preferable that the certificates be issued by a nonprofit academic association; therefore, the Japan Society of Perinatal and Neonatal Medicine, whose members are professionals
involved in neonatal medicine in pediatrics and obstetrics departments, is taking the initiative,
12

What is Neonatal Cardiopulmonary Resuscitation?

along with other societies such as the Japan Association of Obstetricians and Gynecologists,
the Japan Academy of Midwifery, the Japanese Midwives’ Association, the Japanese Nursing
Association, the Japan Academy of Neonatal Nursing, the Japan Society of Obstetrics and Gynecology, the Japan Pediatric Society, the Japan Society of Maternal Health, and the Japan
Resuscitation Council.

in the Ministry of Health, Labour, and Welfare’s “ProIX Role
ject to Establish Perinatal Care Measures and Systems”
General and regional perinatal medical centers that receive public funding have a public responsibility to implement projects to train those involved in perinatal medical care in each region.
● In the first phase of this training, the Neonatal Resuscitation Committee of the Japan Society of Perinatal and Neonatal Medicine plays a pivotal role in providing training courses
for those who plan to become Course A instructors for the main targets, namely, doctors at
general and regional perinatal medical centers, provisional senior fellows of the Japan Societyof Perinatal and Neonatal Medicine, and those responsible for education and training in theJapan Association of Obstetricians and Gynecologists, the Japan Academy of Midwifery, theJapanese Midwives’ Association, and the Japan Academy of Neonatal Nursing.
● In the second phase, qualified Course A instructors organize Course A primarily for doctors
at general and regional perinatal medical centers and those who are responsible for educationand training at relevant associations and societies.
● In the third phase, doctors at general and regional perinatal medical centers and those whoare responsible for education and training at relevant associations and societies organize
Course A and Course B for doctors, midwives, and nurses at local obstetrics clinics. In thisway, ideally, everyone involved in perinatal medical care will complete Course A or Course B.
As of December 2020, a total of 4,705 instructors (3,007 Course A instructors and 1,698
Course B instructors) are working actively across Japan 12), and more than 170,000 health care
professionals have participated in NCPR-accredited courses; Phase 3 is well underway.
It is desirable that in the future, all board-certified pediatricians, obstetricians, and gynecologists become qualified Course A instructors and that Course A is integrated into training in pediatrics departments and obstetrics and gynecology departments during the early post-graduate
clinical rotation. The Japan Institute of Midwifery Evaluation started the certification program
for the Clinical Ladder® of Competencies for Midwifery Practice (CLoCMiP ®) in 2015, which requires the completion of Course B or a more advanced course within a specified period 18).

for neonatal resuscitation based
X Indications
on the NCPR guidelines 19)
A neonate is medically defined as a child younger than 28 days old. Differences between pediatric cardiopulmonary resuscitation (CPR) and neonatal CPR have become more apparent since
the introduction of CoSTR2010. Because of this, confusion is expected when CPR is performedon an infant younger than 1 month of age in a pediatric ward or a pediatric emergency department. The Japan Resuscitation Council has issued the following recommendations for infant CPR
13

Chap.

1

based on the idea that the highest priority is to avoid delays in the initiation of resuscitation
due to excessive concern about whether a patient should be classified as a neonate or an infant.
● Neonatal resuscitation procedures should be performed on neonates who are in the delivery
room or neonate room and on infants (corrected age <1 year) who are staying in the NICU.
● Pediatric CPR can be performed on infants in cardiac arrest who are younger than 28 days old(neonates) during prehospital care or emergency resuscitation at a pediatric ward, a pediatricintensive care department, or an outpatient department.
● The selection of resuscitation procedures for neonates, NCPR or pediatric CPR should bebased on predetermined institutional policies.
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https://josan-hyoka.org/personalidentification/approvaltraining/（2020年11月17日アクセス）19）第 4 章 新生児の蘇生 1 -4新生児の区分．JRC蘇生ガイ
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Chap.1

Assessment of certainty of evidence
and strength of recommendation
using the GRADE approach

Chap.

1

Tetsuya Isayama

ILCOR Neonatal Life Support Task Force CoSTR2020 author
Member of the Committee on Neonatal Resuscitation, Japan Society of Perinatal and Neonatal Medicine
Editor of the neonatal section of the Japan Resuscitation Council Guidelines 2020

I

Assessment of certainty of evidence using the
GRADE approach

Neonatal cardiopulmonary resuscitation (NCPR) is based on the neonatal resuscitation guidelines of the Japan Resuscitation Council (JRC), which were developed in accordance with theneonatal resuscitation guidelines established by the International Liaison Committee of Resuscitation (ILCOR). The ILCOR is an international organization consisting of resuscitation councils from various regions of the world, and representatives from Japan have participated in
updating and revising the neonatal resuscitation guidelines every 5 years. As shown in Fig.1,
the ILCOR’s international guidelines are used by resuscitation councils around the world, withminor modifications appropriate to each region. The JRC’s neonatal resuscitation guidelines, on
which this NCPR textbook is based, were developed exclusively for Japan based on the 2020 ILCOR guidelines, taking into account the health care system, clinical practices, and sociocultural
background in Japan.
The ILCOR conducts systematic reviews of various issues in neonatal resuscitation (using thePatient-Intervention-Control-Outcome [PICO] model), develops the Consensus on Science with
Treatment Recommendations (CoSTRs), and develops neonatal resuscitation guidelines based on
the CoSTRs. Since 2010, the ILCOR’s resuscitation guidelines have been developed based on
the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach,which has become a global standard for conducting systematic reviews and developing clinical practice guidelines (Fig. 2) .1, 2) The GRADE approach was developed by the GRADE Working
Group, an international group of experts in systematic reviews and clinical practice guidelines,
in collaboration with the Cochrane Collaboration, and it is still evolving. It is a global standard
approach that has been adopted by many leading organizations around the world, including theWHO, the Cochrane Collaboration, ILCOR, UpToDate, and the Medical Information Distribution
Service (MINDS) of the Japan Council for Quality Health Care.
The GRADE approach has the following characteristics: 1) it assesses the risk of bias and certainty of evidence (previously called the “quality of evidence”) of each study on an outcomesbasis; 2) it develops recommendations that are not only based on scientific results but also incorporate various perspectives, such as patients’ values and preferences, costs, and health careresource utilization; and 3) it clearly separates the certainty of evidence from the strength ofrecommendation in its assessment.

15

Fig. 1 Country-specific neonatal resuscitation guidelines based on ILCOR guidelines
American Heart Association(AHA)

American Academyof Pediatrics (AAP)
NRP guidelines

Heart and Stroke Foundationof Canada(HSFC)ILCOR Common guidelines

Inter American Heart Foundation(IAHF)

Japan Resuscitation Council
guidelines

Resuscitation Council of Asia
(RCA)
*Membership JRC

The Textbook of NCPR

European Resuscitation Counsil
(ERC)

ERC
Neonatal resuscitation
guidelines

Australian and New Zealand Committee
on Resuscitation(ANZCOR)ANZCOR
Neonatal resuscitation
guidelines

Resuscitation Coucil of Southem Africa(RCSA)RCSA
Neonatal resuscitation
guidelines

II Assessment of strength of recommendation
In the GRADE approach, the first step is to assess the risk of bias of individual studies for eachoutcome. Then, the overall results of the relevant studies are summarized for each outcome and assessed according to the following five parameters: risk of bias, inconsistency, indirectness, imprecision, and other considerations, including publication bias. Based on the results of these assessments,
the certainty of evidence is rated on a four-point scale: “high,” “moderate,” “low,” or “very low. The
details of the certainty of evidence assessment for each outcome are usually summarized and published in an evidence table (e.g., an evidence profile table or summary of findings table). This table
is the core of the scientific rationale for the ILCOR guidelines but is not the only basis on which
recommendations are made.
The direction and strength of recommendations are determined based on four criteria: (1) the overall certainty of evidence across outcomes, (2) the benefit-harm balance, (3) values and intentions,and (4) resource requirements and costs (optional). Other factors that are taken into consideration
include feasibility, fairness, and acceptability. The final strength of recommendation is divided into
two levels: strong recommendations (expressed as “it is recommended that...”) and weak recommendations (expressed as “it is suggested that...”). This process of determining recommendations isusually published in an evidence-to-decision (EtD) table. This attempt to make the decision-making
process as public and transparent as possible is another important merit of the GRADE approach.
16

What is Neonatal Cardiopulmonary Resuscitation?

Fig. 2 Process of creating recommendations using the GRADE system
Systematic review
es
ce
om
tan
utc
por
o
lates
m
t
u
i
m n
ec
te
Ra
Sel
For estioquleltip memu utco
e
m
o
file
o
enc
pro
a frr each
vid
t
e
e
a
c
f
o e
l d foen )lity com
Pooudies
vid GDTquah outte eEpro/
st
a
e
t
e
Cr RADRa r eac(Gfo

Outcomes 1 criticalHigh(A)
Moderate(B)
Low(C)
Verylow(D)Outcomes 2 critical
Outcomes 3 important
Outcomes 4 not
im p
or

t an

Determine the certainty of evidence(CoE) and produce a summary offindings (SoF) for each outcome(important/critical)t

Re-evaluation of the outcomesand study selection

Start with “high” for RCTsand “low” for controlled
observational studies
RCT → highSTART Observational
study → low
8 factors of GRADE
GRADE
Down

GRADE
Up

Chap.

1

1. Risk of blas
2. Inconsistency
3. Indirectness
4. Imprecision
5. Publication bias
1. Large effects
2. Dose responses
3. Confounders

Re-evaluation of the relative
importance of the outcomes
and the precision of theeffect estimates

Guideline
Formulate recommendations:-For or against(direction)-Strong or conditional/weak(strength of recommendation)Panelconsiderations:-Quality of evidence-Balance benefits/harms-Values and intentions
EtD framework(GDT)
Revise if necessary considering:-Resources(cost)

Assessment of the overall CoE
Overall CoE across outcomes

Treatment guidelines*Feasibility, fairness, acceptability

Lowest CoE for critical outcomes(highest CoE for outcomes with thesame direction)

Recommendation (↓↑／⊕ ) ex:GRADE 28 (↑／⊕⊕⊕ ◯)- “....using (strong recommendation)”- “....using(weak recommendation)”- “....not using(strong recommendation)”- “....not using(weak recommendation)”

III Differences among the three types of reviews
In addition to the traditional systematic review (SysRev), two new review methods were introduced in the 2020 revision of CoSTR: the scoping review (ScopRev) and the evidence update(EvUp). To understand the process used in the latest revision of the CoSTR, it is important tounderstand the differences among these three types of reviews, as shown in Table. 1.
Table.1 Three types of reviews in CoSTR2020
types of reviews

Details and purpose

effect on CoSTR

Systematic Review(SysRev)

To evaluate the effectiveness of an intervention by
conducting a regular SysRev based on clarified clinicalquestions (according to the Patient-Intervention-Control-Outcome [PICO] model).

Scoping Review(ScopRev)

Usually used to review clinical questions that are broader
or less clear than those addressed in a SysRev and often
used to clarify PICO or assess PICO priorities.
The purpose is to connect to a subsequent SysRev.

Evidence Update(EvUp)

This type of review is used to search for newly-publishedliterature on PICOs for which the ILCOR has alreadyconducted a SysRev, with the aim of determining whether
to repeat the SysRev.

Reflected in the ILCOR’s CoSTRs

Usually not reflected in the ILCOR’s CoSTRs.
A formal SysRev must be performed tochange the recommendations.

References
１）相原守夫：診療ガイドラインのためのGRADE システム
（GRADE System for Clinical Practice Guideline）. 第3版（3rd ed）．中外医学社，東京，2018．

２）Guyatt GH, Oxman AD, Vist GE, et al: GRADE: anemerging consensus on rating quality of evidence
and strength of recommendations. BMJ 2008; 336（7650）: 924-6 .

17

Chap.1

Major revisions to the 2020 Japan Resuscitation Council Guidelines on Neonatal
Resuscitation based on Consensus 2020
Shigeharu Hosono

Chair, Committee on Neonatal Resuscitation, Japan Society of Perinatal and Neonatal Medicine
ILCOR Neonatal life Support Task Force
Director, Neonatal Division, Japan Resuscitation Council

The most important skill in neonatal resuscitation is the ability to introduce effective ventilation without delay. The concept underlying the previous revision of the Neonatal Cardiopulmonary Resuscitation Guidelines 2015 (NCPR2015) was that the actions to be taken within 60 s
in the algorithm are the process for introducing ventilation without delay, and the initial steps
taken in the algorithm are to prepare for effective ventilation in one aspect. 1) Although the importance of ventilation remains unchanged in NCPR2020, the following changes have been madeto reflect revisions made in CoSTR2020. 2)
The most important aspect of neonatal resuscitation is the lifesaving sequence leading to ventilation or chest compressions. The importance of briefing is clearly stated because team performance is as important as individual skills for introducing effective ventilation without delay. If the patient’s condition does not improve with effective ventilation or chest compressions,adrenaline should be administered in the presence of a pediatrician as early as possible. During
the stabilization sequence, when labored breathing or cyanosis is present, CPAP or free-flow oxygenation should not be administered immediately; instead, SpO 2 monitoring should be performed,
and treatment should be selected according to the patient’s condition and followed by evaluation.
The following sections provide a summary of the changes from NCPR2015 to NCPR2020 3)(Table. 1) and an overview of the 22 issues addressed in the latest revision; additionally, theysummarize the actual flow of NCPR.

I

Revisions and rationale

1 Emphasizing the lifesaving sequence as theessence of neonatal resuscitation

Until 2015, the algorithm started with initial steps and the subsequent assessment of respirationand heart rate and then separated into the left branch (lifesaving sequence) and the right branch (thestabilization sequence), which were presented in a contrasting manner. However, because the main pathof neonatal resuscitation is the lifesaving sequence, starting with the introduction of effective ventilation without delay when there is no spontaneous breathing or when the heart rate is less than 100
bpm, the assessment and intervention steps of the lifesaving sequence have been arranged in a linear
fashion starting from birth, and the stabilization sequence has been arranged as a branch to the right.
18

What is Neonatal Cardiopulmonary Resuscitation?

Table.1 Major changes in NCPR2020
Item

1

Briefing

2

Oxygenation after
the initiation ofchest compressions

3

Changes in the Japanese
Neonatal Cardiopulmonary
Resuscitation Guidelines 2020

Reason for the change andoperational considerations

The “Briefing” and “Birth”
boxes have been added
before the step of “Assess
the neonate immediately
after birth” in the algorithm.

A systematic review concluded that briefing or debriefing may improve short-term clinical outcomesfor neonates and performance outcomes for staff.
To improve team performance, understand the
expected resuscitation requirements of theneonate, confirm the availability of equipment
and role sharing, and ensure that measures arein place to protect health care professionals
against infection.

The term “oxygenation”
has been added to thechest compressions step,
following ventilation.

Since oxygenation during chest compressions isoften omitted during scenario-based practicaltraining at workshops, the term has been added
to the algorithm to improve awareness of theneed for oxygenation.

The adrenaline administration step has been separated from the medication
step as an intervention tobe performed before theadministration of circulatory volume expanders.

There is no evidence to recommend routine supplementation with circulatory volume expanders
in nonbleeding neonates. Therefore, during the
medication step, the administration of circulatory volume expanders should not precede theadministration of adrenaline.
For adrenaline administration, umbilical venous
infusion is recommended as the administrationroute of first choice. Even if the first dose of
adrenaline was given intratracheally, the subsequent establishment of the venous route should
not be delayed. If the heart rate is still below 60
bpm after intratracheal adrenaline administrationand if the venous route is available, intravenous
adrenaline should be administered regardlessof the interval from the preceding intratracheal
administration.

Adrenaline andvolume infusion

The requirement forproceeding to the stabilization sequence has
been changed from “bothlabored breathing and cyanosis” to “either laboredbreathing or cyanosis.”

CoSTR2020 recommends proceeding to intervention if there is either labored breathing or
cyanosis. In NCPR2020, the requirement for proceeding to the step of “attach an SpO 2 monitor
and consider administering CPAP or oxygen as
needed” has been changed from “both” laboredbreathing and cyanosis to “either” of them.

5

Assessment andintervention after
the application of
CPAP or free-flow
oxygenation

A new evaluation criterion,“improving”, has been
added after the administration of CPAP or free-flow
oxygen, along with the recommendation to continue
the same intervention.

In clinical practice, it is practical to continue
CPAP or oxygenation when the patient’s condition is improving. Therefore, the evaluation
criterion “improving” has therefore been added,
and if this criterion is met, the same intervention
should be continued, and the presence/absenceof labored breathing and cyanosis (poor oxygenation) should be reassessed later.

6

Postresuscitation
care

Changed to recommend
only “continue careful
respiratory monitoring.”

Postresuscitation care should be initiated only
when the symptoms have resolved or improved.

4

Evaluation of polypnea and cyanosis
and subsequentintervention

PICO
CQ

Types ofreviews

Chap.

1

NLS1562 ScopRev

NLS593
NLS616

SysRev
SysRev

SysRev: Systematic Review, ScopRev: Scoping Review

2 Inclusion of “briefing” as a prenatal step
A systematic review of the effects of briefing (preliminary conference) and postresuscitation
debriefing (review) concluded that briefing or debriefing may improve short-term clinical outcomes for neonates and performance outcomes for staff. The use of briefing and debriefing was
also recommended for simulation education and learning in clinical settings. Briefing has been
added along with “birth” in the algorithm because of its importance not only for the conven19

tional prevention of infection through blood and other bodily fluids and the confirmation of theavailability of resuscitation supplies but also for protection against droplet infection during thesevere acute respiratory syndrome-corona virus 2 (SARS-CoV-2) pandemic and the preparationof protective equipment.

3 Addition of “oxygenation” to the chest compressions step
following ventilation

If the heart rate is less than 60 bpm on assessment after 30 s of effective ventilation, chest
compressions with oxygenation should be initiated while continuing ventilation. Given that theprovision of oxygenation during chest compressions is often omitted during scenario-based
practical training at workshops, it has been included in the latest revision of the algorithm.
The oxygen concentration at the start of ventilation remains the same: room air for neonates ≥ 35 weeks of gestation and a low oxygen concentration of 21% to 30% for preterm
neonates < 35 weeks of gestation.

4 Listing “adrenaline administration” as a separate step
because it is the first-line medication

An evidence update on volume expanders was conducted. The results showed that there was
no evidence to recommend routine use of circulatory volume expanders in nonbleeding neonates.
Therefore, the administration of circulatory volume expanders should not precede the administration of adrenaline, and if the heart rate remains below 60 bpm even after effective ventilation and chest compressions with oxygen, adrenaline should be the first-line medication. Thus,“adrenaline” has been listed as a separate step in the latest revision.
A systematic review of adrenaline administration was conducted, and it recommended umbilicalvenous infusion as the first-choice administration route for adrenaline. The dose and dosinginterval (every 3 to 5 min if the heart rate remains below 60 bpm with intravenous or intratracheal administration) remain unchanged. Even if the first dose was given intratracheally, theestablishment of the venous route should not be delayed, and if the heart rate is still below
60 bpm after intratracheal adrenaline administration and if the venous route is available, intravenous adrenaline administration should be performed as soon as possible regardless of theinterval from the preceding intratracheal administration. In such cases, additional doses should
be administered at the usual intravenous dose.

5 Changing the requirement for proceeding to the stabilization sequence from “both labored breathing and cyanosis”
to “either labored breathing or cyanosis”

In the NCPR2015 algorithm, the patient was examined for labored breathing and cyanosis, andif both were present, CPAP or oxygen was administered with SpO2 monitoring. If either of them
was present, the algorithm proceeded to postresuscitation care, during which the cause was
explored and the introduction of CPAP was considered if there was labored breathing alone, andthe possibility of a cyanotic heart disease was considered if there was cyanosis alone. In clinical20

What is Neonatal Cardiopulmonary Resuscitation?

practice, if cyanosis or labored breathing is present, it is practical to perform SpO2 monitoringfor differential diagnosis and to provide treatment as necessary. In addition, in accordance with
CoSTR2020, in which the presence of labored breathing or cyanosis leads to the introduction ofintervention, NCPR2020 also recommends to “attach an SpO2 monitor and administer CPAP or
oxygen as needed” if labored breathing or cyanosis is present.

6 In the stabilization sequence, the first intervention is not

performed immediately; instead, the first step has beenchanged to “attach an SpO2 monitor and administer CPAP or
oxygen as needed”

To proceed to the stabilization sequence, the patient must have spontaneous breathing and aheart rate of 100 bpm or more. In this state, the brain and organs, including the heart, do not
immediately suffer hypoxic-ischemic damage. Therefore, the first step has been changed to “attach an SpO2 monitor and consider administering CPAP or oxygen as needed.” Even in neonates
who are breathing spontaneously or crying well after initial resuscitation, generalized cyanosis
may persist, or oxygenation may be poor for the first few minutes after birth. Therefore, it is
not necessary to immediately administer oxygen to a neonate who has cyanosis alone, withoutlabored breathing.

7 The term “poor oxygenation” has been added after cyanosis
Systemic cyanosis is a condition that occurs when the hemoglobin (Hb) content in capillary
blood is reduced by more than 5 g/dL. Oxygen saturation represents the proportion of oxygen-bound Hb relative to the total amount of Hb in all red blood cells in the arterial blood. It is
not possible to determine a universal threshold for arterial oxygen saturation at which cyanosis
occurs as it varies depending on the Hb concentration. Thus, generalized cyanosis and poor oxygenation are not synonymous. Poor oxygenation is defined as a level of oxygenation below thereference value described in the NCPR algorithm. Therefore, the presence of poor oxygenation
may be determined by skin color, namely the presence or absence of cyanosis, before the SpO2
monitor is applied or in situations where SpO2 information is not available. In facilities wherean SpO2 monitor is available, however, poor oxygenation should be determined by arterial blood
oxygen saturation.

8 A new evaluation criterion, “improving”, has been added after the administration of CPAP or free-flow oxygen

The NCPR2015 algorithm stated that if both labored breathing and cyanosis are present, CPAPor oxygenation should be started immediately after an SpO2 monitor is applied, and if bothlabored breathing and cyanosis is still present after 30 s, the patient should proceed to theventilation step. In clinical practice, it is practical to continue CPAP or oxygenation when thepatient’s condition is improving. Therefore, the evaluation criterion “improving” has been added,
and if this criterion is met, the same intervention should be continued, and the presence or absence of labored breathing and cyanosis (poor oxygenation) should be re-assessed later.
21

Chap.

1

9 Action to be taken when there is no improvement in laboredbreathing or cyanosis (poor oxygenation) during postintervention assessment has been changed to “consider the response” while searching for the cause

In to the NCPR2015 algorithm, the absence of improvement in labored breathing and cyanosis
led to the introduction of ventilation. In contrast, the NCPR2020 algorithm recommends thatwhen there is no improvement in labored breathing or cyanosis (poor oxygenation) after theadministration of CPAP or free-flow oxygenation, instead of introducing ventilation in all cases,
either of the following actions should be taken while searching for the cause: “consider ventilation if labored breathing and poor oxygenation persist” and “consider the possibility of cyanotic
heart disease if only poor oxygenation persists.” If there is no cyanosis (poor oxygenation) andonly labored breathing persists, then there is no problem with oxygenation, and the resuscitation procedure is completed. The next step is to identify the causative disease and initiate
the appropriate treatment. This is because in NCPR, labored breathing encompasses the four
symptoms of nasal flaring, grunting retractions, and tachypnea, and because these symptoms
are characteristic of different conditions, it is necessary to determine the underlying cause andselect the appropriate treatment.

10 Postresuscitation care has been changed to recommend only“continue careful respiratory monitoring”

In the NCPR2015 algorithm, the presence of labored breathing or cyanosis led to the initiationof postresuscitation care, in which careful respiratory monitoring should be continued while
exploring the cause, the introduction of CPAP should be considered if only labored breathing
persists, and the possibility of cyanotic heart disease should be considered if only cyanosis persists. In the NCPR2020 algorithm, postresuscitation care is initiated only when there is neither
labored breathing nor cyanosis (poor oxygenation), and thus, only “continue careful respiratory
monitoring” is recommended.

11 Simplification of notes (a) and (b)The following changes have been made for simplification:(a) Ventilation: In more than 90% of cases of neonatal asphyxia, bag-mask ventilation alone
improves the situation, and there is no need to intubate quickly. Start with room air andadd oxygen if there is no improvement in skin color or SpO2.
→ Add or increase oxygen if there is no improvement in heart rate or SpO2.
(b) If the patient is not properly ventilated, do not proceed to chest compressions; instead,concentrate on securing and implementing ventilation.
→ If the patient is not properly ventilated, do not proceed immediately to chest compressions; instead, try to ensure effective ventilation first.
No change has been made to note (c).

22

What is Neonatal Cardiopulmonary Resuscitation?

II

Summary of 22 issues addressed in the
CoSTR2020 and recommendations

Chap.

The 22 issues addressed in the CoSTR2020 2) are listed in Table. 2. Seven systematic reviews(SysRev), 3 scoping reviews (ScopRev), and 12 evidence updates (EvUp) are discussed. The following sections provide a summary of these issues.

1 Anticipation and preparation(1) Prediction of the need for respiratory support in thedelivery room (NLS 611: EvUp)
CoSTR2020: Cesarean deliveries performed under local anesthesia without preidentified risk
should be attended by a health care professional with experience in ventilation, but it is notnecessary for the delivery to be attended by a physician skilled in intubating neonates. This
recommendation is unchanged from CoSTR2010.
In NCPR2015, it was stated that “Research has shown that the need for endotracheal intubation during resuscitation is no higher in term infants born by cesarean section under local
anesthesia than in term infants delivered vaginally. Therefore, attendance by personnel capableof ventilation should be sufficient for cesarean deliveries of risk-free term infants under local
anesthesia.” This recommendation remains unchanged in NCPR2020.

(2) Effect of briefing/debriefing following
neonatal resuscitation (NLS 1562: ScopRev)
CoSTR2020: Although there is emerging evidence in many fields that holding a briefing session
before delivery in the delivery room and a debriefing session after resuscitation may lead to improvement in practices and outcomes, there have been no recommendations regarding briefing/debriefing in the neonatal area. A systematic review concluded that briefing and debriefing may
improve the short-term outcomes of neonates and the performance of health care professionals. However, the effects of briefing and debriefing on long-term clinical outcomes and performance are not known.
NCPR2020 recommends the introduction of briefing and debriefing.

