"Approximately 10% of newborns require some assistance to begin breathing at birth; ~1% require extensive resuscitative measures." ^[1]

The earlier CPR starts, the better the outcome and the shorter the time to revival. The transition from intrauterine to extrauterine life requires the lungs to take over gas exchange within seconds. If this fails → progressive asphyxia → organ damage → death.

When a fetus/neonate becomes hypoxic:

Why this matters for exams: You cannot distinguish primary from secondary apnoea clinically at the bedside. Therefore, if a baby is apnoeic and does not respond to brief tactile stimulation, you must assume secondary apnoea and begin PPV immediately. ^[1]

"Gasping respiration is ineffective and should be considered the same as apnoea." ^[1]

How to read the physiology graph on slides 4–5

The graph is a time sequence, not two unrelated types of apnoea:

1. With continuing asphyxia, rapid breathing stops: primary apnoea begins. Heart rate falls, but blood pressure is initially maintained.
2. Irregular gasps briefly appear. Heart rate may transiently recover, while peripheral vasoconstriction helps preserve blood pressure.
3. Gasping then stops: secondary apnoea. Heart rate and blood pressure now fall progressively.
4. Stimulation may reverse primary apnoea, but a baby presenting apnoeic at birth may already be in secondary apnoea; do not wait to distinguish the two. Ventilate.

Every birth should be attended by at least 1 qualified individual who can initiate resuscitation and whose only responsibility is the management of the newly born baby. ^[1]

4 Pre-birth questions: ^[1]

1. Expected gestational age?
2. Amniotic fluid clear?
3. Additional risk factors?
4. Umbilical cord management plan?

Why certain risk factors matter:

• Opioids within 4 hrs → cross placenta, depress neonatal respiratory drive
• Maternal magnesium → neonatal neuromuscular depression
• Meconium-stained fluid → risk of meconium aspiration syndrome
• Chorioamnionitis → neonatal sepsis risk
• Preterm → immature lungs, surfactant deficiency, fragile germinal matrix vessels

Before birth: provide antenatal counselling when indicated, brief the team, check equipment, identify a team leader, allocate workload, communicate clearly, and call for additional help when needed. After resuscitation, debrief the team as part of post-resuscitation care. ^[1]

The branch for a newborn who is not apnoeic/gasping and has HR ≥100 bpm should also assess for laboured breathing or persistent cyanosis. If present, position the airway and suction if needed, apply a pulse oximeter, give oxygen if needed, and consider CPAP before proceeding to post-resuscitation care and team debriefing. ^[1]

Provide warmth aiming baby's temp 36.5–37.5°C → Dry → Stimulate → Position head/neck in neutral or "sniffing" position → If needed, clear secretions (mouth before nose). ^[1]

Tactile stimulation: ^[1]

• Two methods: (1) Gently rub back/trunk/extremities, (2) Slap/flick sole
• Do not perform one after the other — try one, and if no response after several seconds, move to PPV
• Vigorous/deep suctioning is harmful → tissue injury + vagal bradycardia

Umbilical cord clamping:

The two key vital signs in neonatal resuscitation are: (1) Respiration and (2) Heart rate. ^[1]

• Auscultate over the precordium when a rapid manual estimate is needed.
• ECG gives a faster and more accurate continuous heart-rate assessment than pulse oximetry during active resuscitation; it does not replace pulse oximetry for oxygen titration. ^[2]
• Place the pulse-oximeter sensor on the right hand or wrist, the reliably preductal site reflecting blood reaching the brain and coronary circulation before ductal mixing.

Targeted Preductal SpO₂ After Birth: ^[1]

The slide warning to avoid saturation above 95% applies to oxygen titration during the early transition/resuscitation period: do not chase 100%. Once compressions stop, reduce oxygen to the age-appropriate target rather than leaving the infant on 100% oxygen. ^[1][2]

Indications for PPV: ^[1]

1. Apnoea / gasping
2. HR < 100 bpm

A spontaneously breathing infant with laboured breathing or persistent cyanosis follows the other algorithm branch: position the airway, suction only if obstructed, monitor preductal SpO₂, titrate oxygen, and consider CPAP. Low saturation alone is not an automatic indication for PPV if ventilation is otherwise adequate. ^[1][2]

PPV Parameters: ^[1]

