Open Access Research Article

Lalana Newborn Resuscitation

Grace Lalana Christopher1*
1
Consultant Paediatrician, Grace Specialist Clinic #6, 1st Floor, Maruthi Complex, Ramamurthynagar Main
Road, Bangalore 560016, India
*
Corresponding Author: Grace Lalana Christopher, MBBS, DCH (CMC and H, Vellore, S. India) (DNB Ped),
Consultant Paediatrician, Grace Specialist Clinic #6, 1st Floor, Maruthi Complex, Ramamurthynagar Main
Road, Bangalore 560016, India; Email: drlalana@gmail.com

Received Date: 14-10-2021, Accepted Date: 10-11-2021, Published Date: 17-11-2021

Copyright© 2021 by Christopher GL. All rights reserved under CC BY-NC-ND. This is an open access article
distributed under the terms of the Creative Commons Attribution License, which provides freedom to read, share,
copy and redistribution of material in any of the medium, provided with the original author and source are credited.

Abstract
Background: Birth asphyxia is a leading cause of perinatal and neonatal morbidity and
mortality predominantly in Asian countries. Effective resuscitation of newborns takes on
priority in saving lives. Newly born resuscitation is unique in that displacement of fetal fluid
filled lung requires continuous positive pressure ventilation by sustained nasal oxygen inflation
as opposed to intermittent positive pressure ventilation to initiate breathing facilitating vital
cardio-vascular changes from fetal to adult life.

Aim: Quick and safe resuscitation of hypoxic/asphyxiated newborns transiting from fetal fluid
filled lungs to well aerated neonatal lungs with onset of rhythmic respiration triggering large
reduction in Pulmonary Vascular Resistance (PVR), facilitating a series of cardiovascular
changes essential for survival after birth.

Method: The study comprised of 1,383 consecutive singleton live births during 14-month
period from 1st April 2016 to 31st May 2017, wherein 60% (n=830/1383) deliveries were
attended, exclusion criteria 12 twin pregnancies and 10 stillbirths. Resuscitation of
hypoxic/asphyxiated newborns involves three simple steps; STEP 1: Assessment of score zero
to +5 by pulse oximetry based on peripheral oxygen saturation, STEP 2: Classification as
“Normal” and hypoxic/asphyxiated newborns Graded I-V based SpO2, pattern of breathing
and heart rate. STEP 3: Lalana Newborn Resuscitation (LNR) Protocol I and II by sustained
nasal oxygen inflation, proven both scientifically and physiologically to initiate rhythmic
respiration.
Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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Results: Incidence of birth asphyxia was 21.4%, all 178 hypoxic/asphyxiated newly borns
Graded I-V within 20-60 seconds of birth, were successfully resuscitated by sustained nasal
inflatory, oxygen flow at rate of 4-15 Litres/minute directed to baby’s nostrils through a wide
bore tube for up to 1 to 3 minutes, initiating rhythmic breathing, respiratory rate 30-60/min,
heart rate 120-160 beats per minute (bpm) and, SpO2 >96% monitored continuously by Pulse
Oximeter.

Conclusion: ‘Lalana Newborn Resuscitation’ (LNR) proved effective in all 178 asphyxiated
newborns, Grade I-V by continuous positive pressure ventilation with sustained nasal oxygen
inflation at flow rates of 4-15 L/min, commenced rhythmic breathing within 1-3 minutes of
birth, respiratory rate 30-60/min, heart rate 120-160 bpm and Zero pulse oximetry score, SpO2
>96%.

Keywords
Lalana Newborn Resuscitation (LNR); Continuous Positive Pressure Ventilation (CPPV);
Sustained Nasal Oxygen Inflation; Pulse Oximetry Score; SPO2; Grade I to V

Aims for Effective Resuscitation of Hypoxic/Asphyxiated

Newborns
 Effective resuscitation of asphyxiated newborns takes on priority in newborns in saving
lives as well as without any residual neurological and other sequelae so children should be
normal
 Unique newly born resuscitation is in transition of fetal fluid filled lungs to well aerated
neonatal lungs by safe and quick resuscitation by sustained inflatory nasal oxygen flow
proven both scientifically and physiologically to generate hydrostatic pressure gradient
between airways and lung tissue to overcome the high resistance of moving fetal lung liquid
through the airways and across the alveolar wall into the interstitial tissue to the lymphatic
and thence to circulation
 Effective resuscitation with continuous distending pressure results in uniform recruitment
of alveoli with functional residual capacity, preventing alveolar collapse, atelectasis and
V/Q mismatch, to achieve optimal gas exchange
 Prevention of hypoxemia and hypercapnia that result in rise of arterial carbon dioxide
causing reduced blood flow to the brain with ischemia resulting in altered mental status and
ill effects
 Also stabilizing newborns at birth with low fraction of inspired oxygen (FiO2) is difficult,
as hypoxia is a potent inhibitor of spontaneous respiration, thus higher FiO2 mitigates