2 Initial assessment and intervention(3) Warming adjuncts (NLS 599: EvUp)
CoSTR2020: For preterm neonates < 32 weeks of gestation kept under radiant warmers in thedelivery room, it is suggested that a combination of interventions be used to reduce hypothermia (< 36.0°C) on admission to the NICU, such as maintaining an environmental temperatureof 23°C to 25°C, warm blankets, wrapping without drying, caps, and thermal mattresses. It issuggested that hyperthermia (> 38.0°C) be avoided due to the potential associated risks. These
recommendations remain unchanged from CoSTR2010.
NCPR2015 suggested that when performing resuscitation procedures under a radiant warmer
in preterm infants born between 28 and 32 weeks of gestation, a combination of interventions
such as an environmental temperature of 23°C to 25°C, warm blankets, wrapping with poly23

1

Table.2 The 22 issues addressed in the CoSTR2020
Issue
Anticipation and preparation
1. Prediction of the need for respiratory support in the delivery room
2. Effect of briefing/debriefing after neonatal resuscitation

EvUp
ScopRev

Initial assessment and intervention
3. Warming adjuncts
4. Suctioning of clear fluid
5. Tracheal intubation and suctioning of nonvigorous neonates with meconium-stained amniotic fluid

EvUp
ScopRev
SysRev

Physiologic monitoring and feedback devices
6. Heart rate monitoring during neonatal resuscitation

EvUp

Ventilation and oxygenation
7. Sustained inflation
8. Positive end-expiratory pressure (PEEP) vs. no PEEP
9. Continuous positive airway pressure (CPAP) vs. intermittent positive pressure ventilation (PPV)
10. T-piece resuscitator vs. self-inflating bag for ventilation
11. Oxygen for the resuscitation of preterm neonates
12. Oxygen for the resuscitation of term neonates

SysRev
EvUp
EvUp
ScopRev
SysRev
SysRev

Circulatory support
13. CPR ratios for neonatal resuscitation
14. Two-thumb versus two-finger compressions for neonatal resuscitation

EvUp
EvUp

Drug and fluid administration
15. Epinephrine (adrenaline) for neonatal resuscitation
16. Intraosseous versus umbilical vein for emergency access
17. Volume infusion during neonatal resuscitation
18. Sodium bicarbonate during neonatal resuscitation

SysRev
SysRev
EvUp
EvUp

Prognostication during CPR
19. Impact of the duration of intensive resuscitation

SysRev

Postresuscitation care
20. Rewarming of hypothermic neonates
21. Therapeutic hypothermia in settings with limited resources
22. Postresuscitation glucose management

EvUp
EvUp
EvUp

SysRev: Systematic Review, ScopRev: Scoping Review, EvUp: Evidence update

ethylene plastic wrap, and thermal mattress should be used to avoid hypothermia (< 36°C) on
admission to the NICU, and whether to dry neonates before wrapping them may be determinedby each institution. This recommendation is unchanged in NCPR2020.

(4) Suctioning of clear fluid (NLS 596: ScopRev)
CoSTR2020: Routine oropharyngeal and nasopharyngeal suctioning of clear amniotic fluid as
an initial treatment after delivery is not recommended. This treatment recommendation is unchanged from CoSTR2010.
The NCPR2020 also recommends against routine oropharyngeal and nasopharyngeal suctioningin neonates with clear amniotic fluid.

(5) Tracheal intubation and suctioning ofnonvigorous meconium-stained newborns (NLS 865: SysRev)
CoSTR2020: It is recommended that routine oropharyngeal and nasopharyngeal suctioning not
be performed immediately after birth in nonvigorous meconium-stained neonates. These recommendations are unchanged from CoSTR2015, although the latest scoping review directly recommends against routine suctioning.
NCPR2020 recommends that routine oropharyngeal and nasopharyngeal suctioning not be per24

What is Neonatal Cardiopulmonary Resuscitation?

formed immediately after birth in nonvigorous neonates with meconium-stained amniotic fluid,which is unchanged from NCPR2015. Meconium-stained amniotic fluid remains an important risk
factor for neonates undergoing advanced resuscitation procedures in the delivery room and,though rate, intubation and endotracheal suctioning may be required to relieve airway obstruction. Therefore, it is recommended to have equipment for endotracheal intubation ready and aphysician experienced in endotracheal intubation available.

3 Physiologic monitoring and feedback devices(6) Heart rate monitoring during neonatal resuscitation (NLS 898: EvUp)
CoSTR2020: It is suggested that electrocardiography (ECG) can be used for the rapid and accurate measurement of heart rate in neonates who require resuscitation. This recommendationis unchanged from CoSTR2015. However, new technologies for detecting and measuring heart
rate are increasingly reported and should be compared with the current gold standard of ECG
monitoring using gel electrodes in the future.
The NCPR2015 recommendation that ECG should be considered as needed remains unchangedin NCPR2020. It is desirable to use and disseminate ECG, especially in facilities that handle
high-risk deliveries, such as general and regional perinatal care centers. It should also be notedthat pulse oximetry can measure oxygen saturation as well as heart rate but is not a substitutefor ECG. Pulse oximetry should be used during positive pressure ventilation (PPV) and in thestabilization sequence.

4 Ventilation and oxygenation(7) Sustained inflation (NLS 809: SysRev)
CoSTR2020: It is suggested that preterm neonates who require PPV due to bradycardia or
ineffective breathing at birth should not routinely receive initial sustained inflation for morethan 5 s.
NCPR2015 also recommended against sustained inflation for more than 5 s in preterm neonates
without spontaneous breathing at birth because there was insufficient evidence to recommend
sustained inflation and because the methods of application and assessment of effectivenesswere not clearly defined. This recommendation is unchanged in NCPR2020.

(8) Positive end-expiratory pressure (PEEP) vs. no PEEP (NLS 897: EvUp)
CoSTR2020: It is recommended that PEEP be used for the initial ventilation of preterm neonates during resuscitation. For term neonates, there is insufficient data to make a recommendation. This recommendation is unchanged from CoSTR2015.
The NCPR2015 recommendation that PEEP of 5 cm H2O be used for the initial ventilation ofpreterm neonates remains unchanged in NCPR2020.

(9) Continuous positive airway pressure (CPAP) vs.
intermittent positive pressure ventilation (PPV) (NLS 590: EvUp)
CoSTR2020: For preterm neonates with labored breathing, it is recommended that CPAP be
introduced first, rather than performing PPV or endotracheal intubation immediately. This rec25

Chap.

1

ommendation is unchanged from CoSTR2010.
NCPR2015 recommended that preterm and term neonates with labored breathing should receive CPAP first, if available, rather than immediately undergoing PPV or endotracheal intubation. This recommendation remains unchanged in NCPR2020.

(10) T-piece resuscitator vs. self-inflating bag
for ventilation (NLS 870: ScopRev)
CoSTR2020: There is insufficient evidence to recommend the use of either a T-piece resuscitator or a self-inflating bag as the device for administering PPV at birth, and therefore, therecommendation of one device over another would be purely speculative. This recommendationis unchanged from CoSTR2010. However, a recent randomized controlled trial with a sufficient
sample size and a large observational study have shown that the use of a T-piece resuscitator
improves survival, reduces intubation rates, and decreases the incidence of chronic lung disease,suggesting the need to conduct a formal SysRev in the near future.
NCPR2020 also does not recommend the use of any specific device. In Japan, self-inflating andflow-inflating resuscitation bags are mainly used, and the adoption rate of T-piece resuscitators is low. Each medical institution should select an appropriate device based on an understanding of the advantages and disadvantages of each device and should provide sufficient training totheir staff to ensure their capability for providing effective ventilation immediately.

(11) Oxygen for preterm resuscitation (NLS 864: 2019 CoSTR publication) 4)
CoSTR2020: For preterm neonates < 35 weeks of gestation who receive respiratory support at
birth, it is recommended to start with a low oxygen concentration (21-30%) rather than higher
oxygen concentration (60-100%). An oxygen concentration range of 21-30% is recommended
because all trials used this range for the low oxygen concentration group. Once oxygenation isstarted, it is recommended that a pulse oximeter be used to adjust the oxygen concentration.
This recommendation is unchanged from CoSTR2015.
In NCPR2020, as in NCPR2015, it is recommended to start with a low oxygen concentration(21-30%) rather than a higher oxygen concentration (60-100%) for preterm neonates < 35weeks of gestation who receive respiratory support at birth.

(12) Oxygen for term resuscitation (NLS 1554: 2019 CoSTR publication) 4)
CoSTR2020: For neonates ≥ 35 weeks of gestation receiving respiratory support at birth, it
is recommended to start with 21% oxygen (air). Starting with 100% oxygen is not recommended. This recommendation is unchanged from CoSTR2015. In NCPR2020, as in NCPR2015, it isrecommended to start with 21% oxygen (air) for neonates ≥ 35 weeks of gestation receiving
respiratory support at birth.

26

What is Neonatal Cardiopulmonary Resuscitation?

5 Circulatory support(13) CPR ratios for neonatal resuscitation (NLS 895: EvUp)

Chap.

CoSTR2020: It is recommended that a 3:1 compression-to-ventilation ratio be used for NCPR.
This recommendation is unchanged from CoSTR2015.
In NCPR2020, as in NCPR2015, it is recommended that a 3:1 compression-to-ventilation ratio
be used for NCPR.

(14) Two-thumb versus two-finger compressions
for neonatal resuscitation (NLS 605: EvUp)
CoSTR2020: It is recommended that chest compressions in neonates be performed using
the two-thumb, hands-encircling-the-chest method. This recommendation is unchanged fromCoSTR2015.
In NCPR2020, as in NCPR2015, it is recommended that the two-thumb, hands-encircling-thechest method be used as the first-line approach for chest compressions in neonates. In situations where the two-thumb method cannot be used, the use of the two-finger method isrecommended.

6 Drug and fluid administration(15) Epinephrine (adrenaline) for neonatal resuscitation (NLS 593: SysRev)
CoSTR2020: If the heart rate has not increased to 60 bpm or greater after optimizing ventilation and chest compressions, the intravascular administration of adrenaline (0.01-0.03 mg/kg) is recommended. If vascular access cannot be established, it is recommended to administerendotracheal adrenaline at a higher dose (0.05-0.1 mg/kg) than that used for IV administration,although this should not delay attempts to establish vascular access after endotracheal adrenaline administration. If the heart rate remains below 60 bpm, it is suggested to administer adrenaline every 3 to 5 min, preferably intravascularly. If the response is inadequate, it is suggested
to administer intravascular adrenaline as soon as vascular access is established, regardless of
the interval from the initial endotracheal dose. This recommendation contains more specificdosage information and guidance on repeated dosing than the CoSTR2010 recommendation.
NCPR2020 also recommends that adrenaline be administered into the umbilical vein if the heart
rate has not increased to 60 bpm or higher after optimizing ventilation and chest compressions.
If vascular access cannot be established, endotracheal administration is the second-line option.
It is recommended that endotracheal adrenaline be administered at a higher dose than that used
for IV administration. If the heart rate does not improve with the endotracheal administrationof adrenaline, an attempt to establish vascular access should not be delayed. If the heart rate
remains below 60 bpm, adrenaline should be administered every 3 to 5 min via the same routeof administration. If the response to endotracheal adrenaline is inadequate, it is suggested
to administer intravascular adrenaline as soon as vascular access is established, regardless of
the interval from the initial endotracheal dose. This recommendation remains unchanged fromNCPR2015 in terms of the dosage or repeat-dose interval by the same route, but it emphasizes
the importance of the IV administration of adrenaline. It is suggested that pediatricians who
27

1

perform resuscitation prepare equipment for securing umbilical venous access so that IV adrenaline can be administered when necessary and that they receive prior training so that umbilicalvenous access can be established promptly. However, in Japan, peripheral venous access is stillused as an alternative to umbilical venous access. Peripheral access may be used as the first
choice of administration route if it can be reliably secured in a time frame similar to that ofumbilical access.

(16) Intraosseous (IO) versus umbilical veinfor emergency access (NLS 616: SysRev)
CoSTR2020: Umbilical venous catheterization is recommended as the first choice for vascularaccess during neonatal resuscitation in the delivery room. If umbilical venous access is not feasible, then the IO route is a reasonable alternative. When performing resuscitation outside thedelivery room, it is suggested that either umbilical venous access or the IO route be used for
drug or fluid administration. The actual route used will depend on the equipment, training, andexperience available at each institution. CoSTR2010 stated that during neonatal resuscitation,
the IO route can be used for drug and fluid administration on a temporary basis only when umbilical venous access has failed or when a health care professional skilled at securing IO access isavailable. Given the extensive reports of complications with the IO route, the CoSTR2020 morestrongly favors the umbilical venous route for resuscitation performed in the delivery room but
continues to allow the IO route to be used in some situations.
In NCPR2020, as in NCPR2015, it is stated that if a physician skilled at securing IO access for
fluid infusion with a bone marrow needle is available, IO administration with a bone marrowneedle may be performed if umbilical venous access cannot be established.

(17) Volume infusion during neonatal resuscitation (NLS 598: EvUp)
CoSTR2020: Early volume replacement with saline solution or packed red blood cells is indicated for bleeding neonates who are unresponsive to resuscitation. There is insufficient evidence
to support the routine use of circulatory volume expanders in nonbleeding neonates who areunresponsive to ventilation, chest compressions, or adrenaline. Because of the possibility ofoccult bleeding, the trial use of circulatory volume expanders may be considered for neonates
who are unresponsive to resuscitation. These treatment recommendations are unchanged fromCoSTR2010.
In NCPR2020, as in NCPR2015, it is stated that volume expansion with saline solution may beconsidered for neonates with a history of premature placental abruption, placenta previa, umbilical cord hemorrhage, fetomaternal transfusion syndrome, or twin-twin transfusion syndrome
and neonates for with unknown medical history who are unresponsive to appropriate resuscitation due to hypovolemic shock caused by an obvious drop in circulatory blood volume. For neonates with suspected anemia since the fetal stage, the administration of type-O Rh-negative
packed red blood cells should be considered.

(18) Sodium bicarbonate during neonatal resuscitation (NLS 606: EvUp)
CoSTR2020: Sodium bicarbonate administration is not recommended during brief CPR but may
be useful during prolonged cardiac arrest after adequate ventilation is established if there is no28

What is Neonatal Cardiopulmonary Resuscitation?

response to other therapies. This recommendation is unchanged from CoSTR2010.
In NCPR2020, as in NCPR2015, it is recommended that sodium bicarbonate administration beconsidered when a neonate has obvious metabolic acidosis despite adequate ventilation management and the acidosis appears to be preventing the improvement of hemodynamics.

7 Prognostication during CPR(19) Impact of duration of intensive resuscitation (NLS 896: SysRev)
CoSTR2020: Failure to achieve the return of spontaneous circulation in neonates despite 1020 min of intensive resuscitation is associated with a high risk of mortality and a high risk ofmoderate to severe neurodevelopmental impairment among survivors. However, there is no evidence that any specific duration of resuscitation consistently predicts mortality or moderate tosevere neurodevelopmental impairment. If, despite all recommended resuscitation procedures,
including ventilation with oxygen, chest compressions, and adrenaline administration and theexclusion of all possible reversible causes, a neonate requires ongoing CPR, it is suggested thatthe discontinuation of resuscitation efforts be discussed with the clinical team and the patient’s family. A reasonable time frame in which to consider this change in the goals of care isapproximately 20 min after birth.
NCPR2015 stated that although neonatal resuscitation may be discontinued if the Apgar scoreremains at 0 for more than 10 min in a near-term or term neonate, recent reports that someneonates with an Apgar score of 0 for 10 min have survived without disability after receiving
therapeutic hypothermia indicate that the decision should be individualized and should consider
factors such as whether resuscitation was performed appropriately; the availability of intensive
care approaches, such as therapeutic hypothermia; the timing of the insult before delivery; andthe wishes of the family. Unlike NCPR2015, NCPR2020 provides guidance for “considering discontinuation” rather than “discontinuing” resuscitation; in particular, it suggests that the discontinuation of resuscitation efforts should be discussed with the patient’s family if the returnof spontaneous circulation is not achieved after 20 min of resuscitation with ventilation, chest
compressions, and adrenaline administration. However, decisions regarding whether to continue
resuscitation should be made on a case-by-case basis and should consider factors such as thenumber of weeks of gestation, the presence or absence of congenital anomalies, the timing of
perinatal injury, the appropriateness of the resuscitation interventions, the wishes and valuesof the family, the availability of postresuscitation resources (e.g., neonatal intensive care) after
the return of spontaneous circulation, and the availability of neuroprotective strategies suchas therapeutic hypothermia.

8 Postresuscitation care(20) Rewarming of hypothermic newborns (NLS 858: EvUp)
CoSTR2020: A recommendation cannot be made for either rapid rewarming (> 0.5°C/h) or slow
rewarming (< 0.5°C/h) for unintentionally hypothermic neonates (body temperature < 36°C).
This recommendation is unchanged from CoSTR2015.
This recommendation remains unchanged from NCPR2015 to NCPR2020.

29

Chap.

1

(21) Induced hypothermia in settings with limited resources (NLS 734: EvUp)
CoSTR2020: It is suggested that therapeutic hypothermia be performed for term or near-termneonates with moderate to severe hypoxic-ischemic encephalopathy, even in low-income countries and/or other resource-limited settings. Therapeutic hypothermia should be considered andconducted under clearly defined protocols only in neonatal care facilities with intensive carecapabilities and adequate resources to provide intravenous therapy, respiratory support, monitoring with pulse oximetry or other technologies, antimicrobial therapy, anticonvulsive therapy,
and laboratory tests. The protocol is the same as that used in randomized controlled trials, thatis, cooling to commence within 6 h, strict temperature control from 33°C to 34°C for 72 h, andrewarming over at least 4 h.
Although this recommendation does not apply to Japan, where systems are in place to provide
therapeutic hypothermia according to standard protocols, some NCPR instructors have the opportunity to participate in the development of neonatal resuscitation systems and educational
efforts regarding resuscitation in developing countries. Therefore, the concept described in
CoSTR2020 is reflected in NCPR2020.

(22) Postresuscitation glucose management (NLS 607: EvUp)
CoSTR2020: Intravenous glucose infusion should be considered as soon as possible after resuscitation, with the goal of avoiding hypoglycemia. This recommendation is unchanged fromCoSTR2010.
In NCPR2020, as in NCPR2015, it is recommended that in neonates at high risk of hypoxic
ischemia due to neonatal asphyxia, blood glucose should be measured after resuscitation, andprompt intervention, including intravenous glucose administration, should be considered if hypoglycemia is present.

30

What is Neonatal Cardiopulmonary Resuscitation?

III Flow of the algorithm

Chap.

1

1 Importance of briefing
In resuscitation, the performance of the team is important, as are the skills of each individual.
It is recommended that team members conduct briefings to confirm the use of infection control
measures, the availability of resuscitation supplies, and role assignments.

2 Neonatal assessments made immediately after birth
In NCPR2020, as in NCPR2015, it is recommended to check for (1) preterm gestation, (2) weak
breathing or crying, and (3) weak muscle tone immediately after birth.

3 Routine care
If the neonate does not meet any of the three criteria, routine care consisting of (1) providing
warmth, (2) ensuring an open airway, (3) drying, and (4) ongoing evaluation should be performed
while having the neonate stay with the mother to promote bonding.

4 Initial steps of resuscitation
If there is abnormality in any of the three assessment items immediately after birth, initialresuscitation procedures should be initiated. In NCPR2010, “meconium-stained amniotic fluid”
was excluded from the assessment items used to determine the need for resuscitation procedures at birth. Therefore, routine tracheal suctioning is no longer necessary, even for nonvigorous neonates with meconium-stained amniotic fluid.
CoSTR2020 again addressed this issue and decided to continue to adopt the 2010 recommendation, although the recommendation against suctioning has been strengthened.
For neonates who are apneic or have a heart rate of less than 100 bpm, initial resuscitation
procedures should be initiated so that ventilation can be started within 60 s of birth (i.e., provide warmth and maintain the body position to ensure an open airway; if necessary, open the
airway, wipe away fluid, stimulate the skin, and reposition the neonate to ensure an open airway). Approximately 30 s should be allocated for initial resuscitation procedures. However, thisdoes not necessarily mean that the initial procedures should be continued for 30 s; rather, theinitial procedures should be conducted properly to prevent hypothermia, open the airway, andintroduce effective ventilation.

5 Evaluation after initial steps of resuscitation
After the initial resuscitation procedures, as in NCPR2015, it is recommended that a generally effective intervention be performed for 30 s, followed by the assessment of respiration and heart rate.
The utilization of pulse oximeters is unchanged from NCPR2015. In the lifesaving sequence, it
is recommended to consider attaching a pulse oximeter probe to the neonate’s right hand andusing an ECG monitor.
31

6 Ventilation
The importance of initiating effective ventilation without delay remains the same in NCPR2020
as in NCPR2015. The recommendation that ventilation with air be performed if apnea continues
or the heart rate remains below 100 bpm despite initial resuscitation procedures in term or
preterm neonates ≥ 35 weeks of gestation at the initiation of ventilation is also unchanged. If
there is no increase in heart rate or improvement in oxygenation, as indicated by pulse oximetry,
despite effective ventilation, the use of oxygen should be considered. However, if the heart
rate is above 100 bpm and oxygen saturation is increasing, there is no need to administer oxygen
immediately.

7 Chest compressions
The recommendation that chest compressions be performed when bradycardia (less than 60bpm) persists after 30 s of effective ventilation is unchanged from NCPR2015. The compression-to-ventilation ratio should be 3:1, with each cycle lasting 2 s. For chest compressions, it isrecommended that the two-thumb, hands-encircling-the-chest method be used, and the lower
third of the sternum should be compressed to a depth of one-third of the anteroposterior diameter of the chest.
The oxygen concentration during chest compressions does not necessarily have to be as high as≥ 80%, but oxygen must be administered. If the heart rate is above 100 bpm and oxygen saturation is 95% or higher, the oxygen concentration should be lowered promptly.

8 Medications
In NCPR2020, as in NCPR2015, it is stated that chest compressions and ventilation should not
be interrupted to administer adrenaline if the heart rate is below 60 bpm despite the combination of chest compressions and ventilation. The recommendations remain unchanged in termsof the administration route and dosage, although CoSTR2020 more strongly recommends theumbilical vein as the route of drug administration. However, in Japan, peripheral venous routes
are also routinely used in many institutions, and each institution should establish its own policy
for venous route selection. If the patient enters the lifesaving sequence, it is desirable to haveat least three personnel available so that adrenaline can be administered without interrupting
effective ventilation and chest compressions. Therefore, efforts should be made to gather personnel as early as possible.
The intravenous administration of circulatory volume expanders such as saline solution, which
was previously recommended in cases of poor response to resuscitation, is now indicated only incases of suspected blood loss.

32

What is Neonatal Cardiopulmonary Resuscitation?

9 Oxygenation
Since NCPR2010, it has been strongly recommended that pulse oximetry be used during theresuscitation of an asphyxiated neonate to avoid overoxygenation. This recommendation remains
unchanged in NCPR2020. Especially in institutions that frequently treat high-risk neonates, it
is recommended that oxygen blenders and pulse oximeters always be available in the delivery
room and that the minimum necessary amount of oxygen be administered while monitoring SpO2.
If, after initial resuscitation procedures, the heart rate is above 100 bpm and spontaneous
breathing is well established but labored breathing or central cyanosis is present, it is recommended that a pulse oximeter be attached to the neonate’s right hand and that continuous positive airway pressure (CPAP) with room air or free-flow oxygenation be introduced if necessary.

10 Postresuscitation management(1) Therapeutic hypothermia
NCPR2015 recommended that term or near-term (36 weeks of gestation) neonates with moderate to severe hypoxic-ischemic encephalopathy should be treated with therapeutic hypothermia (33.5-34.5°C) for 72 h starting within the first 6 h of life, followed by rewarming over at
least 4 h.
The recommendation remains unchanged in NCPR2020 in terms of indications and protocol.

(2) Blood glucose management
NCPR2020 follows the recommendations of NCPR2015. In neonates at high risk of hypoxic
ischemia due to neonatal asphyxia, blood glucose should be measured after resuscitation, andprompt intervention, including intravenous glucose administration, should be considered if hypoglycemia is present.

11 Considering discontinuation of resuscitation
CoSTR2010 contains only a general statement that “it is reasonable to withhold resuscitation
when early death or an unacceptably severe outcome is almost certainly predicted based on thelength of gestation, birth weight, and congenital anomalies.”
In NCPR2015, it is stated that although resuscitation may be discontinued if the Apgar scoreremains at 0 for more than 10 min in a term or near-term neonate, recent reports that someneonates with an Apgar score of 0 for 10 min have survived without disability after receiving
therapeutic hypothermia indicate that the decision should be individualized and should consider
factors such as whether resuscitation was performed appropriately; the availability of intensive
care methods, such as therapeutic hypothermia; the timing of the insult before delivery; andthe wishes of the family.
NCPR2020 recommends that the discontinuation of resuscitation be considered if the Apgar
score remains at 0 for more than 20 min despite adequate ventilation, chest compressions, andadrenaline administration in all neonates. This 20-min duration is based on the fact that theseries of procedures leading up to adrenaline administration takes approximately 20 min.

33

Chap.

1

12 Other(1) Timing of cord clamping in term and near-term neonates
Japanese people have significantly higher transcutaneous bilirubin levels than Caucasians, resulting in a higher incidence of jaundice. This is attributable to a higher prevalence of race-associated gene mutations in bilirubin uridine diphosphate glucuronosyltransferase. 5,6)
Against this background, NCPR2020 continues to withhold the recommendation of delayed
cord clamping for term or near-term neonates because “there is insufficient evidence to support or refute delayed cord clamping in Japan” and because of concerns that the introductionof delayed cord clamping may increase the need for phototherapy and consequently prolong the
hospitalization of neonates.

(2) Timing of cord clamping in preterm neonates
CoSTR2020 follows NCPR2015 because no SysRev was available at the time and recommends,
albeit weakly, that cord clamping be delayed for at least 30 s in preterm neonates as doing so
reduces the frequency of serious complications such as intraventricular hemorrhage and necrotizing enterocolitis, although it may increase the risk of jaundice. In Japan, one-time umbilicalcord milking after cord clamping and disconnection appears to be a reasonable intervention forpreterm neonates who require resuscitation.