2025 update: start at 21% for infants ≥35 weeks, 21–30% at 32–34+6 weeks, and 30–100% below 32 weeks, then titrate against preductal saturation. Current ventilation guidance is 30–60 inflations/min with an initial peak pressure of 20–30 cmH₂O; chest movement and especially a rising HR determine whether pressure is adequate. ^[2]

If CPAP or mask PPV continues for more than several minutes, insert an orogastric tube. ^[1]

Most important indicator of successful PPV: Rising heart rate ^[1]

Deck checkpoint after the first 15 seconds of PPV: check whether HR is rising and the chest is moving. ^[1]

If HR is not increasing and there is no chest movement, perform MR SOPA in sequence. The slide table makes the staging important: do M + R, give 5 breaths and assess; if ineffective, do S + O, give 5 breaths and assess; then increase P in 5–10 cmH₂O increments and reassess before moving to A. The deck's ceilings of 40 cmH₂O for term and 30 cmH₂O for preterm infants are teaching limits, not pressures to reach routinely; current guidance stresses titration to effective but non-excessive ventilation. ^[1][2]

• HR rising + chest movement → continue
• HR not rising, no chest movement → MR SOPA corrective steps ^[1]

"MR. SOPA!!" ^[1] — This mnemonic is for when PPV is not working (no chest rise, HR not improving):

Indications: ^[1]

1. HR < 100 bpm and not increasing after PPV with face mask or LMA
2. Before starting chest compressions (if intubation unsuccessful and weight > 2 kg → LMA)
3. Special circumstances:
   • Direct tracheal suction for thick secretions/airway obstruction
   • Surfactant administration
   • Suspected diaphragmatic hernia
4. Prolonged PPV — ETT improves efficacy

What the airway diagrams show

• Position: align the oral–pharyngeal–laryngeal view with the head neutral or slightly extended. Excessive flexion or extension lets the tongue or laryngeal structures obstruct the line of sight.
• Landmarks: lift the tongue and epiglottis to identify the glottic opening between the vocal cords; the oesophagus lies posteriorly.
• Depth: pass the tube through the cords only until the vocal-cord guide is at cord level. A tube advanced too far can enter a main bronchus; one too shallow can dislodge.
• Time: the deck's clock image reinforces keeping an intubation attempt brief (about 30 seconds) before returning to effective ventilation.

Confirming correct ETT position: ^[1]

• Rapidly rising HR
• Exhaled CO₂ detected by CO₂ detector (colorimetric: purple → yellow = CO₂ present)
• Equal breath sounds in both axillae
• Symmetrical chest movement
• Little/no air leak from mouth during PPV
• Decreased/absent air entry over stomach

DOPE Mnemonic — if baby deteriorates after intubation: ^[1]

• D = Displacement (of ETT)
• O = Obstruction (of ETT)
• P = Pneumothorax
• E = Equipment failure

"A misplaced tube is worse than having no tube at all!!!" ^[1]

The slide's auscultation diagram marks both high lateral chest walls/axillae and the epigastrium: hear equal breath sounds in both axillae and little or no air entry over the stomach. Exhaled CO₂ is the main objective confirmation, but very low pulmonary blood flow can reduce detected CO₂; always interpret it with HR response, chest movement, and examination. ^[1][2]

Indications in the deck: ^[1]

• PPV with face mask ineffective AND intubation not possible AND baby weight > 2 kg
• Congenital anomalies involving mouth/lip/tongue/palate/neck making mask seal difficult
• Very small mandible or relatively large tongue (e.g., Pierre Robin syndrome, trisomy 21)

Current framing: a laryngeal mask is a reasonable alternative when face-mask ventilation fails in infants ≥34 weeks; it may also be used as the primary ventilation interface in that group. Many device labels still use a 2-kg lower limit, but smaller devices now exist and evidence below 34 weeks or 2 kg remains limited. During compressions, an ETT is preferred; at ≥34 weeks an LMA may be used if intubation is impossible or unsuccessful. ^[2]

Indications: ^[1]

"HR < 60 bpm despite at least 30 seconds of PPV that inflates the lungs."