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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hypoxia-induced inhibition of breathing, stimulating the central respiratory center in

initiating rhythmic respiration.
 Oxygenation mitigates hypoxia-induced inhibition of breathing and stimulates the central
respiratory center to initiate rhythmic respiration, reducing Pulmonary Vascular Resistance
(PVR) causing reflex physiological mechanism promoting vital cardio-vascular changes
adapting to extra-uterine life
 The primary measure of adequate initial ventilation is the prompt improvement in heart rate
is a primary measure of adequate initial ventilation, based on the concept that a low heart
rate indicates vagal-induced bradycardia in response to perinatal asphyxia. Pulse oximetry
plethysmograph pulsatile waveform indicates cardiac function and pumping of oxygenated
blood throughout the body
 Monitoring of peripheral tissue oxygenation (SpO2) with Pulse oximeter allows for real
time assessment of newborns with classification within 20-60 seconds ‘Normal’ or
hypoxic/ asphyxia newborns Graded I-V that determines oxygen flow rates, as well as
discontinuation at 96%
 Prevention of lung injury by avoiding potentially harmful Intermittent Positive Pressure
Ventilation (IPPV) considered both physiologically and scientifically weak in transition of
fetal fluid filled lungs to well aerated neonatal lungs, as entire tidal volume will only enter
previously aerated regions due to much lower airway resistance causing overexpansion
with intermittent collapse, surrounding atelectasis and V/Q mismatch with right to left
shunting, perpetuating hypoxia and Persistent Pulmonary Hypertension (PPH) with poor
outcome in neonates

Introduction
Birth asphyxia accounts for 29% neonatal deaths, ranging from 20-40% with 2.76 million
annual neonatal deaths with 97.8% or 2.02 million deaths occurring in the first week of life, of
which 70% or 1 million deaths occurred within the first three days of life, 56.8% within the
first day of life [1-3]. Globally of 2.5 million children who die in the first month of life, about
one-third dies within 24 hours with similar intrapartum 1.2 million stillbirths, occurring
predominantly in Asian countries, it is estimated that 4 to 9 million babies per year experience
birth asphyxia with only 1 to 2 million successfully resuscitated [1,4]. Incidence varies from
2 to 28 per 1000 live births with three-fold higher risk of asphyxiated infants dying in the
neonatal period compared to non-asphyxiated infants; however the major impact is on larger
and more mature babies, who otherwise have a good chance of survival [5-10]. During 2020,
36.3% of 7,000 neonatal deaths took place within the first 24 hours comprising 47% of all child
deaths under five years, up from 40% in 1990.

A slower decline in neonatal mortality is reported from 5 million in 1990 to 2.4 million in 2019,
compared to under-five mortality rate, children facing the greatest risk of death in their first 28
Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 4

days [12-15]. Misclassification of live born, apneic, cyanotic neonate with pulse who die due
to non or inadequate resuscitation labelled as stillbirth are actually viable newborns as unskilled
birth attendants are unable to distinguish between the two, have significant implications on
national health policies and global strategies for reducing perinatal mortality, as even 1 in 100
stillbirths if effectively resuscitated will result in more than 30,000 lives that could potentially
be saved each year. Worse still for every newborn baby that dies mainly by birth asphyxia at
least another twenty newborn suffer birth injuries etc [16, 17].

Thus birth asphyxia constitutes one of the leading causes of preventable perinatal and neonatal
morbidity and mortality predominantly in Low and Middle Income Asian countries. India
reported high neonatal mortality rate (NMR) 22/1000 live births compared to about 1% in
developed countries with vast technological advances in antenatal and neonatal critical care
report low Perinatal Mortality Rate (PMR) of 6.1/1,000 births with 10-15% reduction in
neonatal mortality rate and low incidence of birth asphyxia below 0.1% over the past decades,
however stillbirth rates have remained unchanged, constituting 70% of perinatal deaths with
30% early neonatal deaths, corrected PMR 4.1/1,000 births excluding congenital anomalies, an
unavoidable proportion of perinatal mortality, which constituted a leading cause in 34%
[12,15,18,19]. In a study from Vellore, South India lethal congenital malformations was the
third cause18.2% of early neonatal deaths following birth asphyxia 24.1% and respiratory
distress syndrome 20%, followed by early onset neonatal sepsis 15%, intracranial
haemorrhages 9.2% and extreme immaturity 4.3% ranked as sixth and seventh cause of early
neonatal deaths [1,2,20,21]. In U.K. intrauterine growth retardation is the single largest
contributor to perinatal mortality in non-anomalous fetuses. Pregnancies with IUGR have an
eight-fold increased risk of stillbirth 19.8 versus 2.4/1,000 births in UK with over 50% of
deaths being SGA having birth weight below 10th customized centile of whom only 30% were
suspected antenatal [18].