References
１）細野茂春：Consensus2015に基づく日本版新生児蘇生法
ガイドライン2015の主な改正点．細野茂春（監修）．新生児蘇生法テキスト．（第３版）．p26 - 33，メジカル
ビュー社，東京，2016．
２）Wyckoff MH, Wyllie J, Aziz K, et al. Neonatal Life
Support collaborators: Neonatal Life Support: 2020
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations. Circulation 2020
; 142 : S185 -221.
３）細野茂春，諌山哲哉：NCPRアルゴリズム 2020の主な改正点．野々木宏（編集）．J R C 蘇生ガイドライン2020．
p8 -9，医学書院，東京，2021．
オンライン版：https://www.japanresuscitationcouncil.org/wpcontent/uploads/2020/12/60bc5b2facde74d8 faf20 c0db8147637.pdf（2020年12月 4 日ア
クセス）

34

４）Soar J. Maconochie I, Wyckoff MH ,et al:2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
With Treatment Recommendations :Summary From
the Basic Life Support: Advanced Life Support: Pediatric Life Support: Neonatal Life Support: Education, Implementation ,and Teams :and First Aid
Task Forces, Circulation 2019:140(24):e826-80.
５）Akaba K, Kimura T, Sasaki A, et al: Neonatal hyperbilirubinemia and mutation of the bilirubin uridine diphosphate-glucuronosyltransferase gene: a common
missense mutation among Japanese, Koreans andChinese. Biochem Mol Biol Int 1998:46(1):21-6.
６）Maruo Y, Nishizawa K, Sato H, et al: Association of
neonatal hyperbilirubinemia with bilirubin UDP-glucuronosyltransferase polymorphism, Pediatrics
1999;103(6Pt1):1224-7.

Chapter2

Basic Neonatal Resuscitation

Chap.2

Basic knowledge forneonatal resuscitation
A firm grasp of the major anatomical and pathophysiological concepts that form the foundation of neonatal resuscitation facilitates
understanding the various conditions that can arise in the process andenables care providers to proceed efficiently. This section provides aconcise explanation of the necessary anatomy and pathophysiology.

I

Anatomical knowledge forneonatal resuscitation

1 Anatomy of the upper respiratory tract andchanges with age

The anatomy of the upper respiratory tract of the neonate, particularly from the pharynx and larynx to the trachea, changes withgestational age. The structure of in term neonates differs from thatin children and adults (Fig. 0-1). The biggest difference in neonates
is the laryngeal position.
The most important anatomical difference between neonates andadults is position of the larynx. In neonates, the area corresponding
to the oropharynx is almost nonexistent because of the high positionof the larynx. The larynx in neonates is located at C3 or C4 and with
Fig. 0-1 Comparative anatomy of neonates and adults’ airways

36Basic Neonatal Resuscitation

development descends to a position corresponding to C5 till it reaches C7 in adulthood. In summary, the position of the larynx gradually
becomes lower as the body develops.
The high position of the larynx during the neonatal period indicatesthat the epiglottis of the neonate is also high, which places the epi-

Chap.

glottis very close to the soft palate. This anatomical feature causes2

neonate to breathe primarily through the nose rather than the mouth.
Therefore, as nasal airway management is essential in establishing
respiration during neonatal resuscitation, emphasis must be placed on
nasal aspiration. In addition, while in endotracheal intubation in adults
the epiglottis is lifted by placing the end of the blade on the epiglottic
vallecular, in neonate it is lifted directly with a straight blade.

2 Anatomy of the lower respiratory tract
and changes with age

During the fetal period, the lungs mature in four stages (Fig. 0-2). As
long as there are no substantial problems during pregnancy, the lungsof a term neonate are mature enough to adapt to extrauterine life.
a. Pseudoglandular period: Weeks 5 to 16 of gestation (differentiation of terminal bronchioles).
Preterm infants born during this period cannot survive because
they are unable to breath independently.
b. Canalicular period: Weeks 16 to 26 of gestation (partial differentiation of alveoli)
Cuboidal primordial alveoli differentiate into squamous alveolar epithelial cells as they are surrounded by capillaries. Preterm
infants born after week 21 are capable of respiration and cansometimes survive. Therapies that are considered effective include surfactant therapy and glucocorticoid therapy.
Fig. 0-2 Histogenesis of the fetal lungs

37

c. Terminal sac period: Week 26 of gestation to birth.
The formation and maturation of the alveoli progresses.
d. Alveolar period: 0 to approximately 10 years
The number of alveoli increases from birth to approximately 10
years of age.
When a term neonate is born, lung fluids are replaced with air uponcrying, and respiration is established when most of the alveoli arefilled with air. However, caution is required for preterm neonates because depending on lung maturity, respiration may not be establishedeven after lung fluids are replaced with air. Endotracheal intubationand medications (e.g., surfactants) may sometimes be required.

II

Respiratory and circulatory
physiology at birth

1 From fetal circulation tobirth and first breath

Before birth, in utero, the fetal lungs are inflated and filled withlung fluid without collapsing. Intrauterine exchange of substances
takes place with the mother via the placenta until the onset of gas
exchange by “pulmonary respiration” after the first breath. Oxygen isalso supplied through the placenta and diffuses into the fetal blood.
Gas exchange occurred in the placenta; maternal blood flows into
the uterine arteries, spiral arteries, and intervillous spaces on thematernal side, and umbilical cord blood flows into the umbilical arteries and intravillous capillaries on the fetal side. Maternal and fetal complications and diseases are involved in each blood flow, which
greatly affect fetal growth.
Unlike in adults, in the fetus, most hemoglobin is hemoglobin F, which
has a higher affinity to oxygen. This allows higher oxygen saturationin the fetal blood, even though the partial pressure of oxygen in fetal
blood is lower than in maternal blood. When the partial pressure ofoxygen is higher in maternal blood, oxygen moves to fetal blood frommaternal blood by simple diffusion. Even when the partial pressureof oxygen is similar in both the mother and the fetus, the oxygen
content of the arterial blood and the oxygen supply to the peripheral
tissues are maintained in fetuses because fetal hemoglobin, which ispresent in high concentrations, becomes more saturated with oxygen.

2 Fetal circulation
Fetal blood, upon receiving oxygen at the placenta, flows from theinferior vena cava into the right atrium via the umbilical vein. Thus,
38

Basic Neonatal Resuscitation

this part of the fetal-placental system has the highest partial pressure of oxygen. Here, the blood mixes with returning fetal systemic
blood from the inferior vena cava and superior vena cava. Because thepressure is higher in the right atrium than in the left atrium, most of
the blood that flows from the inferior vena cava into the right atrium
reaches the left atrium through the foramen ovale and then flows
into the left ventricle, while most of blood from the superior vena
cava, which has a low partial pressure of oxygen, flows into the rightventricle from the right atrium.
Blood is ejected from the right ventricle to the pulmonary artery,but only a small portion of this blood flows into the fetal lungs. Arterioles that perfuse the fetal lungs are contracted mainly becauseof the low partial pressure of oxygen. This results in extremely highpulmonary vascular resistance, and consequently, most of the bloodejected from the right ventricle cannot perfuse the lungs; instead,
it flows towards the aorta through the ductus arteriosus, which is a
low-resistance bypass between the aorta and the pulmonary artery.
Meanwhile, blood that enters the left atrium flows into the left
ventricle to reach the upper body through the ascending aorta. It
then joins the blood from the right ventricle, which passes throughthe ductus arteriosus, to reach whole body (Fig. 0-3). Because of
these fetal hemodynamics, major circulatory disorders do not commonly occur, even in the presence of a heart defect.

Chap.

2

Fig. 0-3 Overview of the fetal circulatory system

39

3 Adaptations at birth and first breath
Why the first breath occurs remains an unsolved mystery. It is extremely important that fetal alveoli are filled with lung fluids and remain expanded in the uterus because this facilitates adaptation to pulmonary respiration and the rapidly changing environment after birth.
With onset of the first breath, the inhaled air fills the alveoli as thefluids in the alveoli are absorbed by blood vessels and lymph vessels in
the lung tissues. The negative pressure in the lungs, which is said toreach –100 cmH2O, causes them to instantaneously expand. Approximately one-third of the fluids in the alveoli move to the oral cavity,
while the remainder quickly moves into the lung tissue.
Air contains 21% oxygen, which can diffuse into the blood vessels
around the alveoli (Fig. 0-4). Absorption is facilitated by the low protein concentration in the lung fluids. Furthermore, the absorption oflung fluids is facilitated by catecholamine, which begins to be secreted in the fetus soon after the onset of labor pains and is stimulatedby the stress of labor.
As the alveoli expand with air and the partial pressure of oxygen
increases, pulmonary blood vessels that were contracted become
relaxed. Thus, resistance decreases, and systemic blood pressure increases, causing pulmonary blood flow to increase dramatically. This
leads to decreases in blood flow through the ductus arteriosus andthe uptake of oxygen by blood vessels around the alveoli. Then, blood
with a high partial pressure of oxygen flows into the left atrium
through the pulmonary vein to enter the systemic circulation.

Fig. 0-4 Changes in alveoli that occur with the first breath40Basic Neonatal Resuscitation

With the first breath after birth, the umbilical artery and vein andductus venosus, which have been used for the exchange of gases andother substances, contract, and the blood flow through them is halted. This is the end of the placental circulation with extremely low
vascular resistance. Consequently, the fetal blood pressure rises.
Chap.

2

4 Role of the ductus arteriosus
The partial pressure of oxygen increase once pulmonary respiration
has started, and the ductus arteriosus begins to contract as the pulmonary blood vessels relax. As neonates adapt to pulmonary respiration, the skin of their chest area turns pink, and the pinkness spreads
to the trunk and then to the limbs. These drastic changes occur withinseveral minutes of birth, although approximately 10 min is likely to berequired before the preductal oxygen saturation exceeds 90% in termneonates. Even more time is required before the postductal oxygen saturation exceeds 90%.
Increases in left atrial pressure due to increases in left atrial perfusion, and decreases in the right atrial pressure due to decreases inpulmonary vascular resistance, cause the functional closure of the foramen ovale, which is believed to occur within several minutes after
birth.
Furthermore, the ductus arteriosus functionally closes 12-24 h after the blood flow is halted, and anatomical closure occurs thereafter.
Although pulmonary vascular resistance drops suddenly as the pulmonary vasculature relaxes, it takes several months for the resistanceto completely decrease and stabilize. When the pulmonary circulation
involving the right heart and the systemic circulation involving the left
heart, which are independent of each other, are established, the transition to adult circulation is complete. The ductus arteriosus plays anessential role in fetal circulation, in which gas exchange does not takeplace in the lungs, but this role ends when neonates adapt to extrauterine circulation; adult circulation is established after the complete
closure of the ductus arteriosus.

5 Establishment of pulmonary respiration
When the body transitions to pulmonary respiration, the lungs must
maintain functional residual capacity to resist the high surface
tension and ensure that they do not collapse once they expand. Iffunctional residual capacity is maintained, the alveoli can expand withslight negative pressure, and lung surfactant forms layers at air/water interfaces in the alveolar space to resist this surface tension.
Anatomically, physiological dead space is larger compared to the alveolar volume.In addition, because of low tidal volume, ventilation occurs
at a respiratory rate of 40 to 50 breaths per minute, many times that41

of adults.
Neonates frequently exhibit irregular respiratory patterns and sometimes stop physiological respiration momentarily. Term infants andnear-term infants exhibit periodic breathing, in which they pause theirbreathing for a period of several seconds to approximately 10 s andthen start breathing again. In addition, neonate respiration is primarily
nasal, and it takes several months for respiration through the mouth
to be established. Therefore, nasal continuous positive airway pressure(CPAP) therapy to prevent lung collapse is used to treat disorders associated with alveolar collapse in neonates (e.g., apnea and respiratory
distress syndrome).
(Isao Kusakawa)
References
1）Alvaro RE, Rigatto H: Chapter 17 Cardiorespiratory
Adjustment at Birth. MacDonald MG, Seshia M MK,
Mullett MD（eds）. Avery’s Neonatology：patho-

42

physiology and management of the newborn.（6thed）. p284-303, Lippincott Williams and Wilkins,
Philadelphia, 2005.

Chap.2

Indications forneonatal resuscitation

Chap.

2

Chap.

2

According to the medical definition, a neonate or newborn is a childunder 28 days of age. The difference between neonatal and pediatric
CPR has been distinct from Consensus 2010 onward. This distinction
could conceivably cause confusion when performing CPR on an infant
younger than 1 month of age. As it is of the highest importance to
avoid hesitation or delay in the initiation of CPR due to excessive
concern about whether the patient is technically a neonate or child,
CPR for infant should be approached as follows.
● Resuscitation in the delivery room or nursery and of infants (corrected age <1 month) admitted to the NICU should be performedin NCPR.
● In emergency resuscitation during prehospital care, in a pediatricward, or in a pediatric intensive care department or other wardor outpatient department, Pediatric basic life support (PBLS) canbe applied for cardiac arrest in infants younger than 28 days ofage. It is important that individual facilities and groups thoroughly
discuss in advance whether to follow PBLS or NCPR when resuscitating an infant and decide on a unified policy.
(Takahiro Sugiura)

43

Chap.2

NCPR algorithm

I

The NCPR algorithm

The NCPR algorithm is shown in Figure 0-5.
Basics of the algorithm● The NCPR algorithm is composed of assessments of the neonate’s status (ventions based on the assessment results () and inter-).

● The neonate’s status must be assessed after approximately 30 s of effective intervention.
● Move only to the step immediately before or after the current step.

Flow diagram of the algorithm(1) Team briefing
In a team briefing held to improve team performance, it is important
to share the anticipated risks of the neonate during resuscitation toensure that there are sufficient supplies, ascertain that every member knows his or her role according to the risk, and share the infection status of the mother and fetus to prevent horizontal infections
from them to medical professionals. Conventionally, the main component of infection control measures is the prevention of contact
transmission, but during the COVID-19 pandemic, the prevention ofdroplet transmission has become crucial, thus increasing the significance of the team briefing.

(2) Moving forward along the resuscitation sequence● Examine the following three criteria to determine whether the neonate requires resuscitation immediately after birth: (1) preterm, (2)weak breathing/crying, and (3) weak muscle tone. If none of thesecriteria are met, move the neonate onto the mother’s chest or to aradiant warmer to provide routine care. If at least one criterion ismet, follow the resuscitation sequence and start the initial steps.
● Complete the initial steps and assess two vital signs (breathing
and heart rate) approximately 30 s after completion. If the neonate is breathing spontaneously and the heart rate is ≥100 bpm,
assess two indicators, namely, labored breathing and central cya44

Basic Neonatal Resuscitation

Fig. 0-5 NCPR2020 Algorithm

Team briefing,
PPE, and Equipment check

Target SpO2
Time
1min.
3min.
5min.
10min.

Birth• Preterm?
•Weak respiration?
• Weak tone?

Warm,
open airway (positioning, etc.),
dry, and stimulate

Routine Care(stay with mother)• Provide warmth• Open airway• Dry
Ongoing evaluation

Spontaneous breathingandHR≥100/min.
Labored breathing or

Breathing • HR
(Consider SpO2
monitoring)

Maintain temperature• PPV (a)• SpO 2 monitoring• Consider ECG monitoring
60/min≤HR<100/min.

HR• Check ventilation (b)• Consider intubationNO

cyanosis (low SpO 2)

Apnea /Gasping or
HR <100/min.

HR≥100/min.

2

NO

YES

Within60 seconds

Chap.

SpO2 (%)
≥60
≥70
≥80
≥90

YES
• SpO2 monitoring• CPAP or O2 asneeded

ImprovingLabored breathing or
cyanosis (low SpO2)

NO

HR<60/min.

PPV(+O2) + Chest compression (1:3) (c)HR≥ 60/min.

HR

HR<60/min.
Consider IV adrenalineHRHR≥ 60/min.
HR<60/min.

PPV + Chest compression and…..
• Normal saline for suspected hypovolemia• Searching for the cause of cardiac arrest
After ROSC (HR ≥ 60/min.)Stop chest compression and continue PPV

Not
Improving• Search for the cause
and…
• Consider PPV if laboredbreathing and low SpO2
continues.
• Check congenital heartdisease if low SpO2
continues without laboredbreathing.

Post
Resuscitationcare• Carefulobservation
on respiration(a) Add or increase supplemental oxygen if HR
or SpO2 are not improved.
(b) If the ventilation is not optimal,
focus on improving ventilation before
proceeding to the chest compressions.
(c) PPV 30/min. and chest compression 90/min

45

nosis (poor oxygen saturation). If at least one of them is observed,
attach the probe of a pulse oximeter to the neonate’s right handand determine the need for respiratory support.
● If the neonate is not breathing spontaneously or is gasping, or if
the heart rate is <100 bpm after completion of the initial steps,
initiate ventilation and attach a pulse oximeter to the neonate. The
heart rate must be measured, even if the neonate is not breathing spontaneously. If multiple medical professionals are in chargeof the neonate’s care, one must initiate ventilation, and anothermust assess the heart rate. An increase in heart rate is the mostsensitive indicator of the effectiveness of ventilation; therefore,pre-ventilation assessment of the heart rate is important and necessary for comparison purposes. Additionally, consider the use of
an ECG monitor at this stage. When performing ventilation, assess
the neonate’s chest movements as well as the heart rate to judge
the effectiveness of ventilation. Even if the heart rate is <60 bpm,
initiate only ventilation first, without chest compressions.
● Approximately 30 s after initiating ventilation, assess the heart
rate while continuing ventilation. If the heart rate is <60-100 bpm,
assess whether ventilation is being appropriately performed; if
ventilation is being performed appropriately, continue ventilation
with an increased oxygen concentration. If high pressure is required, consider performing endotracheal intubation. If the heart
rate remains <60 bpm even after ventilation is appropriately performed, chest compressions should be started in conjunction withventilation using a high oxygen concentration.
● If the heart rate remains <60 bpm even after ventilation with oxygen and chest compressions are performed in a coordinated mannerfor ≥30 s, proceed to the adrenalin administration step.
● If the heart rate still remains <60 bpm at 30 s after adrenalin administration, proceed to the next step and search for causes. If thecirculating blood volume is expected to be low due to hemorrhage,consider administering a drug to address this issue. If the heart rate
remains <60 bpm after that, administer adrenalin every 3-5 min.
● Perform each procedure for 30 s, assess its effectiveness, and thendetermine whether to proceed to the next step. If the preceding
step is not completed effectively, the next step cannot be started. Therefore, the time frame of 30 s is not an absolute rule. For
example, chest compressions must not be started after 30 s ofventilation if the ventilation was not appropriately performed.
● The time frame of “within 60 s” shown in the algorithm is a guideline to ensure the initiation of necessary ventilation without delay
for neonates. In other words, if the airway is open and responses
46

Basic Neonatal Resuscitation

to stimuli are assessed to quickly determine the need for ventilation in the initial steps, care providers do not necessarily have tocontinue those processes for 30 s. It is most important that ventilation be initiated by 60 s after birth at the latest.
Chap.

(3) Moving backward to the previous step in the resuscitation sequence2● After ventilation is initiated, assess the heart rate while performing ventilation. If the heart rate is ≥100 bpm, assess whether theneonate is breathing spontaneously. If the neonate is breathing
spontaneously, assess whether the neonate has labored breathing
and/or cyanosis.
● After the initiation of coordinated ventilation and chest compressions, assess the heart rate only while delivering ventilation. Heartrate assessment after ventilation and chest compressions shouldbe performed without interrupting the ventilation. Even when theheart rate is ≥100 bpm, do not assess the neonate for spontaneous
breathing: discontinue chest compressions only and continue ventilation. If the SpO2 level is ≥95%, reduce the oxygen concentration.

II

Assessments in the algorithm

1 Breathing● Breathing is assessed based on its rate and quality. Immediately after birth, neonates must be assessed for quality of breathing, which can be determined by the presence or absence of weak
breathing and weak crying. After the initial steps of resuscitation
are performed, the presence or absence of spontaneous breathing
must be assessed.
● Gasping is an abnormal breathing pattern consisting of rapid inhalation and slow exhalation caused by hypoxia in the brainstem. Boththe ventilation cycle and the tidal volume are more irregular duringgasping than during normal breathing. Gasping can be regarded as
secondary apnea. Distinguishing gasping from normal breathing isdifficult, although the heart rate is usually <100 bpm in the case of
gasping. Even when the heart rate is ≥100 bpm, it slows down gradually when gasping continues. Thus, when distinguishing between
gasping and normal breathing is difficult, it is important to assess
both breathing and heart rate every 30 s.
● Labored breathing refers to nasal flaring, grunting, retractions,and tachypnea (≥60/min.).
47

2 Heart rate
● An increase in heart rate is the most reliable indicator of effective
resuscitation. For neonates soon after birth, chest auscultation is thefirst-line approach for assessing heart rate. Although palpation of
the arterial pulse is not reliable, the umbilical cord pulsation is betterfor palpation than other sites. The number of heart beats counted in
6 s is multiplied by 10 to obtain the heart rate in beats per minute.
● Heart rate assessment using a pulse oximeter is superior to auscultation and palpation because it enables objective and continuous
assessment. Thus, a pulse oximeter should be used when advancing
to the steps involving ventilation and/or respiratory support.
● Facilities that handle many high-risk deliveries are advised to consider the addition of an electrocardiographic (ECG) monitor to
obtain more rapid and accurate heart rate measurements. An ECG
monitor can show the heart rate more quickly than a pulse oximeter but cannot be used to assess oxygen saturation. Thus, an ECG
monitor is not a replacement for a pulse oximeter. Since pulselesselectrical activity (PEA) has been reported even in neonates, theinitial assessment of heart rate and its assessment after the return of spontaneous circulation via chest compressions must be
performed by auscultation.

3 Cyanosis (poor oxygen saturation)● Visual assessment of central cyanosis is not very reliable because results vary among individuals. Furthermore, it is easy to detect cyanosis in polycythemia, but not in anemia; consequently, cyanosis can be
missed in anemia, which is characterized by reduced oxygen transportcapacity. To solve this problem and use an appropriate amount of oxygen during resuscitation, the use of a pulse oximeter is recommended.
● Peripheral cyanosis, that is, cyanosis of only the tips of the hands
and feet, is sometimes observed in healthy neonates for a period
after birth and is therefore not an indication for intervention. Oxygen saturation is within the normal range in peripheral cyanosis.
On the other hand, central cyanosis, that is, cyanosis of the lips,
oral mucosa, and center of the trunk, is a sign of low oxygen saturation and thus indicates that intervention may be required. Central cyanosis is sometimes observed in healthy neonates for several
minutes after birth; therefore, the need for interventions must be
determined by measuring SpO2 using a pulse oximeter and referringto the target SpO2 at the given time after birth.
● The use of a pulse oximeter is effective for distinguishing between
peripheral cyanosis and central cyanosis.
48

Basic Neonatal Resuscitation

4 Gestational age● Whether a neonate was born at term or preterm is one of the items
to assess immediately after birth. The weeks of pregnancy must
be confirmed before delivery. If this is unknown because a woman with no prenatal care or emergency delivery outside the health

Chap.

2

checkup facility, proceed to the initial steps of resuscitation.

5 Muscle tone
● The presence or absence of hypotonia is one of the items to assess
immediately after birth. Hypotonia is diagnosed when the upperand lower extremities are relaxed and not flexed, and there is little
spontaneous movement.
(Shigeharu Hosono)

behind the NCPR algorithm
III Rationales(recognition of primary and secondary apnea)
The NCPR algorithm is a process for determining the severity of exposure to hypoxia that a nonbreathing neonate experienced in utero.
The primary of the hypoxic process in utero is based on animal studies
conducted in the 1960s.
Fig. 0-6 shows how the fetus reacts when exposed to hypoxia inutero in an asphyxia model. Specifically, upon exposure to hypoxia,
the fetus makes rapid, large chest movements to breathe, but the
blood oxygen concentration drops rapidly, and consequently, the fetus loses consciousness within a few minutes. The respiratory cenFig. 0-6 Primary and secondary apnea (asphyxia model)(The American Academy of Pediatrics. American Heart Association and John Kattwinkel MD FAAP.
et al.: Neonatal Resuscitation Textbook, Fifth Edition. Chapter 1, 2006)49

ter in the brainstem then becomes dysfunctional due to hypoxia, andthe breathing movements stop. This state is called primary apnea.
In primary apnea, the heart rate gradually decreases to the level ofbradycardia (100 bpm), but the blood pressure remains near the normal level. This is because of the mechanism that prioritizes bloodflow to critical organs (i.e., the heart, lungs, and brain) by peripheral
vasoconstriction. At the same time, a transition from normal aerobic metabolism to anaerobic metabolism, which consumes less oxygen,takes place. In this way, the fetus manages to maintain circulation
while conserving oxygen consumption during primary apnea. However,
if primary apnea is prolonged, lactic acid accumulates, gradually leading to acidosis.
When hypoxic status progress further, the fetus will start “gasping”,
a special pattern of breathing that is equivalent to agonal breathingin adults. Gasping which is intermittent breathing occurs every oncein a 5 s. Circulation is still maintained when gasping starts, but as hypoxia and acidosis progress over time, the gasping stops, which leads
to secondary apnea (terminal apnea). Once secondary apnea happens,
the intrauterine condition deteriorates rapidly, and myocardial cells
gradually stop effectively contracting. At this point, the fetus canno longer maintain adequate circulation, and death will occur if nointervention is implemented.
When a neonate is not spontaneously breathing after birth, youmust initiate the initial steps of resuscitation immediately. And you
must assess the following status.
Suppose the neonate is born with primary apnea without airway obstruction at the time point indicated by arrow A in Fig.0-6. In thatcase, the neonate starts spontaneous breathing by initiating gentle tactile stimulation because the circulation is sufficiently preserved and the intrauterine environment has not yet deteriorated.
If a neonate is born with secondary apnea, at the time point indicated by arrow B in Fig.0-6, only tactile stimulation is not enough tostart breathing, and ventilation is also required in order to initiate
breathing. Because the circulation is still preserved, oxygen taken in
via the lungs through ventilation soon reaches the myocardium, andconsequently, normal heart beats are reestablished, and oxygenatedblood is delivered to the brainstem to establish regular spontaneous
breathing.
In advanced secondary apnea, at the time point indicated by arrow C
in Fig.0-6, the circulation has already deteriorated, and oxygen cannot be delivered to the myocardium. Thus, circulatory support is required, and ventilation with chest compressions must be performed.
Note that the purpose of chest compressions here is to push oxy50

Basic Neonatal Resuscitation

genated blood to the myocardium; therefore, chest compressions arepointless if ventilation is not performed simultaneously.
If a neonate is born with more advanced secondary apnea, at thetime point indicated by arrow D in Fig.0-6, chest compressions alone
will be insufficient, and medication (adrenaline) is required to sup-Chap.

port circulation. If hypoxia has progressed beyond this point, it is too

2late to save the neonate’s life.
It is impossible to determine whether an apneic neonate is in primary or secondary apnea by visual observation alone. An apneic neonate can be diagnosed as primary or secondary apnea with the NCPR
algorithm. If a neonate responds to the initial steps immediately andstarts breathing, he/she can be determined to have had primary apnea(Fig. 0-6, arrow A). A lack of response to the initial steps indicatesthat the neonate had secondary apnea, and you must ventilate him/
her immediately. Immediate resolution of bradycardia indicates early secondary apnea, in which the circulation is preserved (Fig. 0-6,
arrow B). If bradycardia does not resolve despite the application of
appropriate ventilation, the apneic neonate has advanced secondary
apnea (Fig. 0-6, arrow C or D), and you must provide chest compressions with ventilation.
In summary, using the NCPR algorithm, determine the severity of hypoxia by applying interventions for a short period of time and assessing the neonate’s responses to them. In neonatal resuscitation, an
apneic neonate is always necessary to be determined with the NCPR
algorithm whether he/she has primary or secondary apnea.
(Takahide Yanagi)

51

Chap.2

Neonatal resuscitation STEP-0

Team briefing

Team briefing,
PPE, and Equipment check

Birth

CoSTR2020 suggests the possibility that briefing and debriefing invarious clinical settings lead to improvement of the quality of resuscitation and prognosis. Thus, the key to successful neonatal resuscitation is establishing a system in which perinatal risks are assessedin a briefing; staff with adequate knowledge and skills and adequate
supplies and equipment to perform resuscitation are allocated accordingly, and the resuscitation that was performed is reviewed ina debriefing. It is desirable that such a system be standardized andused at every facility.