Technique — Thumb Technique (preferred): ^[1]

• Thumbs on the lower third of the sternum, above the xiphoid (the slide locates this just below the imaginary nipple line)
• Encircle torso with both hands, support back with fingers
• Thumbs flexed at first joint
• Depress sternum approximately 1/3 of AP diameter of chest
• Pressure vertical, maintained on sternum

Coordination with ventilation: ^[1]

• 3 compressions : 1 breath = 4 events in 2 seconds
• ~120 events/min (90 compressions + 30 breaths)
• When compressions begin → ventilate with 100% O₂ until HR ≥ 60 and pulse oximeter reliable

After 60 seconds of compressions + PPV: ^[1]

• HR ≥ 60 bpm → discontinue compressions and continue PPV if required (deck: 40–60/min; current guideline: 30–60/min)
• A cardiac monitor is the preferred method for assessing HR during compressions (pulse ox unreliable with poor perfusion)

Before or alongside epinephrine and emergency vascular access, reassess: Chest movement with each breath; Airway secured with an ETT or LMA; Rate of 3 compressions to 1 ventilation every 2 seconds; Depth of compressions at one-third of the chest AP diameter; and Inspired oxygen at 100%. ^[1]

When: HR < 60 bpm despite 30s effective PPV + 60s coordinated compressions with 100% O₂ ^[1]

Route: Prepare umbilical vein catheter (UVC) or intraosseous (IO) access ^[1]

Epinephrine dosing: the slide highlights a usual IV/IO dose of 0.02 mg/kg, but the recommended range is 0.01–0.03 mg/kg (0.1–0.3 mL/kg of 0.1 mg/mL solution), followed by a 3-mL normal-saline flush. While vascular access is being established, endotracheal epinephrine may be given at the larger dose 0.05–0.1 mg/kg (0.5–1 mL/kg). Give intravascular epinephrine as soon as access is obtained if the ET dose has not worked, and consider further doses every 3–5 minutes if HR remains < 60/min. ^[1][2]

If volume expansion is indicated, give normal saline 10 mL/kg IV/IO over 5–10 minutes; type O Rh-negative packed red blood cells may be used when severe anaemia is suspected. Use caution with volume expansion in preterm newborns < 32 weeks. ^[1]

When to stop: ^[1]

"If confirmed no HR after all appropriate steps, cessation of resuscitation should be discussed with the team and family. A reasonable timeframe is around 20 minutes after birth." Decision should be individualized.

Why preterms are at higher risk: ^[1]

• Rapid heat loss (high surface area:volume ratio, thin skin, less subcutaneous fat)
• Immature organ systems (lungs: surfactant deficiency; brain: germinal matrix fragility)
• Small blood volume (total ~80 mL/kg)
• Vulnerability to hypoglycaemia (limited glycogen stores)

Additional resources needed: ^[1]

• Polyethylene plastic wrap/bag (< 32 weeks), hat, thermal mattress
• Preterm-sized mask, size-0 laryngoscope blade, ETT 2.5 & 3.0 mm
• Device providing PEEP and CPAP
• Surfactant
• Pre-warmed transport incubator

The image-heavy slides show the practical bundle: the very-preterm infant is placed undried inside a polyethylene wrap/bag under a radiant warmer, with the face left accessible for ventilation; a temperature probe permits servo control. The nasal-CPAP image shows a soft interface that maintains end-expiratory lung volume in a spontaneously breathing preterm infant—CPAP is support for breathing, not a substitute for PPV in apnoea. ^[1][2]

To decrease risk of neurologic injury (esp. IVH): ^[1]

• Handle baby gently
• Avoid positioning legs higher than head (avoids rapid changes in cerebral blood flow)
• Avoid high PPV or CPAP (barotrauma, pneumothorax)
• Use pulse oximeter and blood gases to adjust ventilation/O₂
• Avoid rapid IV fluid infusions (rapid volume shifts → IVH)

• Routine care: vigorous term babies with no risk factors
• Post-resuscitation care for babies with depressed breathing/activity or requiring supplemental O₂:
  • Close monitoring: respiratory effort, oxygenation, BP, blood glucose, electrolytes, urine output, neurologic status, temperature
  • Avoid overheating during or after resuscitation
  • If indicated, therapeutic hypothermia must be initiated promptly (for selected infants with neonatal encephalopathy: current target 33.5–34.5°C, started within 6 hours and continued for 72 hours under protocol) ^[2]

Documentation: ^[1]

"Thorough documentation is essential for good clinical care, communication and medicolegal concern." Must include narrative description of interventions, their timing, and personnel responsible.

