Neonatal resuscitation at birth — structured SAQ (15 marks)

(a) Immediate assessment and first actions — first 60 seconds (4 marks)

One mark per point, maximum four. ^[1]

• Call for help and start the clock — summon the neonatal team, assign a scribe and named roles; this is a baby who will need more than support of transition.^[1][2]
• Assess tone, breathing and heart rate — the limp, apnoeic baby with a heart rate under 60 bpm is in arrest, not just slow to transition.^[1]
• Warm, dry briskly, remove the wet towel, position the head neutral with a shoulder roll — a moulded occiput flexes the airway; a towel roll is airway management.^[1][3]
• Begin positive pressure ventilation in air immediately, attaching the oximeter to the right hand, aiming for effective ventilation by one minute of age. Reassess every 30 seconds.^[1][2]

Reasoning marks are awarded for stating the principle: an unaerated lung defeats everything downstream, so ventilation is the resuscitation. ^[1]

(b) Heart rate 48 bpm despite 90 seconds of effective ventilation (4 marks)

The threshold for compressions is a heart rate under 60 bpm despite 30 seconds of effective ventilation that visibly moves the chest. ^[1][5]

• Start chest compressions with the two-thumb technique on the lower third of the sternum, compressing one third of the anteroposterior diameter, at a 3:1 ratio (90 compressions and 30 inflations per minute).^[1][5]
• Increase inspired oxygen to 100% once compressions begin, then wean as the heart rate recovers.^[1]
• Simultaneously prepare umbilical venous access and adrenaline — adrenaline 10 to 30 microgram/kg intravenously (0.1 to 0.3 mL/kg of 1:10,000), repeated every 3 to 5 minutes.^[1][6]
• Reassess the heart rate every 30 seconds; if it is not rising, reconfirm ventilation efficacy and access before the next adrenaline dose.^[1]

(c) Ventilation settings and saturation target for a term baby (4 marks)

One mark per element. ^[1][3]

• Gas: start in room air at term, titrating oxygen only to the saturation target.^[1]
• Pressure: initial peak inflation pressure 30 cm H2O (20 to 25 cm H2O preterm), with PEEP starting at 5 cm H2O.^[1][3]
• Rate and inspiratory time: 40 to 60 inflations per minute, inspiratory time 0.3 to 0.5 seconds, using the least pressure that moves the chest.^[1]
• Preductal (right hand) saturation target at 5 minutes is 80 to 90% — and a baby at 65% at two minutes is transitioning normally.^[1][4]

(d) Subsequent care and documentation (3 marks)

• Admit to the neonatal unit — any baby who needed compressions or adrenaline goes to the unit for observation; the well baby with brief mask ventilation may stay with mother under observation.^[1][2]
• Take paired cord gases and a blood glucose within the first hour; assess for therapeutic hypothermia if the baby is encephalopathic, keeping them normothermic rather than actively warmed.^[2]
• Document a contemporaneous timeline with times, drug doses and routes, and the reassessment intervals; debrief the team and speak with the parents in plain language the same day.^[1][2]