I

Briefing/debriefing

The effects of the following several approaches to briefing/debriefing in neonatal resuscitation have been studied, and the results
suggest the that briefing/debriefing improves the short-term clinicaloutcomes and the practice performed by the staff. Briefing/debriefing approaches include video-assisted debriefing 1), a combination ofa checklist and video-assisted debriefing 2), team briefing/debriefing
using a checklist 3), and rapid-cycle deliberate practices (rapid cycling
between deliberate practice and feedback) 4).

Team briefing before providing resuscitation
The first step of preparing for resuscitation is making a concise plan thatdefines which staff member takes which responsibilities and how the responsibilities are fulfilled. Members of the team must confirm and understand their roles, responsibilities, and expected actions through the brief52

Basic Neonatal Resuscitation

ing. During the briefing, it is important to analyze perinatal risk factors;
appoint key persons, such as the main person who will provide resuscitation(team leader) and a record keeper; check necessary materials for resuscitation; and consider whether additional support is needed.

II

Chap.

Attendance at a cesarean sectiondelivery2

STEP-0It has been reported that compared with normal vaginal delivery,
cesarean section delivery under regional anesthesia does not increase
the number of term neonates who require endotracheal intubation
during resuscitation. Thus, if a term neonate without a known risk is
to be delivered by cesarean section under regional anesthesia, attendance by a staff member who can perform ventilation is sufficient.

for resuscitation
III Preparation(including supplies and actions)
It is not always possible to predict the need for resuscitation.
Therefore, staff attending even a low-risk delivery must make preparations for resuscitation and have good awareness of when and under which situations additional support needs to be requested. The
following are commonly needed supplies and preparatory actions (fordetails regarding supplies, refer to the section explaining each step):● Confirm perinatal risk factors;● Introduce yourself to the mother and other family members;● Practice hand hygiene and infection control measures (describedlater);● Ensure a clean location for performing procedures involving thermal management;● Check the room temperature and warming equipment (e.g., radiantwarmer);● Ensure the availability of a timer or stopwatch,● Prewarmed and dried linen (plastic bags/wrap for preterm neonates),● Ventilation equipment (self-inflating bags, flow-inflating bags,
T-piece resuscitators, and face masks),● An oxygen blender and a gas supply source,● A stethoscope,● A pulse oximeter and probe of appropriate size, and● An EGC monitor and electrodes for neonates (when the need foradvanced resuscitation is anticipated);53

● Confirm the appropriate size of the suctioning tube and appropriate suctioning pressure; and● Ensure the availability of equipment for advanced airway management (e.g., endotracheal tubes, a laryngoscope, and a laryngealmask),● Equipment to secure venous access (umbilical venous catheters, peripheral venous indwelling needles, and intraosseous needles), and● Medications (Epinephrine, normal saline, and glycose).

IV Infection control
Staff who perform resuscitation are at risk of exposure to various
infectious diseases, and appropriate preventive measures must be put
in place.
Standard preventive measures are basic measures that are implemented irrespective of the mother’s and neonate’s infection status and disease status to reduce the risk of health care-associated infections in
mothers, neonates, and medical professionals. These include practicing
hand hygiene (washing and sanitizing hands) and using personal protective equipment (PPE) such as gloves, masks, and gowns (Fig. 0-1, 0-2).

54

Fig. 0-1
Standard preventive measures

Fig. 0-2
Maximal barrier precautions.

Put on gloves, a surgical mask, andan apron.

Put on gloves, an N95 mask, agown, goggles, and shoe covers.

Basic Neonatal Resuscitation

To prevent infectious diseases (e.g., COVID-19) that may have a significant impact on the public health, infection control measures mustbe formulated and implemented in compliance with relevant guidelines and recommendation 5, 6). Simulations and rehearsals should be
performed at each facility to assess whether the order and contents

Chap.

of these proposals are feasible. Additionally, staff members should

2practice donning and doffing PPE in advance.

STEP-0Please note that these proposals are based on the limited evidence
available as of the time of this publication and may be revised according to new scientific evidence in the future.
(Takahiro Sugiura)

Key points
1 The key to successful neonatal resuscitation is establishing a system

in which perinatal risks are assessed in a briefing; staff with adequate knowledge and skills and adequate supplies for resuscitation
are allocated accordingly, and the resuscitation that was performed
is reviewed in a debriefing.

2 Infection control measures must be implemented according to thesituation to reduce the risk of health care-associated infections in
mothers, neonates, and medical professionals.

55

Chap.2

Neonatal resuscitation STEP-1

Assess the neonate immediately
after birth

Birth・Preterm?
・Weak respiration?
・Weak tone?

To determine the need for resuscitation at birth, a neonate must
be assessed for the three criteria shown in Table.1-1: (1) preterm,(2) weak breathing/crying, and (3) weak muscle tone. If at least one
criterion is met, the neonate must be transferred to a radiant warmer
to initiate resuscitation.
Whether the neonate is preterm or not needs to be assessed because
preterm neonates are at higher risk of conditions requiring resuscitation than term neonates with various factors. Preterm neonates
will not easily initiate spontaneous breathing because their lungs are
stiff, and their respiratory muscles and respiratory centers are poorly
developed. Additionally, preterm neonates have more difficulty maintaining body temperature than term neonates do. Thus, even without
obvious signs indicating the need to start the initial steps of resuscitation, preterm neonates need careful further assessment while theinitial steps are performed in a radiant warmer.
If there is no vigorous crying or breathing accompanied by adequate
chest movements, it can be determined that a neonate has weak
breathing/crying, and the initial steps of resuscitation must be initiated. As described earlier, gasping is a sign of intrauterine exposureof the fetus to hypoxia, and thus, the initial steps of resuscitation
Table. 1-1 Criteria checked immediately after birth56

Basic Neonatal Resuscitationmust be initiated immediately. Gasping should not be mistaken as thepresence of spontaneous breathing.
The presence of weak muscle tone is based on whether the neonate
flexes his/her extremities while lying down. The extremities of a termneonate with normal muscle tone are in a W-M shaped position. If

Chap.

extremities are floppy and hang straight down, it can be determined

2that the neonate has weak muscle tone (Fig. 1-1).

STEP-1

These three criteria, unlike heart rate and SpO2, can be assessed
immediately after birth and judgements can be made instantaneously,
allowing resuscitation to be initiated promptly. Additionally, the Apgar score is an objective numerical measure of the neonate’s status
and is useful for conveying information about the neonate’s generalcondition at birth and responses to resuscitation. However, it cannot
be used to determine the need for resuscitation or to decide when resuscitation should take place and which interventions should be performed. The Apgar score is generally examined 1 min and 5 min after
birth; this system is too slow to be used to determine the resuscitation strategy. Furthermore, there is no time to spare for calculating
the Apgar score during resuscitation.
Fig. 1-1 Muscle tone in a neonate immediately after birth(extremities in a W-M–shaped position)
a: Normal muscle toneb: Weak muscle tone

（細野茂春（監修）. 病院前新生児蘇生法テキスト. p43, メディカ出版, 大阪, 2020年. より引用）

57

NCPR2005 also included the examination of meconium-stained amniotic fluid and recommended performing tracheal suctioning if a neonate is born through meconium-stained amniotic fluid and is nonvigorous. However, due to insufficient evidence, this criterion has been
excluded since NCPR2010.
If none of three criteria in Table. 1-1 is met, routine care is provided
for the neonate.
(Takahide Yanagi)

Key points
1 To determine the need for resuscitation at birth, a neonate must

be assessed for the three criteria: (1) preterm, (2) weak breathing/crying, and (3) weak muscle tone. If at least one criterion is met, theneonate must be transferred to a radiant warmer to start the initialsteps of resuscitation.

2 The Apgar score cannot be used to determine the need for resuscitation or to decide when and which interventions should be used.

58

Chap.2

Neonatal resuscitation STEP-2

Provide routine care
Chap.

2

STEP-2・Preterm?
・Weak respiration?
・Weak tone?

NO
Routine Care(stay with mother)・ Provide warmth・ Open airway
・ Dry
Ongoing evaluation

Routine care is provided for a neonate who does not meet any of
the three criteria immediately after birth. More specifically, when aneonate (1) is term, (2) is either crying vigorously or adequate spontaneous breathing, and (3) has good muscle tone, the amniotic fluid
must be wiped off to dry the neonate’s skin, and the neonate must beplaced in a position to open the airway and hypothermia must be prevented using a radiant warmer or similar means. The removal of nasal
and oral secretions with gauze or a towel is sufficient, and the oral
and nasal suctioning that are routinely performed during delivery and
immediately after birth are not required. Aggressive suctioning of thepharynx can cause laryngospasm and bradycardia associated with vagal
response, and this can delay the onset of spontaneous breathing.
Labored breathing and cyanosis must be assessed after routine care,and the use of a pulse oximeter must be considered if any problems
are observed. Additionally, it is recommended that routine care be
performed at the mother’s side in consideration of the mother-childrelationship. Wiping away amniotic fluid to dry the neonate’s skin,placing him/her on the mother’s chest, and wrapping them with a bath
towel, so that the mother is holding the neonate with direct skinto-skin contact, is effective for warming the neonate. Early mother-child contact is effective for facilitating bonding, but care providers need to take safety precautions, for example, using a monitor(e.g., a pulse oximeter) and carefully observing the neonate’s breathing, body movements, skin color, etc.
(Takenori Kato)
59

Key points
1 Routine care (keeping the neonate warm, opening the airway, anddrying the skin) is provided for a neonate who does not meet any of
the three criteria immediately after birth.

2 It is recommended that routine care be provided at the mother’s sidein consideration of the mother-child relationship to facilitate bonding, although safety precautions must still be taken.

60Chap.2

Neonatal resuscitation STEP-3

Perform initial steps ofresuscitation
Chap.

2

STEP-3・Preterm?
・Weak respiration?
・Weak tone?
YES
Warm,
open airway (positioning, etc.),
dry, and stimulate

The initial steps of resuscitation must be initiated for a neonate whomeets any of the three criteria (preterm, weak breathing/crying, andweak muscle tone) immediately after birth.

I

Basics of initial stepsof resuscitation

Perform the initial steps following the process indicated in Table. 3-1
Table. 3-1 Initial steps of neonatal cardiopulmonary resuscitation

61

and maintain
II Warm
normal temperature
Since NCPR2015, it has been recommended that the core temperature of nonasphyxiated neonates be maintained at 36.5℃-37.5℃ frombirth throughout the hospital stay. Additionally, in the algorithm, theimportance of maintaining the body temperature is incorporated into
all steps of resuscitation, and the body temperature on admission isregarded as a prognostic factor and therefore must be recorded. For
preterm neonates born at less than 32 weeks of gestation, it has also
been proposed that, in addition to using a radiant warmer, the following
measures should be taken on admission to prevent hypothermia (bodytemperature <36.0℃), while taking care to avoid overheating: appropriate ambient temperature (23℃-25℃), warm blankets, plastic wraps, acap, and/or a thermal mattress. An ambient temperature ≥26℃ should
be considered for neonates born at less than 28 weeks of gestation.

management (positioning
III Airway
and suctioning as needed)
If the need for the initial steps of resuscitation is confirmed, theneonate must be promptly positioned in the supine “sniffing position”(in which the neck is slightly extended, the head is tilted backward,
and the chin is lifted) for airway management. For a neonate whose
occiput is large, the placement of a shoulder roll (a rolled-up hand
towel) under the shoulders helps keep the neonate in position for
airway management 7) (Fig. 3-1).
Fig. 3-1 Shoulder roll for airways’ management62

Key point
Thermal management
must be ensured tomaintain the neonate’s
core temperature at
36.5C-37.5C from
36.5°C-37.5°C
frombirththroughout
birththroughout
the hospital
the
stay.
hospitalstay.

Key point
For preterm neonatesborn at less than 32
weeks of gestation,
hypothermia must be
prevented with the
combined use of a radiant warmer with otherwarming equipment (e.g.,plastic wraps), while
taking care to avoid
overheating.

Basic Neonatal Resuscitation

Weak breathing or inadequate ventilation despite the presence oflabored breathing indicates airway obstruction that required suctioning. In this case, oral suctioning must be performed first using
either a rubber bulb syringe or a suctioning catheter with the suction
pressure <100 mmHg (13 kPa) 8), and then nasal suctioning must be

Chap.

performed (Fig. 3-2). This is because nasal suctioning tends to induce

2

spontaneous breathing, and performing nasal suctioning before oral

STEP-3suctioning increases the risk of aspiration of oral secretions.
The size of the suction catheter depends on whether the amniotic fluid is stained with meconium. If the amniotic fluid is meconium-stained, a large-bore suction catheter (12 or 14 Fr) should be
used for oral and nasal suctioning. If the amniotic fluid is clear, a6-Fr or an 8-Fr catheter must be used for low birthweight neonates,
depending on their weight, and a 10-Fr catheter should be used forterm neonates (Fig. 3-3). Stimulation of the pharynx within several
minutes after birth may induce a vagal response that can cause bradycardia and apnea; therefore, deep insertion of the catheter into thepharynx and prolonged implementation of the suctioning proceduremust be avoided.
Suctioning of the oral and nasal cavities must be completed within
Fig. 3-2 Suctioning with a suction bulb syringe (the mouth first and then the nose)

Fig. 3-3 Suctioning with a suction catheter (suction the mouth first and then the nose)63

approximately 5 s, and caution should be taken to avoid aggressive or
deep suctioning.
Routine suctioning is not necessary if the amount of secretions
is small and breathing is normal. In NCPR2005, if the amniotic fluid is meconium-stained, the removal of any meconium that is pres-Key point
Placing a shoulder rollunder the shoulders
facilitates the positioning of the neonate for
airway management.

ent in the airway was prioritized over the induction of spontaneous
breathing to prevent meconium aspiration syndrome. However, in
NCPR2010 and NCPR2015, it is recommended that routine suctioning
is not necessary, even for nonvigorous neonates born through meconium-stained amniotic fluid, because of the inadequate evidence
that the onset of meconium aspiration syndrome and mortality is reduced when tracheal suctioning is performed compared with when it
is not performed 9, 10). Since 2015, three new randomized controlled
studies 11-13) and one observational study 14) have been reported, and ameta-analysis of these studies did not show the efficacy of routine
tracheal suctioning 15). Thus, in NCPR2020, greater emphasis is placed
on “not performing tracheal suctioning routinely”. Nevertheless, it is
not contraindicated, and therefore, an appropriate suctioning method
can be chosen (e.g., if a care provider is proficient in endotracheal
intubation, intubation and suctioning may be performed).
However, if the neonate is vigorous even with meconium staining of

Key point
When performing tracheal suctioning in a neonate who is not breathing spontaneously, oral
suctioning must be performed first, followed bynasal suctioning.

Key points
The appropriate size ofthe suction catheter is
as follows:●When the amniotic
fluid is meconium
stained: 12 or 14 Fr●Term neonates: 10 Fr●Low birth weight neonates: 6 or 8 Fr

the amniotic fluid, tracheal suctioning will not improve the prognosis and can cause complications of suctioning and intubation 16). Thus,
tracheal suctioning is not recommended for such neonates, unlike inthe past.
Furthermore, suctioning during delivery does not prevent meconi-

Key point
Suctioning pressure must
not exceed 100 mmHg
(13 kPa).

um aspiration syndrome when the amniotic fluid is meconium-stained. Moreover, oral and nasal suctioning has been found to potentially17)cause respiratory and circulatory complications 18, 19). Therefore, routine oral and nasal suctioning during delivery is not recommended,
regardless of whether the amniotic fluid is meconium-stained.

IV Tactile stimulation
The first breath is induced by tactile stimulation. Wiping off theskin with a dry towel not only prevents hypothermia but also induces
breathing.
Warmed, absorbent towels should be made available in advance inpreparation for resuscitation. Place one of these towels under theneonate after birth and use it to wipe moisture from the surface ofthe body. After that, remove the first towel and use another warmed64

Key point
Stimulate the skingently, and do not takeany longer than necessary for the induction of
spontaneous breathing.

Basic Neonatal Resuscitation

Fig. 3-4 Tactile stimulation to induce breathing

Chap.

2

STEP-3

towel to gently rub the neonate’s back, trunk, or limbs.
If this does not induce spontaneous breathing, tap the soles of theneonate’s feet with the palm of the hand or flick them with the fingertips two or three times (Fig. 3-4a). Gently rubbing the back isanother acceptable approach (Fig. 3-4b). After this, re-position the
neonate for airway management.

used for initial steps of
V Timeresuscitation
The time frame of within 60 s for initiating ventilation has been
indicated since NCPR2015. This does not mean that the initial steps
must be performed until 60 s after birth; rather, it means that ventilation must be started by 60 s after birth at the latest.
In the NCPR2010 algorithm, breathing and heart rate are assessed
30 s after the initial steps of resuscitation are performed, before
proceeding to the next step. Maintaining this 30-s time frame is effective for inexperienced care providers to prevent a life-threatening
delay in initiating resuscitation, but there is little scientific evidence
to support it, and the early introduction of ventilation has been reported to be effective in neonates who have responded poorly to initial steps of resuscitation. Consequently, this point is debatable.
In light of the above findings, the detail of “30 s” after birth has
been removed as of NCPR2015. This change occurred to ensure thatcare providers avoid delays in resuscitation by performing the initialsteps of resuscitation within approximately 30 s and then assessing
breathing and heart rate while remaining prepared to promptly initiate ventilation when the need is confirmed, even if the initial stepsof resuscitation have not been performed for 30 s.
(Takenori Kato)

Key points●The rule of thumb isto perform the initialsteps of resuscitationfor 30 s, but shortening this time for the
early introduction ofventilation must be
considered according
to the circumstances.
●Ventilation must be
initiated no later than
60 s after birth upon
the confirmation of
the need for ventilation.

65

Key points
1 The initial steps of resuscitation must be initiated for a neonate whomeets any of the three criteria (preterm, weak breathing/crying, andweak muscle tone) immediately after birth.

2 It is recommended that the body temperature of nonasphyxiated ne-

onates be maintained at 36.5℃-37.5℃ from birth throughout thehospital stay. For preterm neonates born at less than 32 weeks ofgestation, hypothermia (body temperature <36.0℃) must be prevented. An ambient temperature ≥26℃ should be considered for neonates born at less than 28 weeks.

3 If signs of asphyxia are observed, the neonate must be positioned

in the supine “sniffing position” for airway management. Weakbreathing or inadequate ventilation despite the presence of laboredbreathing indicates airway obstruction that required suctioning.

4 Wiping off the neonate’s skin with a dry towel prevents hypothermia
and provides tactile stimulation to induce breathing.

5 Time to spend on the initial steps of resuscitation: Ventilation must
be started by 60 s after birth at the latest.

66

Chap.2

Neonatal resuscitation STEP-4

Assess effectiveness of
initial steps
Chap.

2

STEP-4Warm,
open airway (positioning, etc.),
dry, and stimulate

Breathing • HR
(Consider SpO 2
monitoring)

Spontaneous breathingandHR≥100/min.
Labored breathing or
cyanosis (low SpO 2)

Apnea /Gasping or
HR <100/min.
• PPV (a)• SpO2 monitoring• Consider ECG monitoringI(a) Add or increase supplemental oxygen
if HR or SpO2 are not improved.

Check breathing and heart rate

After the initial steps of resuscitation (1. warm and maintain normal temperature, 2. Open the airway, and 3. dry the skin and provide
tactile stimulation) are performed, check breathing and heart rate
to assess the effectiveness of the initial steps. When resuscitation
and/or respiratory support is required, attach a pulse oximeter to theright wrist or palm of the neonate. Facilities that handle many highrisk deliveries are advised to consider the addition of an ECG monitor
to achieve more rapid and accurate heart rate measurements.

1 Breathing
Assess whether the neonate is breathing and crying vigorously.
Gasping is not effective breathing and must be regarded as apnea.

2 Heart rate
A prompt increase in heart rate is the most reliable indicator of
the effectiveness of resuscitation 20). Palpation of the umbilical pulse,which was recommended previously, is superior to palpation of other67parts of the body, but the heart rate is likely to be underestimated, and therefore, direct auscultation of the chest is a more reliable
method 21, 22). The number of heart beats counted in 6 s is multipliedby 10 to obtain the heart rate per minute. A pulse oximeter and an
ECG monitor (see below) can provide a more objective and continuous
assessment of heart rate.

II

Pulse oximeter (Fig. 4-1)

Since NCPR2010, the use of a pulse oximeter in delivery rooms has
been recommended. The use of a neonatal probe and a pulse oximeter
designed to reduce artifacts produced by body movements enables themeasurement of SpO2 and heart rate within 90 s after attachment 23,, but in the actual setting, providers find that measurement takes

24)

longer. The preductal value obtained at the right wrist or palm is higher than the post-ductal value obtained at the left hand or left leg 25,, and the reference range for SpO2 measured at the right wrist or

26)

palm has been reported 27). When resuscitation and/or ventilation are
required, the probe of a pulse oximeter should be attached to the righthand, where free from the interference of the ductus arteriosus.
Fig. 4-1 Pulse oximetera: Pulse oximeterb: Probe for neonates

68Basic Neonatal Resuscitation

III

ECG monitor

Facilities that handle many high-risk deliveries, especially generaland regional perinatal medical centers, are advised to consider use of

Chap.

an ECG monitor to achieve more rapid and accurate heart rate mea-2

surements (see p. 83, STEP 5 II, Attachment of an ECG monitor).

STEP-4IV

Practical assessmentof the heart rate

If a pulse oximeter is already attached, and consistent waveforms
are observed, consider the displayed heat rate as the neonate’s heart
rate (Fig. 4-2). If an ECG monitor is already attached and ECG waveforms are detected, use those to obtain the heart rate. However,for neonates in a serious condition, differential diagnosis of PEA is
required; therefore, auscultation needs to be performed during thefirst heart rate assessment and the reassessment after chest compressions are performed.
Fig. 4-2 Pulse oximeter waveforms
a: Good waveforms
Pulse amplitude and width areconsistent, and the baseline ishorizontal

b: Poor waveforms
Pulse amplitude and width are
irregular, and the baseline isirregular

69

V

Branching point to either
resuscitation or stabilization

If apnea, gasping, or bradycardia (heart rate 100 bpm) is confirmed
through the assessment of breathing and heart rate, initiate bagmask ventilation immediately, and attach a pulse oximeter to the neonate’s right hand (rescue sequence).
On the other hand, if labored breathing (nasal flaring, nasal grunting, retractions, and tachypnea) or central cyanosis is confirmed, attach a pulse oximeter to the neonate’s right hand, and then choose
either watchful waiting or treatment such as CPAP or oxygen administration (stabilization sequence). More precisely, if central cyanosis
is confirmed, urgent oxygen administration is not necessary, but theneonate must be observed carefully with reference to the changes in
SpO2 in normal term neonates, which were described earlier (see p.
72, STEP 5, Fig. 5-1, Changes in neonatal SpO2), to determine the timing of oxygen administration. If both labored breathing and central
cyanosis are observed, a conventional approach (CPAP or free-flow
oxygen delivery) must be taken. If only labored breathing is observed,
consider providing CPAP and observe breathing carefully (see p. 100,
STEP 8, Stabilization of breathing).
(Takahiro Sugiura)

Key points
1 After the initial steps of resuscitation, assess two measures (breathing and heart rate).

2 Assess heart rate by auscultation first. Use a pulse oximeter, andconsider the use of an ECG monitor for more rapid and accurate
heart rate measurements.

70

Chap.2

Neonatal resuscitation STEP-5

Provide ventilation
Chap.

2

STEP-5Warm,
open airway (positioning, etc.),
dry, and stimulate

Target SpO2
Time
1min.
3min.
5min.
10min.

Breathing • HR
(Consider SpO2
monitoring)

SpO2 (%)
≥60
≥70
≥80
≥90

Apnea /Gasping or
HR <100/min.
• PPV (a)• SpO2 monitoring• Consider ECG monitoringI(a) Add or increase supplemental
oxygen if HR or SpO2 are not
improved.

Ventilation

1 Initiating Ventilation(1) Following the initial steps of resuscitation, initiate
ventilation upon noting apnea,gasping, or bradycardia(heart rate <100 bpm).
In the rescue sequence of the algorithm, it is important to initiate
effective ventilation within 60 seconds after birth. Over 90% of as-

Key point
A rapid increase in heart
rate is the most reliableindicator of the effectiveness of resuscitation.

phyxiated neonates can be resuscitated without additional intervention beyond bag-mask ventilation, soventilation should be masteredboth in theory and in practice.

(2) In the stabilization sequence, if breathing does not
improve despite the provision of CPAP or oxygen administration
If both labored breathing and poor oxygen saturation persist despite the provision of CPAP or oxygen administration, consider initiating ventilation while searching for the cause (for details, see p.100,
STEP 8, Stabilization of breathing).
71

2 Administering oxygen and target SpO2 values
Initiate ventilation with room air for term neonates and preterm
neonates born at ≥35 weeks of gestation. If ventilation is required, besure to attach a pulse oximeter to the neonate’s right hand, which is
not affected by the ductus arteriosus. It may take several minutes
for the pulse oximeter to produce measurement results after being
attached. Thus, until accurate SpO2 values are displayed, observe theneonate carefully for central cyanosis by inspecting the color of thelips, tongue, and skin of the trunk. If the heart rate does not increaseor oxygenation does not improve (no alleviation of cyanosis or no improvement in the SpO2 value) despite the provision of effective ventilation, consider administering oxygen.
In NCPR2020, the stabilization sequence was changed to recommend
providing CPAP or oxygen administration, if required, after attachinga pulse oximeter to the neonate when either labored breathing or
central cyanosis (poor oxygen saturation) is observed. In the clinicalsetting, determine the timing of oxygen administration based on thepreviously published changes in the SpO2 value in normal term neonates 28) (Fig. 5-1) and the neonate’s breathing. The target SpO2 forboth term and preterm neonates is ≥60% at 1 min after birth, ≥70%
at 3 min after birth, ≥80% at 5 min after birth, and ≥90% at 10 min
after birth, with an upper limit of 95% during oxygen administration.
Use a mixture of oxygen and room air prepared with an oxygen
blender. Start with an oxygen concentration of approximately 30%
and adjust the concentration while assessing heart rate, skin color,
Fig. 5-1 Changes in neonatal SpO2

72

Key point
Initiate ventilation withroom air in term infants.