Multidisciplinary team: ^[1]

"Obstetrician, Midwife and Paediatrician should work as close partnership for better mother and infant care."

The deck's room-temperature threshold is ≥24°C. Current resuscitation guidance uses an ambient temperature > 23°C as one component of a warming bundle and makes the infant's measured temperature the endpoint: maintain 36.5–37.5°C, avoiding both hypothermia and hyperthermia. Healthy infants benefit from monitored skin-to-skin care; preterm or resuscitated infants may need a radiant warmer, wrap/bag, hat, warmed humidified gas, or thermal mattress in combination. ^[1][2]

The slide teaching point is: "Postnatal weight loss of up to 7% of birth weight due to fluid loss; start gaining weight from day 5–7."

This reflects normal contraction of extracellular fluid volume, but it is not a permission to ignore feeding. Interpret the trajectory with gestation, delivery fluids, milk transfer, urine/stool output, jaundice and hydration. Loss approaching or exceeding 10%, continued loss, or failure to regain should prompt a feeding and clinical assessment rather than a rigid wait-until-day-7 rule.

Problematic fluid management: ^[1]

• Keep the stump clean, exposed and dry. Fold the nappy below it.
• If soiled, clean with water and dry with a clean cloth; do not routinely apply alcohol, powder, herbs, dressings or other substances.
• Separation often occurs within the first 1–2 weeks, but timing varies.

Abnormal conditions: ^[1]

• Omphalitis — periumbilical erythema, purulent discharge; may need systemic antibiotics (risk of portal vein septicemia)
• Granuloma — pink/red tissue at stump base after cord separates; treat with silver nitrate application
• Malformation — persistent urachal cyst (bladder connection), vitelline duct (bowel connection)

The expanded IEM/SCID/SMA sample is normally collected by heel prick at 24–72 hours after birth with parental written consent; one specimen is used for all three programmes. Prematurity < 34 weeks, birth weight < 2 kg, or NICU admission can require additional specimens. A screen-positive result requires confirmatory testing—it is not itself a diagnosis. ^[4][5]

Why G6PD screening matters in HK: G6PD deficiency is common locally. Affected neonates are at risk of haemolysis, severe jaundice and kernicterus after oxidant exposure (e.g., naphthalene, fava beans and certain medicines), so caregivers need trigger-avoidance advice.

Why congenital hypothyroidism screening matters: early disease may be clinically silent. Prompt confirmatory testing and levothyroxine can prevent major, irreversible neurodevelopmental harm.

Continue routine immunisation at MCHC / private sector. Hong Kong's current programme lists BCG and the first hepatitis-B vaccine dose for newborns; subsequent HBV doses are at 1 and 6 months. Infants born to mothers with HBV infection should later undergo post-vaccination serology under the local programme. ^[7]

"Breast milk is the best. Nutritionally adequate for the first 6 months for term infants."

• Consider supplement — vitamin D (breast milk is relatively low in vitamin D; 400 IU/day recommended)
• Promotion of breastfeeding: starts from antenatal preparation → early maternal contact after birth → room-in → feeding on demand

"Supine preferable; prone position associated with a higher chance of sudden infant death; lateral position also slightly higher risk."

• No pillow required
• Tight bed sheet and no loose blanket

Translate the slide into a complete safe-sleep environment: back for every sleep; firm, flat, non-inclined surface; infant's own cot/bassinet in the parents' room; no pillows, bumpers, toys or loose bedding; no bed-sharing; avoid smoke exposure and overheating. If an infant is brought into the adult bed for feeding or comfort, return them to their own sleep surface before the caregiver sleeps. ^[8]

Why supine: Prone sleeping is the single most modifiable risk factor for SIDS. Prone → impaired arousal, CO₂ rebreathing, overheating. The "Back to Sleep" campaign dramatically reduced SIDS incidence worldwide.

• Establish good rapport with parents
• Open, sensitive and informative communication
• Advise on infant care: cleaning of umbilical cord, newborn sleeping pattern/position, sneezing and hiccup (physiological — reassurance), bathing, diaper care
• Reassurance and positive reinforcement