Key point
In the stabilization sequence, if either laboredbreathing or central
cyanosis is observed,
attach an SpO2 monitor,
and if necessary (in theabsence of a tendency
toward improvement),
provide CPAP or administer oxygen.

Key point
Cyanosis is a condition
that develops when theconcentration of deoxygenated hemoglobin
in capillaries exceeds
5 g/dL. Neonates withpolycythemia are prone
to cyanosis.

Basic Neonatal Resuscitationand SpO2 value (Fig. 5-2a). During oxygen administration, when the
SpO2value reaches 95% or higher or exceeds the target value, despite
not reaching 95%, and shows a increasing trend, consider reducing or
terminating oxygen administration. On the other hand, if the heart
rate remains under 100 bpm or the oxygenation status does not improve after oxygen administration is initiated, consider increasing
the oxygen administration to normalize the heart rate and improve
When a blender is unavailable, attach an oxygen tube to a self-inflating bag without a reservoir and use them for ventilation. If the
SpO2 value does not reach the target value, attach a reservoir to administer a higher concentration of oxygen (for details, see the section
on self-inflating bags).
Although there are no clearly defined standards for the oxygen concentration at which to start chest compressions, increase the oxygen
concentration to 80%-100% according to the heart rate, skin color,and SpO2 value.

Resuscitation of preterm neonates(<35 weeks of gestation)
As in NCPR2015, in NCPR2020, the initiation of ventilation using a
low oxygen concentration (21%-30%) is also recommended when resuscitating preterm neonates born earlier than 35 weeks of gestation
to avoid excessive exposure to oxygen (NLS864). As in the procedure

Key point
Both hyperoxemia andhypoxemia must be
avoided during neonatal
resuscitation.

Key point
Initiate ventilation withlow oxygen (21 to 30%)
in preterm infants.

for term neonates, attach a pulse oximeter to the neonate, and adjust
the oxygen dose to achieve the target SpO2 (≥60% at 1 min after
birth, ≥70% at 3 min after birth, ≥80% at 5 min after birth, and≥90% at 10 min after birth, with an upper limit of 95%).

3 Supplies required for ventilation
A set of supplies required for ventilation is shown in Fig. 5-2b. Supplies must be inspected routinely for shortages, damage, and deadbatteries.
Either of two types of bags (a self-inflating bag or a flow-inflatingbag) or a T-piece resuscitator can be used for ventilation. Ideally, careproviders should be able to use any of these, but they should at least
be trained to confidently deliver ventilation using familiar supplies.

73

Chap.

2

STEP-5oxygenation status.

Key point
If the heart rate does
not increase or oxygenation does not improveto an acceptable level(i.e., if there is no alleviation of cyanosis or
no improvement in SpO2
value) despite the provision of effective ventilation, consider oxygen
administration. In thissituation, start with an
oxygen concentration of
approximately 30%, andadjust the concentration
as needed.

Fig. 5-2 Set of supplies required for ventilation
a: Oxygen flowmeter and blenderb:① (Optional) Laryngeal mask (LM) (Size 1)② Face mask
③ Flow-inflating bag (with manometer)④ Self-inflating bag (with closed-system oxygen reservoir)⑤ Endotracheal tubes (with internal diameters of 2.5,3, and 3.5 mm) and stylet⑥ End-tidal CO2 monitor⑦ Feeding tube
⑧ Laryngoscope (straight blade) (No. 0 and 00 blades)⑨ Stethoscope⑩ Suction catheters (6, 8, 10Fr) and suction bulb syringe (12,14Fr will be prepared as needed)

74Basic Neonatal Resuscitation

4 Self-inflating bag (Fig. 5-3a-c)

Key point

One advantage of a self-inflating bag is that it enables the prompt
initiation of ventilation because it does not require a gas supply. It
also has an overpressure protection valve (pressure release valve).
Disadvantages are that it cannot be used to administer free-flow

A special reservoir isneeded for administration of freeflow oxygenwith a self-inflating
bag.

Chap.

2

oxygen without attaching a special closed-system oxygen reservoir
and that the mask can be pressurized even when not sealed tightly

STEP-5to the face, making it difficult to determine whether proper ventilation is being provided. If a blender is not available, a self-inflating
bag without a reservoir can be attached to the oxygen tube to adjust
the oxygen concentration to a certain degree. In practice, the oxygen concentration to be administered will vary depending on factors
such as the manufacturer of the bag, the ventilation rate, ventilationpressure, and oxygen flow rate (in L/min) (Fig. 5-4). 29) Attaching areservoir allows for administration of high oxygen.

Fig. 5-3 Self-inflating bag
a: Self-inflating bag with closed-system oxygen reservoir (enables administration of high oxygen)b: Self-inflating bag with closed-system oxygen reservoir equipped with Positive end expiratory pressure(PEEP) valve and manometerc: Pre-use inspection of self-inflating bag (confirm
that pressure release valve is functioning properly)75Fig. 5-4 Self-inflating bags and range of oxygen concentrations without reservoir

76

Basic Neonatal Resuscitation

The ideal bag volume is 450-500 mL (for neonates weighing ≤5 kg, thetarget tidal volume is 4-8 mL/kg); a bag that enables the application ofa peak inspiratory pressure ≥30 cmH2O must be selected. The pressure
release valve should be triggered at ≤45 cmH2O, and, if necessary, ventilation at higher pressure should be able to be delivered by adjusting
the valve 30). Self-inflatable bags enable ventilation in a disaster medicine setting when the gas supply is interrupted, and it is therefore

Key point
Self-inflatable bags
enable ventilation
when the gas cylinder
becomes empty during
delivery or when the gas
supply is interrupted
during a disaster.

Chap.

2

STEP-5

recommended to keep them ready for resuscitation during a disaster.

5 Flow-inflating bag (Fig. 5-5)
A flow-inflating bag requires a gas supply. A flow rate of approximately 5 to 10mL/min is optimal for neonatal resuscitation. Using thegas supply, oxygen can be administered at the exact concentration,
which enables the administration of either high or free-flow oxygen.
Flow-inflating bags have the following advantages: they canalso be used for mask CPAP with room air, and it is easy to determine
if the mask is airtight because the bag will not inflate if the mask is
not tightly sealed. Experts can also feel lung compliance by touching
the bag as it inflates.
However, when using a flow-inflating bag without a pressure releasevalve, it is essential to attach a manometer (pressure gauge) to checkventilation pressure. Additionally, the use of a flow-inflating bag
when a blender is not available means that ventilation and CPAP areperformed with 100% oxygen, and thus, caution must be exercised to
avoid hyperoxemia in the neonate.

Key point
When using a flow-inflating bag, connect amanometer to the bag
to monitor ventilationpressure.

Key point

Inspection of bag before use
As shown in Figure 5-5b, place a hand over the mask to apply pressure to the bag and check whether the bag inflates properly, whether pressure increases sufficiently, whether there are any leaks, andwhether the manometer is working.

When using a flow-inflating bag, it is ideal touse a blender and attacha pulse oximeter tothe neonate to prevent
hyperoxemia.

Fig. 5-5 Flow-inflating bag
a: With manometer and pressure release valve

b: Pre-use inspection77

6 T-piece resuscitator (Fig. 5-6)
Along with self-inflating bags and flow-inflating bags, the T-piece
resuscitator is another ventilation device, and its use is spreading
gradually throughout Japan. It is easy to operate and enables positiveend-expiratory pressure (PEEP) to be set when providing CPAP or intermittent positive pressure ventilation (IPPV). However, there is noevidence for or against the superiority of a T-piece resuscitator versus bag ventilation, and therefore, any of these devices can be used
for neonatal resuscitation (NLS870).
A T-piece resuscitator enables a preset peak inspiratory pressure(PIP) to be applied by covering the expiratory valve (PEEP/PIP switching hole), which is located near the connection to the mask, with afinger. The inspiratory time is the time when the expiratory valve iscovered with a finger. PEEP is provided upon the removal of the finger
from the expiratory valve (Fig. 5-7).
Fig. 5-6 T-plece resuscitator
a: Preset peak inspiratory pressure (PIP) and positiveend-expiratory pressure (PEEP) can be applied byconnecting the resuscitator to a gas supply. It Thereis some resemblance resembles to a flow-inflating
bag but this device offers easier and safer pressureadjustment.

b: Releasing the expiratory valve produces expiration(PEEP)

c: Occluding the expiratory valve produces inspiration
(PIP)

78

Basic Neonatal Resuscitation

PEEP is adjustable by pulling the PEEP knob up and turning it clockwise or counterclockwise. Air leakage and pulmonary injury due toexcessive pressure can be avoided by setting the maximum openingpressure on the main unit and monitoring the circuit pressure while
performing resuscitation. The disadvantages of a T-piece resuscita-

Chap.

tor are that it requires a gas supply and is ineffective if there is sub-2

stantial leakage due to poor mask placement and that users cannot

STEP-5feel lung compliance.

7 Choosing a mask
There are two types of masks: round and anatomic (Fig. 5-8). Choosea mask size that will cover the neonate’s nose and mouth but not theeyes (Fig. 5-9) because pressure on the eyes can lead to eye damage
or bradycardia associated with vagal response. A mask with a cushion
can seal the face easier and will not leak much from the edges.
Fig. 5-7 Ventilation with a T-plece resuscitator

Key point●Choose a mask sizethat will cover thenose and mouth but
not the eyes
●Pressure on the eyes
can lead to bradycardia associated withvagal response must
adjust the oxygen
concentration.

Peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP)

Fig. 5-8 Mask shapes
An anatomical mask is easier to seal tightly to the face than a circular mask.
a: Round maskb: Anatomic mask

79

8 Providing bag-mask ventilation
When providing ventilation, hold the neonate’s jaw and seal the maskwith one hand while squeezing the bag with the other. Make a“ C” withthe thumb and index finger to seal the mask tightly to the face. Use
the middle finger (“I” shape) to gently lift the jaw (Fig. 5-10). Thisis called the IC clamp technique. The airway can be easily opened forventilation by putting the neonate in the“ sniffing position” with theneck slightly extended, the head bent backwards, and the jaw lifted.
Placing a rolled towel or small blanket under the shoulders facilitates
opening the airways without
consciously lifting the jaw, enabling complete focus on keeping themask sealed to the face (Fig. 5-11).
The pressure used for initiating ventilation with room air immediately after birth is usually 30 cmH2O for term infants and 20 to 25
cmH2O for preterm infants. However, a higher pressure (~40cmH2O)
or longer inspiration time may benecessary in some cases. The neonate’s chest movements are a morereliable indicator for assessing the effectiveness of ventilation. If
pressure is not being monitored, ventilation should be provided using
the minimum amount of pressure required to increase heart rate, andFig. 5-9 Face mask
a: Incorrect (too large)

Fig. 5-10 IC clamp technique80

b: Correct (appropriate size)

Key point●Placing a shoulder rollunder the shoulders
facilitates airway
opening.
●The positions forventilation and intubation are not the same.
Removing the shoulder
roll and placing padding under the head
helps maintain thesight into glottis once
the laryngoscope has
been inserted

Basic Neonatal Resuscitation

excessive chest wall movements should be avoided.
Ventilation must be delivered at a rate of 40 to 60 breaths per minute (30 breaths per minute when combined with chest compressions).
No matter how critical the situation, ensure that the ventilation rate
does not exceed one breath per second.

Key point●No matter how critical

the situation, be sure
to avoid excessive ventilation of more than
one breath per second(60 per minute) !

(1) Sustained inflation

2

STEP-5

Sustained inflation at birth was a PICO question that was also dis-Chap.

cussed in NCPR2020. This is still not a common procedure in Japan,
and there is insufficient evidence to recommend it. Thus, it is proposed that sustained inflation (≥5 s) not be routinely used for transitioning preterm neonates who have bradycardia or are not breathing
spontaneously.

(2) When prolonged ventilation is required
When providing ventilation for more than several minutes, insert a
6 –10 Fr feeding catheter into the stomach via the mouth, and suction
the air and stomach contents thoroughly. Then, provide ventilation
with the end of the catheter left open (Fig. 5-12). This prevents poor
extension of the lungs and reflux and aspiration of stomach contents
due to distension of the stomach. However, care must be taken to
avoid leakage from the mask due to the presence of the catheter.
Fig. 5-11 Bag-mask ventilation technique81

(3) When bag-mask ventilation is not feasible
When a delivery occurs at a location that is not properly equipped(e.g., in a car or at home), resuscitation needs to be performed without devices. In such situations, mouth-to-mouth-and-nose resuscitation is performed.
To perform this procedure, open the airway using the head-tilt,
chin-lift maneuver; cover the neonate’s mouth and nose with yourmouth through a face shield; and give the first rescue breath for 1
to 1.5 s while observing the neonate’s chest movements (Fig. 5-13).
Mouth-to-mouth-and-nose resuscitation without anti-infection appliances (e.g., a face shield) is not recommended because of the riskof infection.
(Hiroyuki Kitano)Fig. 5-12 Measuring the length of the tube to place in the stomach
Base of nose - External auditory foramen- Midpoint of xiphoid process and umbilicus

Fig. 5-13 Mouth to mouth and nose rescue breathing82

Basic Neonatal ResuscitationII

Use of ECG monitor

Acquiring accurate heart rate information is crucial for judging theneed for neonatal resuscitation and its success. When bradycardia

Chap.

persists, the need for a better or more advanced intervention must2

be considered. Auscultation alone may not allow proper assessment of

STEP-5the heart rate, leading to the selection of inappropriate actions 31).
Furthermore, a pulse oximeter requires several minutes to produce
measurements and may also show low heart rates for several minutes
immediately after birth 32).
Several observational studies have demonstrated that ECG monitors
are more useful than pulse oximeters for rapidly and accurately measuring heart rate 33-35), and therefore, they are expected to be disseminated to and used in facilities, particularly those that handle a large
number of high-risk deliveries.
An ECG monitor can be used during the ventilation steps when aneonate requires resuscitation.

3 ECG with leads 34) (Fig. 5-14)
When the body surface is wet or coated by vernix caseosa, it is difficult
to attach electrodes, and a long time is required until waveforms stabilize. Thus, the skin must be wiped thoroughly during the initial steps.
For 3-lead ECG, place the red electrode below the right clavicle, theyellow electrode below the left clavicle, and the green electrode below
the left ribs. Given that PEA can be observed in neonates 36), the heart
rates displayed do not necessarily represent effective cardiac output.
Thus, the initial heart rate measurement and the first measurement
upon return of spontaneous circulation after chest compressions mustbe performed by auscultation. Auscultation and pulse oximetry measurements should also be used as references to make judgements.
(Hiroshi Mizumoto)Key point
PEA
A condition in which
there is no effective
cardiac output despite
the presence of cardiac
electrical activity. Clinically, it must be treatedas cardiac arrest. Heartbeats cannot be detected by auscultation.

Fig. 5-14 ECG leads position

83

III Ventilation corrective steps
1 Insufficient chest movements despite
bag-mask ventilation

Resuscitation skills is not only the ability to perform resuscitation
procedures according to the algorithm; they also include the ability
to quickly solve unanticipated problems occurring during resuscitation (troubleshooting) 37). In NCPR, where effective ventilation without delay is paramount, the inability to ventilate effectively withbag-mask ventilation must be resolved quickly. This is because chest
compressions and medications will not be fully effective without effective ventilation.

(1) Prepare the equipment Preliminary check of equipment is the first step
The causes of ineffective bag-mask ventilation are diverse. To respond to unexpected situations smoothly and rapidly, thorough preparation of the equipment in advance is necessary to reduce risk factors
as much as possible. Preparation of the equipment is not just having
enough supplies (quantity); but also checking their function (quality). It should be remembered that shortages or inadequate equipment
cause substantial confusion in critical situations such as resuscitation. Resuscitation providers must personally check for any deficien-

Key point●Preparation of theequipment requires
checking both quantity (the equipment arecomplete) and quality(the equipment are
fully funtional).
●The better prepared
you are, the quicker
you can solve theproblem.

cies of equipment during the briefing.

(2) Three indicators for assessing the achievement ofeffective ventilation
In NCPR, three indicators are proposed for assessing the achievement of effective ventilation: (1) rising heart rate, (2) chest wall
movements, and (3) detection of end-tidal CO2 (Table. 5-1). These
indicators must be checked constantly while providing ventilation
during resuscitation.
The absence of these indicators may indicate that ventilation is ineffective. In that case, the following three steps (Table. 5-2) are recommended to solve the problem.
Table.5-1 Three indicators for assessing ventilation
Method 1
Method 2

Heart rate
Chest movements

Method3End-tidal CO 2
		84

Bradycardia improves or heart rate increases
Chest rises symmetrically in accordance with ventilation
End-tidal CO 2 monitor shows a pronounced response to breathing(particularly while the neonate is intubated)Basic Neonatal Resuscitation

Table.5-2 Three steps
1

2
3

Mask adjustment

Check if mask is the proper size, in the proper position, and tightly sealed to the face

Reposition airways’
management position

Confirm that the neonate is properly in the sniffing position

Oral/nasal suctioning

Check for secretions in the oral and nasal cavities before suction

Increase ventilation pressure

Gradually increase ventilation pressure until both sides of the chest rise.

Consider alternative airway

Consider other ventilation techniques such as laryngeal mask airway insertion andendotracheal intubation(shoulder roll: Adjust so that the ears and the top of the shoulders form a straight line)
Chap.

2

STEP-5*Check for any deficiencies of equipment in advance.
*The order of the items in each step does not matter.

2 Three steps to solve problems for achievement of effective ventilation(1) Mask adjustment and reposition airway
Many problems that occur during bag-mask ventilation are related
to the mask fitting and positioning for airway management (sniffing
position). Thus, checking these parameters first is the most effective way to solve problems. With flow-inflating bag, a good mask seal
can be confirmed by examining the degree of bag inflation. However,with self-inflating bag, the mask fitting cannot be determined by the
inflation of the bag even if it is inadequate. As a result, inadequate
bag ventilation may continue, resulting in ineffective ventilation. Additionally, when a mask with an air filled cushion is used, it must be
pre-filled with an appropriate volume of air to achieve a tight fit of
the mask to the face 37).
The position for airway management may be affected during maskbag ventilation, even if the neonate is initially positioned appropriately. Furthermore, too much attention to the mask fitness may cause
the neonate’s head to be tilted forward or backward. Make sure thatthe position for airway management is well maintained, especiallyduring mask-bag ventilation.

(2) Suction mouth and nose and increase pressure
The second step in solving problems is performing oral/nasal suctioning and increasing ventilation pressure. Inadequate oral/nasal
suctioning during the initial steps interferes ventilation.Tracheal
or gastric secretions may accumulate in the oral and nasal cavities
during various procedures, and this can be solved by opening the airway with scution.
Additionally, the optimal ventilation pressure varies among individual neonates. A high initial ventilation pressure may be required due
to deficiency or decreased activity of pulmonary surfactants, the anatomical structure of the respiratory tract, and alveoli being filledwith lung fluids. On the other hand, ventilation with unnecessari85

ly high pressure carries a risk of pneumothorax. If chest movements
cannot be seen even after the procedure shown in (1) is performed,
try to increase ventilation pressure, but avoid applying excessive
pressure. Pressure should be monitored by using a manometer and observing chest movements.

(3) Consider alternative airway : laryngeal mask airway
insertion and endotracheal intubation
If ventilation remains ineffective after completing all of the steps
above, a technique other than bag-mask ventilation must be used. If
effective bag-mask ventilation is difficult, laryngeal mask airway insertion or endotracheal intubation must be considered, depending on
the experience and qualifications of the resuscitation provider.
(Rinshu Shimabukuro)

Key points
1 For neonates with secondary apnea, ventilation must be started at
the latest within 60 seconds of birth.

2 A rapid increase in heart rate is a sensitive indicator of successful
resuscitation.

3 For term neonates or preterm neonates born at ≥35 weeks of gestation, ventilation must be started with room air.

4 For preterm neonates born at <35 weeks of gestation, ventilationmust be started with room air or a low oxygen concentration (21%30%).

5 Central cyanosis must be assessed by observing the color of thelips, tongue, and skin of the trunk, and poor oxygenation must be
assessed according to the SpO2 value.

6 Procedures, characteristics, and advantages/disadvantages of resus-

citation using a self-inflating bag, a flow-inflating bag, or a T-piece
resuscitator must be understood before providing resuscitation.

7 The use of an excessively large mask carries the risk of eye damage
and bradycardia associated with a vagal response.

8 When ventilating term neonates, an initial ventilation pressure of

approximately 30 cmH2O (for preterm neonates, 20-25 cmH2O) or
higher, and longer inspiratory time may be required.

9 The ventilation rate must be 40 to 60 breaths/min. The rate must
not exceed 1 breath/s, even in the most urgent situations, to avoid
overventilation.

10 Electroencephalogram can display the heart rate more quickly thana pulse oximeter, but the possibility of PEA must be considered.

11 To perform appropriate bag-mask ventilation, the three indicators

must be assessed first to confirm effective ventilation, and when
the chest movement is inadequate, problems must be solved using
the three ventilation corrective steps.

86Chap.2

Neonatal resuscitation STEP-6

Assess effectiveness of ventilationand proceed to next step
(chest compressions)

Chap.

2

STEP-6

HR• Check ventilation (b)• Consider intubation

HR<60/min.

PPV(+O2) + Chest compression (1:3) (c)(b) If the ventilation is not optimal, focus on
improving ventilation before proceeding to
the chest compressions.
(c) PPV 30/min. and chest compression 90/min

I

Assessments after ventilation

Heart rate and breathing must be assessed after performing effective ventilation for approximately 30 s. The main cause of bradycardia
and cardiac arrest at birth is not cardiogenic; it is secondary apnea
due to hypoxia. Thus, if bradycardia (heart rate, <100 bpm) persists
even after ventilation, make sure that ventilation is being performed
appropriately, for example, by observing chest movements.
Ventilation is stopped when the heart rate exceeds 100 bpm andspontaneous breathing is confirmed. Ventilation should be continued
when the heart rate exceeds 100 bpm but spontaneous breathing or
effective breathing is not confirmed or when the heart rate is atleast 60 bpm but less than 100 bpm. After assessing whether ventilation is being performed appropriately, the need for endotracheal
intubation must be considered.
When the heart rate is less than 60 bpm despite effective ventilation, chest compression must be started, and the oxygen concentration should be increased (Fig. 6-1). However, if ventilation is performed inappropriately, do not start the chest compression, and focus
on ensuring the effective ventilation (see p. 84, STEP 5 III, Corrective
ventilation steps).

87Fig. 6-1 Chest compressions
coordinated with positive
pressure ventilation

II

Chest compressions

1 Ratio of ventilations to chest compressions
When bradycardia and cardiac arrest occur, the neonate has severe
hypoxia with extremely low oxygen saturation. To revive the neonate

Key point
Use oxygen when initiating chest compressions.

in this situation, effective ventilation that restores oxygenation andcirculatory support is critical.
When chest compressions are required, one rescue breath should be
provided for every three compressions. It takes 2 s to perform eachcycle, thus, 90 chest compressions and 30 rescue breaths must be
provided in 1 min. In principle, the person performing chest compressions serves as a pacemaker by repeatedly counting aloud “1, 2, 3,bag” (Fig. 6-2).

2 Depth and location of chest compressions
Chest compressions are delivered on the lower third of the sternum because an analysis of chest X-rays has shown that the heart islocated there and compressions there produce higher blood pressure
than compressions delivered on the middle third of the sternum (Fig.
6-3). 38,39)
Deliver compressions to a depth of one-third of the anterior-posterior diameter of the chest. 40) Do not remove the fingers from thechest even when releasing pressure. Ventilation must not be stopped
to prepare for chest compressions.

88

Key points●Ventilation must not

be stopped to prepare
for chest compressions.
●The person performing
chest compressions
must adjust the oxygen concentration.

Basic Neonatal Resuscitation

Fig. 6-2 Timing of ventilations and chest compressions
Counting aloudcare provider A:
Chest compressions

care provider B: Positive
pressure ventilations
Chap.

2

Bag

STEP-6

One

Two

2s
(one cycle)

Three
Key point

Bag

Do not use room air for
ventilation;Use highoxygen or titrate oxygen toward high oxygen
during chest compressions, or a high concentration of oxygen can beadministered from the
beginning.

89Fig. 6-3 Chest compressions: Compression with two thumbs with the hands encircling the chest(two-thumb technique)a: Positioning of the two
thumbs• Deliver compressions
with both thumbs tothe lower third of thesternum• Encircle the chest withthe rest of your hands• Compress to a depth ofapproximately one-thirdof the depth of thechest

c: Thumb position from the neonate’s headb: Thumb position from above

d: Chest compression depth (Approximately
onethird of the anterior-posterior diameter ofthe chest)

3 Chest compression techniques(1) Compression with two thumbs with the hands encircling the chest (two-thumb technique)
The two-thumb technique involves encircling the chest with the two
hands placing the thumbs on the chest (Fig. 6-3). Compared to thetwo-finger technique, this technique causes less fatigue and can produce higher blood pressure. 41) In addition, delivering compressions to
the lower third of the sternum has the least impact on other organs.
42)

Thus, the two-thumb technique is chosen as the first-line approachfor chest compressions in neonates. Overlapping the thumbs rather than positioning them adjacent to one another produces greater
blood pressure and pulse pressure but should be done with care because it causes greater fatigue. 43)

90

Basic Neonatal Resuscitation

Fig. 6-4 Compression with two fingers (two-finger technique)a: Compression with two fingers, the index
finger and middle finger

Chap.

2

STEP-6b: Correct positioning of two fingers during
diastole

c: Incorrect positioning of the fingers (donot remove the fingers from the chest, evenduring diastole)(2) Compression with two fingers (two-finger technique)
In the two-finger technique, two fingers, either the index finger
and middle finger or the middle finger and the ring finger are used
to compress the sternum (Fig. 6-4a, b). If the neonate is lying on asoft surface, it is acceptable to place the other hand on the neonate’sback instead of using a CPR board. Care must be taken not to remove
the fingers from the neonate’s chest, even during the diastole phase(Fig. 6-4c).
Choose the two-finger technique over the thumb technique in thefollowing situations● When the umbilical cord has been catheterized to administer drugs(it is not possible to maintain a clean abdominal field with the twothumb technique)● When performing resuscitation alone (the same person cannot
deliver both ventilations and chest compressions with the twothumb technique)● When the provider has small hands

91

4 Assessment after chest compression
The heart rate must be checked every 30 s by either 6-s auscultationor ECG monitoring. Chest compressions must be continued until theheart rate returns to ≥60 bpm. Ventilation must be continued whileassessing the heart rate. If the heart rate does not return to ≥60
bpm，the administration of adrenaline, in addition to ventilation andchest compressions, must be considered.
In cases of cardiac arrest or bradycardia requiring chest compression, caution must be taken when interpreting measurements from an
end-tidal CO2 detector or a pulse oximeter.

administration and decreasing
III Oxygen
oxygen during chest compressions
The oxygen concentration must be increased when starting chest
compressions. Although there is no clear standard for the oxygen
concentration in this situation, the oxygen concentration should be
increased to a high concentration (80%-100%) according to the assessment of the heart rate, skin color, and SpO2, or a high concentration of oxygen (80%-100%) can be administered from the beginning.
According to NCPR2015, the results of animal studies showed thatroom air can be used during neonatal chest compressions and that there
is no benefit to using 100% oxygen, but neither of these findings was
supported by adequate evidence. It is recommended that ventilation be
started with air for term neonates and with an oxygen concentrationof 21%-30% for preterm neonates, and the oxygen concentration must
be adjusted based on the SpO2 value 44, 45). However, there are no data
indicating the optimal oxygen concentration during chest compressions.
In fact, when neonates require chest compressions, it is likely that theyreceived ventilation using oxygen that did not improve skin color and SpO2and that they have severe hypoxia and require oxygen administration.
After chest compressions are started, the heart rate must be assessedroughly every 30 s. Stop chest compressions but continue ventilation if theheart rate increases to ≥60 bpm and stop ventilation if the heart rate increases to ≥100 bpm and the neonate starts breathing spontaneously. The
oxygen concentration should be decreased if the SpO2 value exceeds 95%
to avoid organ damage due to exposure to a high oxygen concentration.
How to increasing and decreasing
oxygen concentrations
There is no clear evidence as to the best approach
to increasing and decreasing oxygen concentrations.
Large-scale studies of oxygen concentration during
the initiation of resuscitation in preterm infants
show that oxygen concentration is adjusted by

Key point

92

approximately 10 to 20% in response to assessments
made every 15 to 60 seconds. 46〜51) Adjusting oxygenin accordance with assessments of heart rate, skincolor, and SpO2 using such a method may be an option.
Institutions and individuals should consider, discuss,and decide on specific policies of increasing anddecreasing oxygen concentration regularly.

Basic Neonatal Resuscitation

Chest compression techniques in the future
CoSTR2020 adopts the recommendations of CoSTR2015 without modification, but studies of the coordination of chest compressions withventilation are underway. Studies of the combination of chest compressions and sustained inflation (the CC+SI method) showed extremely interesting results. Several animal experiments showed that spontaneous circulation returns significantly more quickly with the CC+SI
method than with the conventional 3:1 method (in which the ratio ofchest compressions to ventilation is 3:1) 52-54). Additionally, a largescale prospective controlled study comparing the CC + SI method andthe conventional 3:1 method in humans 55) is underway: the results ofthis study are eagerly awaited.

Chap.

2

STEP-6(Takahiro Sugiura)

Key points
1 The oxygen concentration must be increased when chest compressions are initiated.

2 The technique using two thumbs with the hands encircling the chest(two-thumb technique) is the first-line approach for chest compressions.

3 One rescue breath should be provided for every 3 compressions (2 s
per cycle) in a coordinated manner.

4 The heart rate must be assessed roughly every 30 s, and stop chest

compressions but continue ventilation if the heart rate increases to≥60 bpm.

93

Chap.2

Neonatal resuscitation STEP-7

Medications

PPV(+O2) + Chest compression (1:3) (c)HR
HR<60/min.
Consider IV adrenalineHR
HR<60/min.
PPV + Chest compression and…..

• Normal saline for suspected hypovolemia• Searching for the cause of cardiac arrest

After ROSC (HR ≥ 60/min.)Stop chest compression and continue PPV(c) PPV 30/min. and chest compression 90/min

More than 99% of neonates who require CPR can be revived by effective ventilation coordinated with chest compressions of adequate
depth delivered at an adequate rate. However, the heart rate remains<60 bpm even with such interventions in approximately 0.05% of neonates who require CPR. Medications are required for the resuscitation of these neonates.
Medications must be provided only when the neonate is receiving effective ventilation using oxygen and chest compressions: ventilationand chest compressions must continue when the neonate is receiving
medications 9, 56).

94

Basic Neonatal Resuscitation

I

Preparation for adrenaline

It is necessary to evaluate whether the heart rate has increased to>=60 bpm after the initiation of oxygen administration. If a proper
pulse wave is detected by a pulse oximeter attached to the neonate,
use the heart rate displayed on the pulse oximeter. If ECG waveforms
are detected by the ECG monitor attached to the neonate, use theheart rate displayed on the ECG monitor.
If the heart rate remains <60 bpm despite with the adequate resuscitation techniques,intravenous adrenaline (Bosmin ®) is the firstline intervention. Furthermore, as described below, the umbilical venous route must be considered as the first-line administration route.
The peripheral venous route can also be used if a peripheral venous
access is secured promptly. If such intravenous administration cannot
be secured promptly, the next best approaches to consider are endotracheal administration via an endotracheal tube and intraosseous
infusion using an intraosseous needle 57).

2

STEP-7

II

Chap.

Route

1 Umbilical vein
Umbilical venous access established by the catheterization of theumbilical vein is the fastest and reliable administration route in neonates and is an acceptable route for the direct administration ofdrugs. It must be noted that, unlike the placement of a long-term
catheter, the catheter for resuscitation is not inserted beyond thepoint where the reflux of blood is observed and is temporarily secured at this point. The drug is injected first, and then the catheter
is flushed with normal saline to ensure that the full amount of theinjected drug is delivered into the body.
The catheter will be fully fixed after drug administration but canremain temporarily fixed until the resuscitation procedures becomeless intensive. Fixation procedures will be implemented according to
the situation, but care must be taken not to neglect clean technique
because of urgency.

2 Peripheral venous administration with peripheral venous catheter

This route is the most commonly used in the routine clinical setting, and it can be used instead of the umbilical venous route in neonates when peripheral venous access is secured promptly. However,
if securing access is expected to be difficulty due to poor circulation95

in asphyxiated neonates, the use of another route of administrationmust be considered promptly. Additionally, as with other routes of
intravenous administration, ensure that the catheter is flushed withnormal saline after administration 58, 59).

3 Endotracheal administration through anendotracheal tube

The advantage of endotracheal intubation is that a care provider
experienced in the procedure can complete it more quickly than securing venous access. However, it is necessary to keep in mind thatthe tracheal route may be less reliable than the intravenous route fordrug administration, and thus, a larger dose of the drug must be usedthan that used intravenously.
For preventing medical accidents, is important to make a clear distinction between drugs that can be administered through an endotracheal tube (adrenaline, pulmonary surfactant) and those that can only
be administered intravenously. In addition, some drugs (e.g., adrenaline) may cause false positives in the exhaled CO2 detector, so caution
should be taken in the interpretation of the results.

4 Intraosseous infusion with an intraosseous
needleThe recommended route of drug administration during resuscitation
in infants, children, and adults is intraosseous administration and inneonate, the umbilical vein is the most recommended route becauseof its ease of use and reliability. If insertion of the umbilical vein isdifficult and the healthcare provider has sufficient experience withusing intraosseous needles, intraosseous administration with intraosseous needle is acceptable (Figures 7-1 and 7-2). However, the useof intraosseous needles has been reported 60) to cause complications
such as bone fractures and damage due to fluid leakage, so caution
should be exercised. All drugs used for intravenous administration canalso be administered by intraosseous infusion
Fig. 7-1 Intraosseous needle

96

Fig. 7-2 Sites for inserting(posterior and medial to thetibial tuberosity) and securing
the intraosseous needle

Basic Neonatal Resuscitation

III Medications used for neonatal resuscitation
1 Adrenaline (Bosmin®: 0.1% adrenaline)

Chap.

Adrenaline increases the contractile force of the heart, increases

2

the heart rate, and increases blood flow perfusing the coronary ar-

STEP-7tery and brain to promote contraction of peripheral blood vessels.
Only 0.1% adrenaline (Bosmin®) is sold in Japan. Therefore, in clinicalpractice, one ampule (1 mL) of adrenaline is normally diluted by a factor of 10 using 9 mL of normal saline (10 mL total) to produce 0.01%
adrenaline (0.1 mg/mL).
The best route of administration is intravenous. It is recommended
to quickly administer 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of theabovementioned diluted solution) intravenously. Administration ofhigher doses is not recommended. After administering the adrenaline, flush with normal saline to ensure that the entire dose has been
administered. For endotracheal administration, which is less reliable
than intravenous administration, use a dose of 0.05 to 0.1 mg/kg(0.5 to 1.0 mL/kg of the abovementioned diluted solution). However,even after endotracheal administration is started, the route can bechanged to intravenous administration as soon as access is secured,
irrespective of the time used for endotracheal administration.
When administering adrenaline, ensure that no drug solution remains in the endotracheal tube or any of the connecting tubes. Start
ventilation promptly after administration because the drug will beabsorbed through the trachea.
To avoid errors when administering these drugs, devise methods toeasily differentiate between intravenous and endotracheal doses, forexample, preparing 1-mL syringes with 10-fold diluted Bosmin® forintravenous injection and 10-mL syringes with 10-fold diluted Bosmin® for endotracheal administration, and clearly label each. Checkthe heart rate approximately every 30 s after administration. If theheart rate is less than 60 bpm, administer a dose of 10-fold diluted
Bosmin® within the abovementioned range every 3 to 5 minutes. 58,59)

Key point
Adrenalin administration
every 3-5 min, not every
30 s.

2 Volume expanders
Consider using a volume expander when the medical history includes
placental abruption, placenta previa, umbilical cord hemorrhage, fetomaternal transfusion syndrome, or twin-twin transfusion syndrome orwhen it appears that resuscitation is inadequate due to hypovolemic
shock caused by an obvious drop in circulating blood volume despite
unknown medical history. Normal saline is the recommended volume
97

expander to use. Lactated Ringer’s solution can also be used, and typeO Rh-negative packed red blood cells can be used if the neonate might
have had anemia during the fetal period.
Administer 10 mL/kg of normal saline intravenously through the umbilical vein or other appropriate route over a period of 5 to 10 minutes. Administer the same dose again if the response is inadequate.
Repeated doses are also administered if massive blood loss can be
anticipated. The use of volume expanders is generally not indicatedwhen there is no history of blood loss. However, the use of volume
expanders can be considered when another cause is not identified andblood loss cannot be ruled out. 58,59)

3 Sodium bicarbonate (Meylon® 8.4%)
The appropriateness of administering sodium bicarbonate is debatable because it poses risks such as intracranial hemorrhage. Nevertheless, consider administering sodium bicarbonate when a neonate has
obvious metabolic acidosis despite adequate ventilation management
and the acidosis appears to be impeding hemodynamic improvement.
Administration of sodium bicarbonate through an endotracheal tube
is contraindicated. Always administer sodium bicarbonate intravenously into a vein that can be checked for flashback. In clinical practice, a commercially available
intravenous preparation such as Meylon® is diluted with distilled water by a factor of two to produce approximately 4.2% sodium bicarbonate solution (0.5 mEq/mL) and injected at a dose of 2 to 4 mL/kg
at a rate of at least 1 mL/kg/min. 58,59)

4 Preparations for effective pharmacologicalintervention during resuscitation

To perform effective and prompt NCPR, it is necessary for facilities
to establish a system that enables medical staff involved in resuscitation to be familiar with resuscitation knowledge and skills withpractical applicability so that the teams can be formed quickly. Providing appropriate resuscitation at the appropriate time is an important element of successful resuscitation. To ensure there are no timedelays, preparations for the next stage of resuscitation should always
be made when the step currently being performed is ineffective.
As shown in Table.7-1, when administering drugs for neonatal cardiopulmonary resuscitation, it is essential to use the necessary drugs
safely and quickly and to have a storage system that ensures thatdrugs are quickly restocked after use.
Preventing accidents such as medication errors and preparing supplies so that the doses are easy to check are also important in these98

Key point
Use distilled water todilute sodium bicarbonate (Meylon®).

Basic Neonatal Resuscitation

urgent situations. Specifically, it is necessary to determine in advance the concentrations of drugs, the amounts to be prepared, andthe syringes to be used, to always dispense drugs in new syringes, andto save syringes after use as well.
It is also necessary to prepare bulletin boards detailing the dosages

Chap.

and administration for drugs, to have different labels for different

2drug types, and to create a record form that enables simultaneous

STEP-7

recording of the timing of drug administration, the drugs administered, and the doses administered along with the resuscitation procedures that were performed. To prevent infection and needlestick
injuries, quick-drying rub-in hand sanitizers and gloves must always
be available, facilities must be equipped with disposal containers forused needles, and the adoption of a needleless system should also be
considered. 58,59)(Isao Kusakawa)
Table. 7-1 Medications for neonatal resuscitation

Key points
1 Resuscitation must be continued even when medications have become necessary.

2 The intravenous route is recommended for medication, and the firstline route is the umbilical venous route. The peripheral venous route,endotracheal administration, and use of an intraosseous needle must
be considered according to the situation.

3 Preparation is important to ensure that the resuscitation drugs canbe used by any staff member.

99

Chap.2

Neonatal resuscitation STEP-8

Stabilization of breathing

Spontaneous
breathingand 100/min.

Labored breathing or
cyanosis (low SpO2)

NO

YES

Target SpO2

• SpO2 monitoring• CPAP or O2 as needed

ImprovingLabored breathing or
cyanosis (low SpO2)

NO

Time
1min.
3min.
5min.
10min.

Not
Improving• Search for the cause

and…
• Consider PPV if laboredbreathing and low SpO2
continues.
• Check congenital heartdisease if low SpO2
continues withoutlabored breathing.

Post
Resuscitationcare• Carefulobservation
on respiration

Next, respiratory status must be assessed, because the confirmationof spontaneous breathing (or crying) and a heart rate of ≥100 bpm
does not necessarily indicate stable breathing. In this situation, important indicators are labored breathing and central cyanosis (or poor
oxygen saturation) in neonates. Unlike in the rescue sequence on theleft side of the algorithm, the neonate is breathing spontaneously,
and the heart rate is sustained. Thus, it is not necessary to rush to
the next step. When labored breathing and central cyanosis (or poor
oxygen saturation) persist, a pulse oximeter must be attached to theneonate and it should be determined whether the provision of CPAP
and oxygen administration is necessary.
100

SpO2 (%)
≥60
≥70
≥80
≥90

Basic Neonatal Resuscitation

I

Labored breathing

Once spontaneous breathing (or crying) and a heart rate ≥100 bpm
are confirmed, labored breathing is assessed next. Specifically, it isChap.

necessary to look for nasal flaring, grunting, and signs of labored2

breathing (retractions and tachypnea ≥60 breaths/min).

STEP-8Respiratory distress with nasal flaring alone tends to be mild andoften resolves spontaneously, and only careful observation is required in such cases.
Grunting occurs when the glottis is slightly closed while exhaling,which maintains high airway pressure and prevents alveoli from collapsing; in other words, it occurs when neonates themselves generate
PEEP 61). Thus, grunting indicates a condition in which the alveoli are
not easily expanded and are prone to collapse.
Retractions include subcostal, intercostal, sternal, and suprasternal retractions. Mild subcostal retractions can be observed in normal
neonates, but others types of retraction generally indicate increased
respiratory effort 62). Harder inhalation reduces the intrapleural pressure to a greater degree, resulting first in subcostal and intercostal
retractions and then in sternal and suprasternal retractions when thepressure reduction becomes more intense.
Gasping must be distinguished from labored breathing. Gasping isan abnormal breathing pattern characterized by irregular, deep, large
gasps at a low rate (1 gasp/5-10 s). It is almost always accompanied
by bradycardia, and this can be used to differentiate it from laboredbreathing. It must be noted that gasping is regarded as apnea, notas spontaneous breathing, and thus requires the prompt provision of
positive pressure ventilation.

II

Central cyanosis or poor oxygen saturation
and attachment of a pulse oximeter

In addition to the assessment of labored breathing, central cyanosis
or poor oxygen saturation must be examined. It takes several minutes
before skin color and oxygen saturation improve, even in neonates
without any underlying conditions. It must be noted that relatively
low target SpO2 values soon after birth (≥60% and ≥70% at 1 min and
3 min after birth, respectively), as shown in the algorithm, are completely normal 63-65). In other words, central cyanosis that is judged
by skin color at only 1-2 min after birth does not require urgent intervention. Given that skin color is not a reliable indicator of central
cyanosis, a pulse oximeter must be attached to the neonate when la101bored breathing is present and central cyanosis persists. It must be
noted that it takes 1-2 min or longer for a pulse oximeter to produce
reliable SpO2 values. Thus, when respiratory support is likely needed,
it is desirable to attach a pulse oximeter to the neonate as soon as
possible.
It is also important to assess the presence of central cyanosis andits changes by constantly monitoring skin color until reliable SpO2values are available for assessing oxygen saturation.

(Continuous Positive Airway
III CPAP
Pressure)
When labored breathing and poor oxygen saturation (below the SpO2target value) persist, the provision of CPAP or oxygen administrationmust be considered. CPAP is indicated for both labored breathing andpoor oxygen saturation, and oxygen administration is mainly indicated for poor oxygen saturation. When the neonate is spontaneously
breathing, CPAP applied to the airway helps the lungs expand, especially by preventing the alveoli from collapsing during exhalation.
Studies of the use of CPAP for preterm neonates have suggested a
possible reduction in mortality and bronchopulmonary dysplasia 66-68),
and therefore, it is recommended that CPAP be provided before PPV(Fig. 8-1).
The provision of CPAP is recommended for term neonates based on
the data obtained from preterm neonates, despite inadequate evidence of its efficacy in term neonates. The use of room air rather than
100% oxygen for resuscitation was shown to reduce mortality in termneonates who required respiratory support 69), and “oxygen administration with utmost care” has been emphasized since NCPR2010 10).
Therefore, it is reasonable to try CPAP with air first. Additionally,
similar to the recommendations when performing positive pressure
ventilation, an initial oxygen concentration of 21%-30%, but not
Fig. 8-1 CPAP102

Basic Neonatal Resuscitation

higher, is recommended when providing CPAP to preterm neonates 70).
When providing CPAP using a bag-mask device, position the neonate
in the supine “sniffing position” (in which the neck is slightly extended, the head is tilted backward, and the chin is lifted) for airway management, as is done when performing positive pressure ventilation,

Chap.

and hold the mask using the IC clamp technique (see p. 80) to make2

sure to avoid compressing the eyes with the mask. Increases in air

STEP-8

leak, such as pneumothorax, due to use of CPAP 66, 71) have been reported; therefore, the pressure inside the airway must be monitored witha manometer or a similar device to maintain a target pressure of 5-6
cmH2O, without exceeding 8 cmH2O, while providing CPAP.

IV Free-flow oxygen
When poor oxygen saturation persists, consider the administrationof oxygen. Oxygen can be administered simultaneously with CPAP, or
free-flow oxygen can be administered. Attach a pulse oximeter to theneonate to monitor for excessive oxygen administration, and use an
air/oxygen blender to start administration at an oxygen concentrationof approximately 30% or lower. Adjust the oxygen concentration bymonitoring the SpO2 value to achieve the target SpO2 values for thecorresponding time after birth 63-65). When a blender is unavailable,
100% free-flow oxygen can be used.
Even in such cases, the SpO2 value must be monitored, and the oxygen dose must be adjusted accordingly by adjusting the distance
between the neonate’s mouth and the oxygen-supplying device andadjusting the flow rate of oxygen.
Free-flow oxygen can be administered with a cupped hand holding
a tube or by using an oxygen mask, a flow-inflating bag, or a T-piece
resuscitator (Fig. 8-2). Noted that it is usually impossible to adminFig. 8-2 Free-flow oxygen
a: Cupping the hand holding the oxygen tube

b: Using a flow-inflating bag

103

Fig. 8-3 Incorrect use of a self-inflating bag
It is usually impossible to administer oxygen using a mask
attached to a self-inflating bag.

ister free-flow oxygen securely with a self-inflating bag (Fig. 8-3).
Certain types of self-inflating bags can be used if they are equippedwith a closed-system reservoir or bellows attached to the opposite
side of the mask; it is crucial to check beforehand how to use thedevices available at individual facilities.

When labored breathing and central cyanosis

V (poor oxygen saturation) persist

When both labored breathing and poor oxygen saturation persist despite the provision of CPAP and the administration of oxygen, search
for the cause while continuing to provide these forms of respiratory
support. If a worsening trend is observed, consider the initiation of
positive pressure ventilation. When only poor oxygen saturation persists despite the absence of labored breathing and the presence ofstable spontaneous breathing, consider the differential diagnosis of
cyanotic heart disease. When only labored breathing persists, continue to provide CPAP, and then admit the neonates to a neonatal
intensive care unit (or a similar unit) or contact an advanced medical
institution to discuss transportation of the neonate.
(Tetsuya Isayama)

104

Basic Neonatal Resuscitation

Key points
1 When spontaneous breathing or crying are observed and the heart

rate is ≥100 bpm, examine the next indicators of respiratory status,that is, the presence or absence of labored breathing and central
cyanosis (or poor oxygen saturation).

Chap.

2

2 Signs of labored breathing include nasal flaring, grunting, tachypnea(≥60 breaths/min), and retractions.

STEP-83 When labored breathing and central cyanosis (or poor oxygen sat-uration) persist, attach an SpO2 monitor to the neonate and thendetermine whether CPAP or oxygen administration is required.

4 CPAP is indicated for both labored breathing and poor oxygen saturation, while oxygen administration is indicated mainly for poor oxygen
saturation.

5 While providing CPAP, monitor the airway pressure using a manometer or a similar device to maintain a target pressure of 5-6 cmH2O,
taking care to keep the airway pressure under 8 cmH2O.

6 Adjust the concentration of oxygen to achieve the target SpO2 values for the corresponding time after birth.

7 When both labored breathing and poor oxygen saturation persist despite the provision of CPAP and the administration of oxygen, search
for the cause and consider initiating positive pressure ventilation.

8 When only poor oxygen saturation persists, consider the differential diagnosis of cyanotic heart disease; when only labored breathing
persists, continue to provide CPAP and admit the neonate to neonatal intensive care unit (or a similar unit) or an advanced medical
institution to discuss transportation of the neonate.

105

Chap.2

Post-resuscitation care

I

Thermal management

Neonates easily become either hypothermic or hyperthermic because of the high ratio of body surface area to body volume. Hypothermia (body temperature <36℃ ) and hyperthermia (>38℃ ) after
birth are associated with increased neonatal mortality (mortality riskincreases by at least 28% with each 1℃ drop in body temperature
below 36.5℃ ) 72,73) and morbidity (e.g., intraventricular hemorrhage,
pulmonary hemorrhage, hypoglycemia and sepsis) in neonates of all
gestational ages.
In NCPR 2020, there is no significant change from NCPR 2015 in therecommendations related to temperature management during resuscitation. An important component of temperature management in NCPR
2015 is to care for monitoring body temperature throughout the algorithm. Based on the notion that inadvertent hypothermia is associatedwith increased mortality and morbidity in neonates, it is emphasizedthat optimal maintenance of the neonate’s core body temperature(36.5℃-37.5℃) after birth and until admission is crucial.
A literature search did not find any prospective studies on the rewarming rate that have been published since NCPR2015, but two retrospective studies were reported 74, 75). Both studies compared therapid (≥0.5℃/h) and slow (<0.5℃/h) rewarming of neonates with inadvertent hypothermia (<36℃) and showed that the rewarming rate did
not affect the studies’ critical and important outcomes. However, one
study suggested that rapid warming might reduce the risk of respiratory distress syndrome 75). Recommendations on the warming rate for
hypothermia may be formulated based on the results of future studies.
However, intervention to prevent hypothermia may cause hyperthermia (>38℃ ) as an adverse reaction. Preventing hyperthermia is justas important because hyperthermia, too is associated with increased
neonatal mortality and morbidity.
Therapeutic hypothermia may be indicated for neonates with moderate to severe hypoxic-ischemic encephalopathy (HIE). Thermal management techniques for this intervention are discussed in a later106Basic Neonatal Resuscitation

section. However, in all other neonates, it is important to prevent
hypothermia and hyperthermia and to maintain an optimum body temperature (core temperature of 36.5 to 37.5℃ ) regardless of what
interventions they may require later. It is recommended that temperature after routine care, after resuscitation, and on admission be

Chap.

recorded as an indicator of the quality of care provided to the neo-2nate up to that point and as a predictor of outcomes.

II Blood glucose management
There has been no changes since NCPR2020 regarding blood glucose
management after resuscitation. Consider a intravenous dextrose assoon as possible after resuscitation to avoid hypoglycemia.
Neonates are at high risk for blood sugar abnormalities. Neonates at ahigh risk of hypoxic ischemia due to neonatal asphyxia are prone to kidney failure, syndrome of inappropriate antidiuretic hormone secretion,and electrolyte imbalances (sodium, potassium, and calcium). Additionally, they sometimes develop post-resuscitation hyperglycemia due tothe stress of hypoxic ischemia. Hyperglycemia as well as hypoglycemia
can be a cause of neurological damage because hyperglycemia in the
post-resuscitation period is associated with neuronal acidosis and oxidative damage. In such cases, insulin production may continue, which
may result in hypoglycemia. If hypoglycemia is detected early post-resuscitation, immediate intervention such as intravenous glucose administration is required. The blood glucose level must be monitored until it stabilizes in the normal range. The management of blood glucose
and electrolytes is also important in regard to preventing convulsions
and arrhythmia and for improving prognosis.
(Takuya Tokuhisa)

III Therapeutic hypothermia
Hypoxic-ischemic encephalopathy (HIE) is a general term for encephalopathy involving exposure of the fetal or neonate brain to hypoxic andischemic conditions resulting from a trigger such as an interruption ofplacental blood flow before birth.
An analysis of multiple large clinical trials in neonates born at 36
weeks of gestation or later with moderate to severe HIE, conducted
mostly in Western countries, show that starting therapeutic hypothermia (33.5 to 34.5℃ ) within 6 h after birth and adding another treat107

Fig. 9-1 Comparison of therapeutic hypothermia and no therapeutic hypothermia
for moderate or severe HIE
Effect of cooling method on mortality and neurological sequelae in survivors
Therapeutic
hypothermia

No Therapeutic
hypothermia

Death or Number
sequelae of cases

Death or Number
sequelae of cases

Weight(%)

Risk ratio(95%CI)

Risk ratio(95%CI)

Selective head cooling

Subtotal (95%CI)
Total sample size
Whole-body cooling

Subtotal (95%CI)
Total sample size
Subtotal (95%CI)
Total sample size

Date support
Favors no coolingtherapeutic hypothermia

ment in the NICU significantly decreases mortality and neurologicalsequelae at 18 months (Fig. 9-1). 76) Accordingly, in NCPR2010, therapeutic hypothermia is recommended for moderate to severe HIE.
In 2013, a meta-analysis that included 1,505 cases of moderate tosevere HIE confirmed a significant effect of therapeutic hypothermia
for reducing mortality and neurological sequelae at 18 months (riskratio, 0.75; 95% confidence interval, 0.68-0.83) 77). It was also demonstrated that this effect was maintained in children aged 7-8 years 78, 79).
NCPR2020 also recommends therapeutic hypothermia for neonatesborn at ≥36 weeks of gestation with moderate to severe HIE.
When a neonate is anticipated to have an indication for therapeutic
hypothermia after resuscitation, contact an advanced medical facility
that can provide therapeutic hypothermia to discuss transportation of
the neonate.

1 Indications for therapeutic hypothermia 80)
Contraindications for therapeutic hypothermia are shown in Table.
9-1. Therapeutic hypothermia is indicated for neonates who meet bothcriteria A and B in Table. 9-2. Evaluation with amplitude-integrated
electroencephalography (aEEG) can also be performed if necessary.
108

Basic Neonatal Resuscitation

Table. 9-1 Exclusion criteria for therapeutic hypothermia

Chap.

2

Table. 9-2 Inclusion criteria for therapeutic hypothermia

There is not enough evidence on the safety and efficacy of therapeutic
hypothermia in preterm neonates born at <36 weeks of gestation or
neonates with mild encephalopathy.

2 Body temperature before and during transportation to another facility

There is insufficient scientific evidence to indicate to what extent
the body should be cooled before and during transportation. However,
the NCPR2020 recommends that the body temperature of non-asphyxiated neonates be maintained at 37.5℃ or lower. Avoid extreme increases in body temperature (≥38.0°C) before and during transportation.

3 Cooling methods and rewarming
Whole-body cooling and selective head cooling are both appropriate.
However, the cooling protocol should follow the efficacy and safety
guidelines established by large clinical trials (i.e., initiation of coolingwithin 6 hour of birth, cooling for 72 hour, and rewarming over a period of at least 4 h). There was no clear effect on reducing mortality
and neurological sequelae at 18 months when cooling was started at109

6-24 h after birth 81). Furthermore, a lower body temperature (32℃)
and lengthy cooling (120 h) increased mortality 82).
Since NCPR2010, instruments enabling the strict adjustment of coreand cooling temperatures have become well established for therapeutic hypothermia in Japan. Simplified cooling methods, such as thoseusing cooled gel packs, should not be used in Japan as their safety andsupporting evidence have not been sufficiently demonstrated.

4 Adverse reactions to cooling
Bradycardia and thrombocytopenia were reported as adverse reactions
to cooling. 77). Neonates must be monitored carefully for signs of hypotension, coagulation disorder, infarction and hemorrhage in major organs, andpulmonary hypertension, but these adverse responses to cooling were notsignificantly increased in several large-scale clinical studies 77).

5 Follow-up
Neonates who receive therapeutic hypothermia require long-term
follow-up.
(Jun Shibasaki)

Key points
1 The key in thermal management during resuscitation is to be mindful of maintaining the neonate’s

body temperature throughout the algorithm. The target core body temperature at NICU admission
is 36.5℃-37.5℃. Each facility must determine the settings temperature at room and incubators
according to their circumstance in advance. All items necessary for resuscitation must be prepared.

2 To be mindful of avoiding hypoglycemia in blood glucose management after resuscitation. In

post-resuscitation glucose management, be aware of avoiding hypoglycemia. It is important totake immediate action including the administration of intravenous glucose.

3 Therapeutic hypothermia is recommended for neonates born at ≥36 weeks of gestation with mod-erate to severe HIE. Try to maintain the neonate’s body temperature at <38℃ before and duringtransportation to another medical facility. Cooling should be carried out in a protocol that has
been demonstrated to have efficacy and safety in large-scale clinical trials. Bradycardia andthrombopenia have been reported as adverse reactions to cooling. Neonates who receive therapeutic hypothermia require long-term follow-up.

110Basic Neonatal Resuscitation

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72）Mullany LC, Katz J, Khatry SK, et al: Risk of mortality
associated with neonatal hypothermia in southern Nepal. Arch Pediatr Adolesc Med 2010; 164（7）: 650-6.

113

Chap.

2

114

Chapter3

Advanced Neonatal Resuscitation

Chap.3

Endotracheal intubation

Endotracheal intubation is a simple, quick, and reliable approach to
airway management wherever the person in charge is adept at theprocedure. However, the procedure itself is inherently invasive, andan inexperienced care provider can cause problems such as mucosal
damage, bradycardia associated with vagal response, and hypoxia byattempting to intubate too many times and taking too much time.
Endotracheal intubation must be performed only when indicated andonly by or with the supervision of someone adept at the technique.
Video laryngoscopy has become widespread in recent years but is
not yet commonly used in perinatal clinical practice. For this reason,
video laryngoscopy is not explained in detail here and is instead introduced briefly at the end of this section. Interested readers areadvised to refer to relevant medical books or journals

I

Indications and timing forendotracheal intubation

Indications for neonatal endotracheal intubation are shown in
Table. 1, and the timing is shown in Fig. 1. In most cases, securing the
airways and providing bag-mask ventilation produce effective ventilation, allowing for a gradual, measured approach. The most common
situations when intubation would be indicated are:(1) When there are no favorable chest movements despite proper positioning of the neonate, good fit of the mask, and adequate ventilation pressure, when prolonged ventilation is required, or whenventilation does not lead to sufficient clinical improvement. Specific situations are as follows:
Table.1 Indications for endotracheal intubation

116

1

Heart rate is still less than 100/min at about 30 s after starting effective ventilation2

Not only ventilation but also chest compressions are continued for a long period of time3

Adrenalin will be administered endotracheally through an endotracheal tube

4

The neonate meets the criteria for resuscitation, the amniotic fluid is meconium-stained,
and tracheal suctioning of meconium could be an effective method of opening the airway

5

The neonate appears to have certain conditions such as congenital diaphragmatic hernia
or respiratory distress syndrome requiring surfactant replacement therapy

Advanced Neonatal Resuscitation

Fig. 1 Timing of endotracheal intubation
Consider endotracheal intubation at the time points marked with the★

Team briefing,
PPE, and Equipment check

Target SpO2
Time
1min.
3min.
5min.
10min.

Birth• Preterm?
•Weak respiration?
• Weak tone?

Spontaneous breathingandHR≥100/min.
Labored breathing or

Breathing • HR
(Consider SpO2
monitoring)

Maintain temperature• PPV (a)• SpO 2 monitoring• Consider ECG monitoring
60/min≤HR<100/min.

HR≥100/min.
HR• Check ventilation (b)• Consider intubation

YES• SpO2 monitoring• CPAP or O2 asneeded

ImprovingLabored breathing or
cyanosis (low SpO2)

NO

HR<60/min.

★ PPV(+O2) + Chest compression (1:3) (c)Not
Improving• Search for the cause
and…

HR≥ 60/min.

HR

★

NO

cyanosis (low SpO 2)

Apnea /Gasping or
HR <100/min.

★

3

Routine Care(stay with mother)• Provide warmth• Open airway• Dry
Ongoing evaluationWarm,
open airway (positioning, etc.),
dry, and stimulate

Within60 seconds

Chap.

NO

YES

★

SpO2 (%)
≥60
≥70
≥80
≥90

HR<60/min.
Consider IV adrenalineHRHR≥ 60/min.
HR<60/min.

PPV + Chest compression and…..
• Normal saline for suspected hypovolemia• Searching for the cause of cardiac arrest
After ROSC (HR ≥ 60/min.)Stop chest compression and continue PPV★

• Consider PPV if laboredbreathing and low SpO2
continues.
• Check congenital heartdisease if low SpO2
continues without laboredbreathing.

Post
Resuscitationcare• Carefulobservation
on respiration(a) Add or increase supplemental oxygen if HR
or SpO2 are not improved.
(b) If the ventilation is not optimal,
focus on improving ventilation before
proceeding to the chest compressions.
(c) PPV 30/min. and chest compression 90/min

117

☆Heart rate of less than 100/min at approximately 30 s after starting effective ventilation.
☆Ventilation and chest compressions are continued for a long periodof time.
If chest compressions are required for a long period of time, intubation may help to maximize the efficiency of the ventilation bycoordinating the rhythm of chest compressions and ventilation.
(2) If the heart rate is less than 60 bpm even after adequately performed resuscitation, adrenaline is required, and intravenous administration is the first choice of administration route. However,if the venous route cannot be secured, the endotracheal route (viaan endotracheal tube) may be selected as the second choice.
(3) When a neonate who was born through meconium-stained amniotic
fluid requires resuscitation based on criteria assessed immediately
after birth and insufficient ventilation is anticipated because of
likely airway obstruction by meconium,(4) If the neonate appears to have certain conditions such as congenital diaphragmatic hernia or respiratory distress syndrome requiring surfactant replacement therapy.
In any of these situations, providers unfamiliar with intubation
should focus on providing effective bag-mask ventilation rather than
wasting precious time attempting intubation.

II

Supplies for endotracheal
intubation (Table. 2)(1) Prepare an aspirator along with a mouth suction tube (10 Fr or
wider) and tracheal suction catheter (5 Fr, 6 Fr, or 8 Fr).
(2) Bag and mask: It is possible to administer either low or high oxygen with a self-inflating bag either with or without an oxygen
reservoir. When using a flow-inflating bag, it is recommended toadjust oxygen concentrations using a blender and to monitor airway pressure with a manometer.

Table.2 Supplies for endotracheal intubation
Equipment
Oxygen pipe
Oxygen cylinderCompressed air
Flowmeter and blender
Suction pipe and aspirator
Radiant warmer

118

Monitoring devices
Pulse oximeter
ECG monitor
End-tidal CO 2 monitor
Manometer

General supplies for resuscitation

Supplies for intubation

Bag (self-inflating bag,flow-inflating bag)
Mask
Stethoscope
TowelsAirways
GlovesEndotracheal tube
Laryngoscope
Straight blade(Stylet)Tape for securing tubes

Advanced Neonatal Resuscitation(3) Oxygen: The oxygen gas in typical oxygen cylinders is dry. Be cautious of airway drying when providing long period ventilation.
Whenever possible use a humidifier.
(4) Laryngoscope: Blade No. 0 (for neonates) or No. 00 (for prematureinfants) When intubating neonates, the epiglottis is lifted directlywith the blade. Always use a straight blade.
(5) Endotracheal tube: Choose the size depending on body weight(Table. 3).Prepare tubes with an internal diameter of 2.0, 2.5, 3.0,

Chap.

3

and 3.5 mm. Always have three sizes ready, the size appropriate for
estimated body weight and the larger and smaller sizes.
(6) Various monitors: Pulse oximeter, ECG monitor, end-tidal CO2
monitor(7) Stethoscope (neonatal stethoscope if available)(8) Stylet (optional): When using, do not advance the tip of the stylet
past the tip of the tube. Caution must be exercised when using astylet, because the straightened endotracheal tube tends to impede the view during intubation.
(9) Oral airway

Size and depth of endotracheal tube
Prepare an endotracheal tube with an internal diameter between
2.0 and 3.5 mm that corresponds to estimated body weight (Table. 3)
Always use an uncuffed tube.
Insert the endotracheal tube so that the thick mark (vocal cordguide), located approximately 1.5 to 2 cm from the tip of the tube, approaches the glottis. Research has shown that 6 cm plus body weight(in kg) can serve as an index for insertion length (in cm) from the lips.
Insertion depth of the endotracheal tube in extremely low
birth weight neonates
Caution must be exercised when caring for neonates with extremely
low birth weight, especially those weighing <750 g. Several studies haveshown that an insertion depth of 6 cm plus body weight (in kg) is excessive. Among them, a Japanese study provided an approximate guideline of shortening the insertion length by 1 cm for every 300 g below
1000 g, i.e., 5 cm for 400 g, 6 cm for 700 g, and 7 cm for 1000 g 3).
Table.3 Supplies for endotracheal intubation
Body weight (kg)

Gestational age

Tube size (mm)Insertion depth from the cornerof the mouth 6 +body weight (kg)cm<1.0
1.0 ~ 2.0
2.0 ~ 3.0
3.0<

<28
28 ~ 34
34 ~ 38
38<

2.0 . 2.5
2.5 . 3.0
3.0 . 3.5
3.5

5.0 ~ 7.0
7.0 ~ 8.0
8.0 ~ 9.0
9.0<

119

III Intubation procedure(1) Achieve adequate oxygenation with bag-mask ventilation (however, intubate without providing ventilation if intubation and suctioning are indicated due to meconium aspiration or when intubating for diaphragmatic hernia).
(2) Place the neonate in the basic position for intubation, similar tothat used for bag-mask ventilation (the, sniffing position with the
midline of the head placed on a flat surface and the neck slightly
extended) (Fig. 2).
(3) Hold laryngoscope in the left hand and the neonate’s face withthe right hand. Use the right hand to open the mouth. When doing so, do not grip the laryngoscope with the entire hand as when
intubating children and adults but rather with three fingers (thethumb, first and second fingers). This ensures that no excessive
force is used and the procedure is gentle.
(4) When using a straight blade, advance the blade to where the tip
pushes directly on the epiglottis right in the middle of the base of
the tongue (Fig. 3).
Caution: It is usually difficult to advance the tip of a curved blade
to the epiglottic vallecula in neonates.
(5) Lift the blade slightly and with it lift the tongue to expose thepharyngeal area. When lifting the blade, lift the entire blade in the
direction indicated on the handle. Do not lift the tip of the blade
alone (Fig. 4).
(6) Look for anatomical landmarks (Fig. 5). If the tip of the blade
is properly depressing the epiglottis, the larynx should be visibly
open. The vocal cords should look like vertical stripes on both sidesof the larynx, or like an inverted V. If these structures are notvisible, immediately adjust blade placement until they are visible.
Fig. 2 Positioning for intubation○ Correct:✕Incorrect:

Position does not impede visibility
Position impedes visibility (neck(lift the tongue with the laryngoscope overextended)blade)

120✕Incorrect:

Position impedes visibility (neckflexed)Advanced Neonatal Resuscitation

Applying downward pressure on the cricoid cartilage (the cartilagethat covers the larynx) may help bring the larynx into view (Fig. 6).
The care provider performing the procedure can either apply pressure using the little finger or ring finger or can have an assistant
do it. Suctioning secretions also improves visibility. Attempting to
intubate while the larynx is not fully visible is the most common
cause of failed intubation.
(7) Insert the endotracheal tube. Hold the tube in the right hand and

Chap.

3

insert from the right corner of the neonate’s mouth while keeping the curve of the tube horizontal. This ensures that the tube
will not impede the view of the larynx. When the vocal cords open,
insert the tip of the endotracheal tube until the vocal cord guide(Fig. 7a) reaches the vocal cords while keeping the larynx visible.

Fig. 3 Anatomical landmarks to reference when positioning
the laryngoscopes 4)

Fig. 4 Inserting the laryngoscope blade○ Correct:

Lift the tongue and the jaw.

✕Incorrect:

Do not lift the tip of the blade alone and pull up on thehandle.

121

Be sure to only advance the tube to the point where the vocal cordline reaches the vocal cords. The tip of the tube should be almost
between the vocal cords and the carina.
When using a stylet, its position should be adjusted so that the
distal tip does not protrude from the endotracheal tube, and theproximal end should be bent to prevent it from slipping down while
procedures are being performed (Fig. 7b). It must be also noted
that, as described previously, the view is impeded if the entire endotracheal tube is straightened when a stylet is used.
(8) After intubation, carefully withdraw the laryngoscope while keeping the tube securely in place with the right hand. Secure the tube
with tape or another securing device. Refer to the rightmost column in Table. 3 for the general length of tube to secure at thecorner of the mouth.

Fig. 5 Anatomical landmarks to reference before Inserting an endotracheal tube

Fig. 6 Thyrold and cricold pressure
Compressing the larynx from above improves visibility.
This can be done by either the handler (left) or an assistant (right).

122

Advanced Neonatal Resuscitation

Photographs and key points of endotracheal intubation procedures are shown in Figure 7. In principle, an endotracheal tube
must be inserted through the mouth during neonatal resuscitation.
A laryngoscope designed for use in neonates with a straight blade(size 0 or 00; Fig. 7c, d) should be used.
When inserting the endotracheal tube, ensure that a pulse oximeter is attached to the neonate. Carefully watch for decreases inheart rate and/or SpO2, and do not perform any procedures force-

Chap.

3

fully; intubation must be performed after sufficient bag-mask ventilation (except when suctioning meconium or when the neonate hasa diaphragmatic hernia). If insertion of the endotracheal tube is notcompleted within 30 s, or if obvious deterioration of the heart rate
and/or SpO2 is observed, perform adequate bag-mask ventilation andthen try again to insert the endotracheal tube (Fig. 7e-h).

Fig. 7 Endotracheal Intubation
The proximal end of thestylet is bent to fix thelength of the stylet.

The stylet tip is kept inside
the endotracheal tube.

The stylet tip is extended
outside the endotracheal
tube.
b: Proper use of stylet

a: Vocal cord mark on theendotracheal tube

c: Laryngoscope for use with neonates and neonates(straight blade, size 0 and 00)

d: Holding the laryngoscope123

f: Holding the neonate for endotracheal intubatione: Holding the neonate for endotracheal intubation

g: Positioning for intubationh: Tube insertion
Insert the endotracheal tube from the rightcorner of the mouth.

IV Causes and solutions of intubation problems
Causes and solutions of intubation problems are shown in Table. 4.
Table.4 Intubation problems and solutions
Situation

124

Problem

Solution

Blade not visible due to tongue
blocking

Tongue not moved out of the way
on insertion

Move the tongue from the right andre-insert the blade

Tongue visible in front of blade

Blade insertion not far enough

Advance the blade farther

Epiglottis hanging in front of blade

Blade has not reached epiglottis

Place blade on epiglottis and lift again

Esophagus visible in front of blade

Blade inserted too far

Slowly withdraw the blade keeping thesame angle

Opening of the trachea and vocal
cords visible on left or right side only

Blade slipped off center to the leftor right on insertion

Shift the larynx left or right from the outside using
the little finger or ring finger of the left hand

Only the lower half of the tracheal
opening and vocal cords are visible

Tongue and jaws not lifted highenoughLift tongue and jaws up or provide
thyroid and cricoid pressure

Advanced Neonatal Resuscitation

V Complications related to intubation
Complications related to intubation are shown in Table. 5.
Table.5 Complications related to intubation
Complication

Cause

Prevention and management

Tube mal positioning

Provide adequate oxygenation before intubation(prevention)
Monitor during intubation (prevention)
Take no more than 20 seconds to intubate(prevention)
Check with end-tidal CO 2 monitor (prevention)
Check insertion depth (prevention)

Bradycardia

Hypoxia
Vagal response caused by intubation procedures

Ensure adequate oxygenation by ventilation(management)
Intubate quickly (prevention)

Pneumothorax

Unilateral pulmonary
overinflation due to unilateral lungintubation

Insert to proper depth (prevention)
Check for equal breathing sounds i.e.
respiratory sounds in left and right lungs(prevention)
Use correct ventilation pressure (prevention)
Transillumination (diagnosis)
Chest drainage (management)

Hypoxia

Excessive duration of intubation

Excessive ventilation pressure

Oral/respiratory tract injury

Aggressive handling of the laryngoscope blade and/or endotracheal tube

Practice and master gentle handling techniques(prevention)

Perforation of trachea or
esophagus

Aggressive handling of endotracheal tube Improper use of stylet

Handle equipment gently (prevention)
Follow procedures properly (prevention)

Obstruction of endotracheal tube

Bent tube
Obstruction by secretions or
meconium

Check and suction with suction catheter(management)
Remove and re-insert endotracheal tube
(management)

Infection

Unsanitary handling of equipment

Wash hands (prevention)
Wear gloves (prevention)

125

Chap.

3

of appropriate
VI Confirmation
endotracheal intubation
When performing endotracheal intubation, the care provider must
use the technique indicated for the instruments used and the situation encountered. To confirm that endotracheal intubation was performed properly, always check for the following indicators of proper
placement of the tip of the tube after intubation (Table.6).
(1) Both sides of the chest rise and fall simultaneously(2) Respiratory sounds auscultated at the same strength in lung fields
in both axillary regions(3) No sound of air entering the stomach(4) No gastric distention(5) “Water vapor” produced by breathing visible in the tube
(6) Neonate’s heart rate, color, and vigorousness improved(7) Expired CO2 observed (fig. 8)

Table.6 Assessing outcomes of endotracheal Intubation
Physical findings, etc.
(1) Both sides of the chest rise and fall in concert(2) Respiratory sounds auscultated at the same strength in lung fields in both axillary
regions(3) No sound of air entering the stomach(4) No gastric distention(5) “Water vapor” produced by breathing visible in the tube
(6) Neonate s heart rate, color, and vigorousness improved
Monitors, etc.
(1) Expired CO 2 detected by end-tidal CO 2 monitor or CO 2 detector (however, CO 2 will not
be detected if there isnno effective cardiac output due to a cause such as cardiac
arrest)(2) Improvement in heart rate and oxygen saturation on pulse oximeter(3) Improvement in heart rate on ECG monitor(4) Position of endotracheal tube observed on chest X-ray films

Fig. 8 End-tidal CO2 detector
The color changes from purple
to yellow as the CO2 concentration increases.

126

Key point
If ventilation is successful in the presence ofpulmonary circulation, the CO2 concentrationof the exhaled gas via the endotracheal tube
will increase, and the color of the detector
will change from purple to yellow with eachventilation.
[Problems]
1 The presence of pulmonary circulation isrequired.
2 Rapid decision-making is not possible in somecases because CO2 may not be detected until
ventilations are performed repeatedly.
3 The detection rate decreases after adrenaline administration.

Advanced Neonatal Resuscitation

VII Video laryngoscopy
Video laryngoscopy offers a better field of view than simple laryngoscopy and enables the operator to share the laryngoscopic view
with other personnel, and it has become widely used in the treatment of children and adults in recent years. There are several typesof video laryngoscopes, including those that offer a fiber optic view

Chap.

3

from the tip of the blade and those that offer views from a camera
receiver attached to the tip to provide images.
There are two types video laryngoscopes, classified according totheir shape: one has the shape of a conventional laryngoscope, andthe other is called an airway device. However, neither type is commercially available in a size suitable for use with low birth weight neonates. Thus, a conventional laryngoscope with an image-recording device attached is most often used for neonates. Although they occupy
a slightly different category than laryngoscopes, a fiberscope-typedevice that employs a bronchial fiber as a guide during intubation is
also used.
Video laryngoscopy has many advantages, especially educational advantages, such as the ability to share the laryngoscopic view between
the operator and others (e.g., an instructor) and the ability to use
recordings for review. However, as described earlier, there are disadvantages to their use in the clinical setting, including that blades areavailable only in certain sizes; the equipment is bulky, which restricts
its use in an incubator; and the equipment is somewhat expensive.
Once these disadvantages are addressed through new developments,
video laryngoscopy is expected to become widely used in the near
future. However, procedures vary depending on the equipment, andthus, adequate training is important to ensure that operators are familiar with the equipment that they use.
(Isao Kusakawa)

127

VIII Laryngeal mask insertion (Fig. 9)
When ventilation with a face mask is not effective in neonates bornat ≥34 weeks of gestation, laryngeal mask airway insertion can beconsidered instead of endotracheal intubation.
Laryngeal mask airway insertion is sometimes beneficial in airway
management when endotracheal intubation is difficult due to micrognathia or macroglossia.
The smallest laryngeal mask airway size can be used for neonates
weighing ≤5 kg. The conventional procedure for inserting a laryngeal
mask airway is shown below. Several types of laryngeal mask airways
are available, and operators must read the relevant instructions carefully and familiarize themselves before use.
(1) Deflate the cuff before insertion (if the laryngeal mask airway iscuffed).
(2) Keep the neonate in the sniffing position.
(3) Place the index finger on the mask aperture and hold the laryngeal
mask airway with two fingers.
(4) Open the neonate’s mouth using the other hand, and, using theindex finger, insert the laryngeal mask airway along the hard palate
until it meets resistance. Insertion should never be forceful.
(5) Remove the index finger while supporting the tube with one hand.
(6) Inflate the cuff with the designated amount of air (if the laryngeal mask airway is cuffed).

Fig. 9 Laryngeal mask (LMA) insertion128

Advanced Neonatal Resuscitation(7) Similar to the process for inserting an endotracheal tube, confirm
that the tip of the laryngeal mask airway is in the appropriate
position by auscultation and by observing chest movements uponpressurization. Additionally, and similar to the process used wheninserting an endotracheal tube, the detection of expired CO2 withan end-tidal CO2 monitor or a capnometer is the most reliable indicator of successful airway opening with the laryngeal mask airway.
(8) Secure the laryngeal mask airway with a piece of tape.

Chap.

(Hiroshi Mizumoto)3

Key points
1 If an experienced staff member is available, perform endotracheal

intubation without hesitation. If not, focus on providing effective
bag-mask ventilation.

2 Endotracheal intubation must be performed after sufficient bagmask ventilation has been performed with a pulse oximeter attachedto the neonate.

3 After intubation, it is important to confirm that the tube is inserted
appropriately.

4 When ventilation with a face mask is not effective in neonates bornat ≥34 weeks of gestation, laryngeal mask airway insertion can beconsidered instead of endotracheal intubation.

References
1）草川 功：呼吸管理の実際 ビデオ喉頭鏡. 周産期医学 2019;40: 427-9.
2）2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 13 : Neonatal Resuscitation Guidelines. Circulation. 2005; 112: 24 suppl IV-188-IV-195.
3）Syusuke Takeuchi, Junichi Arai, Motomichi Nagafuji, etal: Ideal endotracheal tube insertion depth in neonateswith a birthweight less than 750g. Pediatr Int 2020;
62（8）: 932-6.
4）Guidelines 2000 for Cardiopulmonary Resuscitationand Emergency Cardiovascular Care. Part 11: neonatal
resuscitation. The American Heart Association in collaboration with the International Liaison Committee
on Resuscitation. Circulation 2000; 102（8 Suppl）:
I343-57.

6）Kattwinkel J, Perlman JM, Aziz K, et al: Part 15 : neonatal resuscitation: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care. Circulation 2010; 122（18 Suppl 3）: S909-19.
7）小林信吾，桜井淑男，田村正徳：呼吸管理の実際 気管挿管. 周産期医学 2019; 49: 475-9.
8）西山美鈴（監修）：麻酔科レジデントマニュアル 第二版.
ライフリサーチプレス, 東京, 2000．
9）Wyckoff MH, Aziz K, Escobedo M, et al: Part 13: Neonatal Resuscitation: 2015 American Heart Association
Guidelines Update for Cardiopulmonary Resuscitationand Emergency Cardiovascular Care. Circulation 2015;
132（18 Suppl 2）: S543-60.
10）細野茂春（監修）：新生児蘇生法テキスト 改訂第3版. メ
ジカルビュー社, 東京, 2016.

5）Kattwinkel J, Perlman JM, Khalid Aziz K, et al: Part 15 :neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation andEmergency Cardiovascular Care. Circulation 2010; 122（18 Suppl 3）: S909-19.

129Chap.3

Resuscitation ofpreterm infants
I

Cord clamping and cord milking

In Consensus 2015, 1) delayed cord clamping for longer than 30 s issuggested for preterm infants not requiring immediate resuscitation.
However, delayed cord clamping is difficult to perform for preterm
infants born at 28 weeks of gestation or less who require resuscitation. Therefore, cord milking is determined to be a reasonable alternative that does not impede resuscitation in such neonates.
Given the level of health care in Japan, there is no evidence supporting the need for placental blood transfusion for all preterm neonates.
However, based on a multicenter study conducted in Japan 4), one-timeumbilical cord milking in which the umbilical cord is clamped and cut
30 cm from the neonate and the cord is milked once under a radiantwarmer is recommended for preterm neonates born at ≤24-28 weeks
of gestation 3). The neonate is transferred to the radiant warmer andthe umbilical cord must be held straight up so that the umbilical bloodflows down naturally: because the umbilical cord is usually twisted, it
is important to untwist it before milking 4).
On the other hand, umbilical cord milking is not recommended in the
AHA 2020 guidelines for neonatal resuscitation 5) because Katheria
et al. reported an increase in the frequency of intracranial hemorrhage with repeated milking before umbilical cord clamping 6), which is
a commonly practice worldwide. Thus, caution must be exercised when
performing umbilical cord milking. That study analyzed neonates bornat ≥23 weeks of gestation but did not compare the frequency of intracranial hemorrhage between umbilical cord milking and delayed
umbilical cord clamping by gestational age. However, an article published in Hot Topics in Neonatology ® in 2019 showed a significantly
higher frequency of intracranial hemorrhage in neonates born at 23
weeks of gestation, but not in those born at ≥24 weeks of gestation. Furthermore, there were no significant differences in the compos-

7)

ite outcome of death and severe intraventricular hemorrhage (Grade
III or IV) between the two groups.

130

Advanced Neonatal Resuscitation

II

Warming and maintaining temperature

The recommendations in CoSTR2020 2) have not changed because
the review was based on an Evidence Update(EvUp) rather than a Systematic Review(SysRev), and the recommendations in NCPR2010 and
NCPR2015 are also maintained in NCPR2020. Specifically, it is recommended that when treating preterm neonates born at ≥28 week and

Chap.

3

<32 weeks of gestation under a radiant warmer, the ambient temperature must be maintained at 23-25℃, and a combination of a warmed
blanket, plastic wrap, thermal mattress, and/or similar methods must
be used to avoid hypothermia (body temperature <36℃) upon NICU
admission. It is also recommended to avoid the risk of hyperthermia(body temperature >38℃).
For the resuscitation of a neonate born at <28 weeks of gestation,
it is recommended to keep the delivery room temperature at ≥26℃,
wrap the neonate’s whole body with plastic wrap, and treat the neonate under a radiant warmer.
The need to dry the skin before wrapping the neonate has not yet
been proven scientifically, and thus, this matter can be discussed
within individual institutions.

positive airway pressure (CPAP)
III Continuous
for neonates with labored breathing
In CoSTR2020, CPAP and sustained lung inflation were reviewed
based on an EvUp. As a result, CPAP, but not sustained lung inflation,is supported as it was in CoSTR2015; thus, there are no changes in
the recommendations. As in NCPR2015, the provision of CPAP at 5
cmH2O before endotracheal intubation and ventilation is recommended for preterm neonates with labored breathing in the delivery room.
However, for neonates who are not breathing spontaneously, there
is no need to routinely perform sustained lung inflation for ≥5 s to
inflate the lungs at birth.

131

IV Ventilation strategy
If ventilation is indicated for a preterm infant, start with an initialinspiratory pressure of 20 to 25 cmH2O and adjust the ventilationpressure in accordance with indicators such as chest movements.
PEEP use continues to be recommended in CoSTR2020 after the review based on an EvUp (NCPR recommends PEEP of 5 cmH2O). Based ona SysRev of the oxygen concentration at the initiation of ventilation,
it is recommended to use a low oxygen concentration (21-30%) when
initiating ventilation and to adjust the oxygen concentration using
the SpO2 value as an indicator. The ventilation rate must be 40-60
breaths/min. Excessive chest movements should be avoided when performing ventilation, but if the heart rate and/or chest movements do
not improve promptly, the pressure needs to be increased.
(Shigeharu Hosono)

Key points
1 When preterm neonates born at ≤28 weeks of gestation require resuscitation, umbilical cord
milking is recommended instead of delayed clamping. One-time umbilical cord milking is the recommended method.

2 For neonates born at <28 weeks of gestation, it is recommended to keep the delivery room tem-

perature at ≥26℃, wrap their whole body with plastic wrap, and treat them under a radiant warmer.

3 For preterm neonates with labored breathing immediately after birth, it is recommended to provide CPAP at 5 cmH2O before ventilation.

4 For preterm neonates who require ventilation during resuscitation in the delivery room, it is rec-ommended to use an initial inspiratory pressure of 20-25 cmH2O, PEEP, and a low initial oxygen
concentration (21-30%). The ventilation pressure should be adjusted by observing chest movements, and the oxygen concentration should be adjusted by using the SpO2 value as an indicator.

References
1）Perlman JM, Wyllie J, Kattwinkel J, et al: Part7 : Neonatal Resuscitation: 2015 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2015; 132（16 Suppl 1）: S204-41.

4）Hosono S, Mugishima H, Takahashi S, et al: One-timeumbilical cord milking after cord cutting has same effectiveness as multiple-time umbilical cord milking ininfants born at ＜ 29 weeks of gestation: a retrospective study. J Perinatol 2015; 35（8）: 590-4.

2）Wyckoff MH, Wyllie J, Aziz K, et al. Neonatal Life Support collaborators: Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation 2020; 142:
S185-221.

5）新生児臨床研究ネットワーク：超早産児の赤血球輸 血回避に対する臍帯のミルキングの多施設ランダム 化比較試験.
http://nrn.shiga-med.ac.jp/milking/（2021年2月1日アクセス）3）細野茂春：Consensus2015 に基づく日本版新生児蘇生法
ガイドライン2015の主な改正点．細野茂春（監修）．新生児蘇生法テキスト．（第3版）．p26-33，メジカル
ビュー社，東京，2016．

1326）Katheria A, Reister F, Essers J, et al: Associationof Umbilical Cord Milking vs Delayed Umbilical Cord
Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. JAMA 2019; 322（19）: 1877-86.
7）Katheria A: The PREMOD2 Trial: Is This the End of Umbilical Cord Milking in Newborns? Hot Topics in Neonatology 2019.

Chap.3

Other recommendations regarding
neonatal resuscitation
I

Chap.

Maternal hyperthermia
and hypothermia

3

Maternal hyperthermia may increase the needs for neonatal resuscitation.
Neonates born to febrile mothers are reported to exhibit a higher rate of respiratory disturbances and seizures during the neonatal
period, cerebral palsy and have a higher mortality rate. There is no
scientific evidence to indicate whether fever itself or other issues
increase the risk to the neonate.
There is insufficient scientific evidence to support or refute
whether the routine reduction of maternal body temperature is effective in lowering mortality. Nevertheless, maternal hyperthermia
may increase the needs for neonatal. Moreover, although there is no

Key point

evidence that maternal hypothermia poses a significant risk to theMaternal hyperthermia
increases the risk thatneonates will require
resuscitation.

neonate, normal body temperature should be maintained to avoid iatrogenic hyperthermia or hypothermia.

II

Considering terminationof resuscitation

Specific criteria for withholding resuscitation were listed in
CoSTR2005, such as gestational age <23 weeks, bodyweight <400 g,
trisomy 13, and trisomy 18. However, based on the notion that treatment for neonates at the limit of viability vary substantially by region and according to health care resources, CoSTR2010 provided
only a general statement that it is ethical to withhold resuscitation
when early death or unacceptable burden are expected based on thegestational age, body weight at birth, and congenital anomalies. This
expression more closely reflects the actual practice in Japan. If return of spontaneous circulation is not achieved after resuscitationis performed appropriately for ≥10 min, death or severe neurologicalsequelae are likely; thus, in CoSTR2015, it is considered appropriate to decide whether resuscitation efforts should be continued insuch cases after taking the following factors into account on an individual basis: specific conditions before delivery (determination of133

the timing of injury); the cause of cardiac arrest; gestational age;
the appropriateness of the resuscitation performed; the availability of intensive care measures, such as therapeutic hypothermia; thereversibility of the condition; and the parents’ thoughts about the
anticipated outcomes.
In CoSTR 2020, the following recommendation was proposed, andthe time frame for deciding whether to terminate resuscitation efforts was extended from 10 min to 20 min on the premise that all
recommended resuscitation procedures were performed beforehand:“Failure to achieve return of spontaneous circulation in newborn infants despite 10 to 20 minutes of intensive resuscitation is associated with a high risk of mortality and a high risk of moderate-to-severe
neurodevelopmental impairment among survivors. However, there isno evidence that any specific duration of resuscitation consistently
predicts mortality or moderate-to-severe neurodevelopmental impairment. If, despite provision of all the recommended steps of resuscitation and excluding reversible causes, a newborn infant requires
ongoing cardiopulmonary resuscitation (CPR) after birth, we suggest
discussion of discontinuing resuscitative efforts with the clinicalteam and family. A reasonable time frame to consider this change ingoals of care is around 20 minutes after birth. (Weak recommendaTable. 1 Modified flow diagram of number of studies and infants
included for each specified outcome for infants experiencing
resuscitation that exceeded 10 minutes.
Systematic Review
15 studies included
470 infants
Survival to Discharge
13 studies included, 432 infants
176/432 (41%)
Survival to Last Follow-Up
15 studies included*, 470 infants
187/470 (40%)*2 studies reported survival to hospital discharge,
13 studies reported survival to post-discharge follow-up

Neurodevelopmental Outcome Among Survivors
13 studies included, 277 infants
86 infants survived
80 infants assessed for neurodevelopment (6 lost to follow-up)
50/80 (62.5%): Moderate or severe neuroimpairment
30/80 (37.5%): No moderate or severe neuroimpairment
Composite: Survival Without Neurodevelopmental Impairment (NDI)
13 studies included, 277 infants
191/277 (69%): Died by last follow-up
50/277 (18%): Survived with moderate or severe NDI
30/277 (11%): Survived without moderate or severe NDI
6/277 (2%): Lost to follow-up(ILCOR CoSTR2020)134

Advanced Neonatal Resuscitation

tion, very low-certainty evidence).”. This recommendation is based ona study that examined the developmental outcome in 277 neonates
who were cardiac arrest or bradycardia (<60 bpm) for at least 10 min
after birth and found an absence of moderate to severe neurodevelopmental disorders in 11% of patients (30) , although death occurredin 69% (191), and moderate to severe neurodevelopmental disorders
occurred in 18% (50) (Table. 1) 1). It is most important to complete
all steps of resuscitation (last step: intravenous administration of

Chap.

3

adrenalin). The rationale for the 20-min time frame is that studies
suggest that the time taken to accomplish steps of a resuscitation up
to the point of administration of 1 or more doses of epinephrine varies widely across studies but may take as long as 20 min 2-5). However,a Japanese study of neonates whose heart beats were not detected
10 min after birth 6) showed a longer time frame for adrenalin administration than in other countries; the timing of adrenaline administration varied greatly (5-85 min, median of 15 min), and adrenalin was
administered >20 min after birth in 9 out of 28 neonates and >30 min
after birth.
This finding suggests that the resuscitation environment and standardization of resuscitation procedures in Japan need to be improved.
Results were also reported for 39 patients whose heart beats weredetected for the first time 20 min after birth or whose heart rates
exceeded 100 bpm: 38% (15/39) survived until the final follow-up,
and 40% of these patients (6/15) did not have moderate to severe
neurological disorders 1): however, 7 out of 9 surviving neonates withpoor developmental prognosis were from Japan, suggesting that thedevelopmental outcome is worse in Japan compared to those in othercountries.
According to the “Justification and Evidence-to-Decision Framework Highlights” in CoSTR2020, the following factors must be considered for individual cases when deciding to terminate resuscitation
efforts:・specific conditions before delivery (the timing of perinatal insult),
the cause of cardiac arrest, gestational age, and the perceived adequacy of resuscitative interventions,・post-resuscitative resources, such as neonatal intensive care, andneuroprotective strategies, such as therapeutic hypothermia.
・reversibility of the condition,・the family’s stated preferences and values
Thus, discontinuing resuscitative efforts should be determined according to each clinical conditions.

135

III Education
Since CoSTR2015, it has been proposed that students and professionals who have completed a resuscitation course should undergo retraining at least once a year because repeated training according toindividual needs may develop certain behaviors and skills. Specifically,in addition to daily clinical practice, repeated and continuous learning
using e-learning materials and the skill training course can contributeto the maintenance and improvement of skills and knowledge for neonatal resuscitation. It is also proposed that neonatal resuscitation
instructors should provide objective, structured and timely feedback
verbally or in writing. This feedback approach is not specific to these
instructors but is common to education and training in general, and it
should be integrated into all NCPR courses.
(Takahiro Sugiura)

Key points
1 When return of spontaneous circulation cannot be achieved, even after adrenaline has been admin-

istered and the preceding procedures have been attempted, discuss the possibility of terminationof resuscitation with the neonate’s family. The time frame for this process is approximately 20
min.

2 This 20-min time frame is based on the fact that, although the time required to complete intravenous adrenaline administration and the preceding procedures varies, it takes at most 20 min.

3 The most important point when considering the termination of resuscitation is to ensure thateach recommended resuscitation step is performed properly and to determine whether to continue resuscitation efforts based on various factors specific to the individual case.

References
1）International Liaison Committee on Resuscitation
Neonatal Life Support Task Force, et al: Duration of
Resuscitation at Birth, Mortality, and Neurodevelopment: A Systematic Review. Pediatrics 2020; 146（3）:e20201449.
2）Halling C, Sparks JE, Christie L, et al: Efficacy of Intravenous and Endotracheal Epinephrine during Neonatal
Cardiopulmonary Resuscitation in the Delivery Room. J
Pediatr 2017; 185: 232-6.
3）Barber CA, Wyckoff MH: Use and efficacy of endotracheal versus intravenous epinephrine during neonatal
cardiopulmonary resuscitation in the delivery room.
Pediatrics 2006; 118（3）: 1028-34.

1364）Sproat T, Hearn R, Harigopal S: Outcome of babies withno detectable heart rate before 10 minutes of age, andthe effect of gestation. Arch Dis Child Fetal Neonatal
Ed 2017; 102（3）: F262-5.
5）McKinsey S, Perlman JM: Resuscitative interventions
during simulated asystole deviate from the recommended timeline. Arch Dis Child Fetal Neonatal Ed
2016; 101（3）: F244-7.
6）Baby Cooling Registry of Japan Collaboration Team, etal: Outcomes related to 10-min Apgar scores of zeroin Japan. Arch Dis Child Fetal Neonatal Ed 2019; 105（1）: 64–8.

Chapter

4

Better utilization of teamworkin neonatal resuscitation

Chap.4

Teamwork in neonatal resuscitation

I

Importance of teamwork

Simulation studies have shown that resuscitation requires rapid decision making and the rapid implementation of procedures under psychological pressure, and such complex tasks lead to errors that resultin an unfavorable prognosis in neonates 1-9).
For providing high-quality resuscitation, teamwork is an importantelement that has attracted attention in recent years. It is incontrovertible that all members involved in neonatal resuscitation must haveaccurate knowledge and solid resuscitation skills, but simply gathering team members will not result in good resuscitation, even if eachparticipating member is highly competent. Cooperation among teammembers—teamwork—is essential to ensure that the team functions
well. This section presents the knowledge related to teamwork.

II

Information sharing

In NCPR2020, a section was added on the provision of briefings toshare information before delivery. Sharing information about mothers
and infants in advance enables the prediction of risks and effective
discussions about whether neonatal resuscitation is required, and if
so, who will take on which responsibilities, whether adequate staff
are allocated, and whether supplies are sufficient. Thorough predelivery preparation for neonatal resuscitation is extremely importantfor high-quality resuscitation. If more advanced resuscitation is required, sharing information about how to request help and the available human resources will be important.

138

Better utilization of teamwork in neonatal resuscitation

III Anticipating critical events
When resuscitation is likely to be required after delivery, it is extremely important to anticipate possible critical events. Preparing
for anticipated events, such as situations requiring ventilation, endotracheal intubation, chest compressions, and medication administration, is crucial for avoiding confusion after resuscitation procedures
are initiated. Good team discussions about anticipated events arealso useful for smooth resuscitation.

Chap.

4

IV Allocation of roles
Allocation of roles within the team facilitates smooth resuscitation.
It is recommended to decide who is the leader, who will implement theprocedures, who will provide support, and similar matters. The tasks
involved in resuscitation are diverse and include respiratory management, heart rate assessment, time management, chest compressions,and the preparation of instruments. Thus, predetermined roles maychange depending on the situation. If predetermined roles need to bechanged, the leader must give instructions, or a member must propose the change to the whole team and obtain team agreement.

V

Situational awarenessThe condition of neonates after birth is extremely unstable, andthey require close observation. The same is true for neonates whoare being resuscitated, and it is essential to respond promptly andappropriately to observed changes.
Situational awareness is a state in which each member perceives theever-changing condition and environment of the patient. A pulse oximeter, an ECG monitor, and similar means that objectively display theneonate’s condition play a substantial role in situational awareness.
Assessing the maneuvers and decisions made by other team members,
making proposals for improvement, and sharing information within
the team will greatly facilitate situational awareness.
The maneuvers used in neonatal resuscitation are delicate and complex and require a great deal of concentration. Therefore, the person
who performs these maneuvers may not be able to perceive otherelements of the neonate’s condition and the overall resuscitation situation. Thus, in some cases, verbal communication may be necessary
to share the ongoing situation within the team.
139

VI Communication
While performing neonatal resuscitation, the whole resuscitationteam must be kept informed of what is happening within the team,what each team member is doing, and whether the resuscitation techniques are being performed correctly by team members. It is desirable
for the resuscitation team members to feel free to communicate witheach other without hesitation. Team members should ensure that themessages that they send are received and understood by the receivers (closed-loop communication) 10). It is essential that team membersfunction in an environment where they can exchange honest opinions
without concerns about authority and seniority and that team members have communication skills.

VII Leadership
Anyone who has completed neonatal resuscitation training and has
full understanding of the NCPR flow can participate in the neonatal resuscitation team as a leader. The leader does not have to be older thanothers and does not have to be in a senior position. What is required isthe leadership to make decisions about resuscitation strategies quickly
and appropriately and to give clear instructions to the team. If, by any
chance, the leader cannot assess the situation or cannot decide on a
strategy, he or she should hand over the leadership without hesitation.
It is common for leadership to be handed over to a more experienced ormore appropriate person in difficult resuscitation cases.

factors and
VIII Psychologicalsupportive behaviors
Being in a situation in which one’s own skills can affect the life of aneonate causes a great deal of psychological stress for the person performing resuscitation. Managing this stress is another important issue
to address. In fact, many errors are caused by psychological stress inactual settings of neonatal resuscitation, for example, being unable tointroduce ventilation properly despite doing it successfully during practice, being unable to count the heart rate properly during auscultation,and being unable to intubate the trachea properly due to nervousness.
To address these errors caused by psychological factors, it is necessary
for team members to help and talk to each other. If the procedure does
not go well, the leader may decide to change role assignments.
140

IX Debriefing
It is extremely important for team members to have a debriefing
after neonatal resuscitation. It is highly useful to review and discuss
the resuscitation sequences taken, the points that were performed
well, and the points that need improvement. In addition to the points
that need improvement, the points that were performed well must be
reviewed to understand why they were performed well. This step isnecessary to validate whether the adequate treatment provided was
the result of correct decisions or was coincidental.
(Hagane Shimaoka)

Key points
1 Good teamwork is essential for high-quality neonatal resuscitation.
2 Information sharing, anticipation of critical events, and preparation for resuscitation are crucial
for performing neonatal resuscitation smoothly.

3 Each team member must be aware of the ever-changing situation.
4 It is necessary to be conscious of leadership responsibilities and of the need for mutual help andcommunication among team members.

5 Team members must communicate actively, help each other with stress management, and compensate for errors due to psychological factors.

6 Having a debriefing after neonatal resuscitation to allow discussion among team members is extremely useful.

References
1）細野茂春（監修）．病院前新生児蘇生法テキスト．p1146，メディカ出版，大阪，2020．
2）McCarthy LK, Morley CJ, Davis PG, et al: Timing ofinterventions in the delivery room: does reality compare with neonatal resuscitation guidelines? J Pediatr
2013; 163（6）: 1553-7. e1.
3）Schilleman K, Witlox RS, van Vonderen JJ, et al: Auditing documentation on delivery room management using
video and physiological recordings. Arch Dis Child Fetal
Neonatal Ed 2014; 99（6）: F485-90.
4）Yamada NK, Yaeger KA, Halamek JP: Analysis and classification of errors made by teams during neonatal
resuscitation. Resuscitation 2015; 96: 109-13.
5）Thomas EJ, Sexton JB, Lasky RE, et al: Teamwork andquality during neonatal care in the delivery room. J
Perinatol 2006; 26（3）: 163-9.
6）Thomas EJ, Williams AL, Reichman EF, et al: Team training in the neonatal resuscitation program for interns:
teamwork and quality of resuscitations. Pediatrics

2010; 125（3）: 539-46.
7）Schilleman K, Siew ML, Lopriore E, et al: Auditing resuscitation of preterm infants at birth by recording
video and physiological parameters. Resuscitation
2012; 83（9）; 1135-9.
8）Carbine DN, Finer NN, Knodel E, et al: Video recording
as a means of evaluating neonatal resuscitation performance. Pediatrics 2000; 106（4）; 654-8.
9）Cutumisu M, Brown MRG, Fray C, et al: Growth Mindset
Moderates the Effect of the Neonatal Resuscitation
Program on Performance in a Computer-Based Game
Training Simulation. Front Pediatr 2018; 6: 195.
10）大阪大学医学部附属病院中央クオリティマネジメント
部：医療チームの安全を支えるノンテクニカルスキル～
スピークアップとリーダーシップ～．http://www.hosp.
med.osaka-u.ac.jp/home/hp-cqm/ingai/instructionalprojects/teamperformance/pdf/2013seminarbook.pdf（2020年12月12日アクセス）141

Chap.4

Need for continuous learning andon-the-job training (OJT) in NCPR
I

Need for continuous learning

1 Why is continuous learning necessary?
To prepare for unexpected encounters with neonatal asphyxia, allstaff involved in neonatal resuscitation must always maintain necessary skills. Taking a 1- to 2-day resuscitation course every few years
to renew qualifications is an effective means of reviewing techniquesand maintaining them for the short term, but that alone is not sufficient for maintaining resuscitation skills over the long term 1-2).
Additionally, the acquisition of a qualification after completing acourse does not necessarily mean that qualified individuals can perform neonatal resuscitation perfectly. They must have the philosophy(attitude), knowledge, and techniques that enable resuscitation to be
performed promptly and appropriately when they encounter a case ofneonatal asphyxia. Continuous learning is necessary to perform neonatal resuscitation confidently after completing a course.

2 Methods for continuous learning
Training for continuous learning does not have to be as lengthy asaccreditation courses. Discussions of questions that come up during
routine clinical practice are also a form of continuous learning (informal learning). Combined low-dose, high-frequency training, in which
brief trainings on techniques are repeated many times with shortsimulations of points for improvement, allow training to be provided
effectively according to the environment and working situations ofindividual facilities, Various learning methods are available, such aslearning resuscitation techniques that take into account the actual
situation and background of the resuscitation site at the learner’s
own institution (i.e., contextual learning), learning to ensure masteryof NCPR (i.e., mastery learning), and intensive practice to achievewell-considered results (i.e., deliberate practice). 1-2)

142

Better utilization of teamwork in neonatal resuscitation

3 Debriefing and repeated simulation
Debriefings should be held after actual neonatal resuscitation in theclinical settings. The use of simulations to review feedback from realclinical experiences is effective for improving the quality of neonatal
resuscitation. Consider taking time for debriefing after a neonatal
resuscitation to foster a workplace culture that facilitates the continuous and autonomous learning of neonatal resuscitation methods.

II

Need for on-the-job training (OJT)

Chap.

4

With the introduction of sophisticated simulators and technologies, simulation-based training is now able to largely reproduce thereal-life resuscitation environment at a realistic level. Nonetheless,simulation is not a universal tool for learning all aspects of neonatal
resuscitation. On-the-job training (OJT) in the actual clinical setting
is an important training element for health care professionals who
hold lives in their hands, and their learning of NCPR comes to fruition when they encounter and successfully resuscitate real patients.
There are many things that can be learned by practicing in the actual clinical setting, such as how to perform accurate and high-quality
resuscitation under the psychological stress of knowing that one’s
technique will affect the outcome of the neonate; how to respondto unexpected situations; and how to be considerate of the family.
In OJT, the safety of the neonates should be the top priority, but interms of the learning environment, it is also important to ensure thepsychological safety of the staff participating in OJT. Resuscitation
instructors need to be aware of the gap between simulation and practice and consider the safety of both the neonate and the learner.
(Hagane Shimaoka)

Key points
1 Continuous learning is necessary for maintaining neonatal resuscitation techniques.
2 Effective training can be provided according to the environment and situation of individual facilities.
3 Learning neonatal resuscitation through OJT is extremely valuable.
References
1）Cheng A, Nadkarni VM, Mancini MB, et al: Resuscitation
Education Science: Educational Strategies to Improve
Outcomes From Cardiac Arrest: A Scientific Statement
From the American Heart Association. Circulation
2018; 138（6）: e82-122.
2）American Heart Association, American Stroke Associ-ation: Highlights From the Resuscitation Education
Scientific Statement. 2018.
https://cpr.heart.org/-/media/cpr-files/resus-science/e d-statement/e ducation-statement- highlights/2018-education-statement-highlights-english-ucm-501720.pdf?la=en (2020年12月20日アクセス)

143

The Textbook of Neonatal Cardiopulmonary Resuscitation

Based on the 2020 Guidelines of theJapan Resuscitation Council
Fourth Edition