Unique resuscitation in the newly borns is transition from fetal lungs containing about 30 ml/kg
body weight of fluid, low protein content of 25mg/dl, that differs from both ultra-filtrate of
plasma and amniotic fluid, requires that newborns make high forceful inspiratory efforts up to
60 cm H2O at birth usually with the first cry, overcomes the resistance of inspiration of air into
the liquid filled lungs, stretching the alveolar epithelial pore radius of 0.5mm impermeable to
solute to 3.5 mm in radius that allows flow of fetal alveolar liquid down a protein osmotic
pressure gradient into the interstitial tissue and thence absorbed via lymphatic’s into the
circulation [22-25]. Subsequently the pores in the alveolar epithelium contract back towards
their fetal size [26]. In fact meconium staining of amniotic fluid often results from normal labor
contractions with hypoxia or even infection, inhibits fetal lung fluid reabsorption at birth,
disturbing the ability of the lungs in vital transition to extra-uterine life and others on guidelines
of basic newborn resuscitation with world-wide decline in neonatal asphyxiated deaths
[4,5,11,27-31].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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Neonatal Resuscitation Program (NRP) introduced in 1988, by American Academy of

Paediatrics and American Heart Association and World Health Organization lacks scientific
clarity and is considered physiologically weak regarding transition of fetal fluid filled lungs to
well aerated neonatal lungs by inflating lungs through the application of Intermittent Positive
Pressure Respiration (IPPR) by short bursts of air/oxygen with bag and mask or endotracheal
intubation, is potentially harmful as entire tidal volume will only enter previously aerated
regions due to the much lower airway resistance predisposing to lung injury and un-even
alveolar ventilation that does not generate adequate intra-pulmonary pressure to remove fetal
lung fluid, while also permitting lung fluid to re-enter the airways causing rising Alveolar-
arterial (A-a) gradient and ventilation perfusion (V/Q) mismatch with right to left cardiac shunt
through foramen ovale and ductus arteriousus, perpetuating hypoxia and persistent pulmonary
hypertension with bradycardia resulting in delayed onset of breathing [23,32-37].

Intrapartum events cause deficient oxygenation defined as respiratory failure or oxygen

insufficiency that requires resuscitative intervention to establish rhythmic respiration defined
as birth asphyxia, since pulmonary arterioles remain constricted in the fetal circulation with
with the right to left shunting through foramen ovale and ductus arteriosus with only about
10% of cardiac output perfusing the lungs [35,37]. Sustained inflation with oxygen at 5 cm
H2O pressure or oxygen flow at 8 litres/min, up to maximum 20 cm H2O pressure or oxygen
flow up to 25 litres/min that extends over 1 to 3 minutes is proven both scientifically and
physiologically achieves better post manoeuvre lung mechanics to effectively resuscitate
asphyxiated newborns, allow for uniform alveolar recruitment and the increased FiO2 results
in exponential increase of the alveolar surface area measured As Functional Residual Capacity
(FRC) with alveolar pressure above atmospheric pressure, that enables the generation of
intrinsic hydrostatic pressure gradient between airways and lung tissue to overcome the high
resistance of moving liquid through the airways and across the alveolar wall that helps keep
the air sacs to stay open, achieving optimal gas exchange, improving ventilation, thereby
triggering large reduction in Pulmonary Vascular Resistance (PVR), with vasodilation of
pulmonary arteriole causing a reflex physiological mechanism that converts fetal circulation to
adult type [23,24,34,38-40].

Oxygen therapy is the only specific treatment to prevent or mitigate the effects of hypoxia with
rapid reduction for the need of high FiO2, thus continuous monitoring by Pulse Oximeter not
only gives accurate insights to peripheral oxygenation (SpO2) but also heart rate within matter
of seconds empowering one to respond quickly and confidently to abnormal SpO2 reading to
determine supplemental oxygen which is discontinued with zero score SpO2>96%, indicate
successful resuscitation [38-43]. Delay in resuscitation by NRP can result in devastating
consequences of the baby being deprived of oxygen causing damage to heart and brain and
other organs sometimes even death [34,35,44]. Thus more severe the fetal asphyxia, the longer
it will take before the infant starts to breathe spontaneously, in fact 20% to 40% of survivors
suffer from considerable impairments depending on extent of asphyxial insult such as

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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blindness, deafness, autism, seizures and cognitive impairments with inability to develop fine
motor skills, memory and mood disturbances etc to permanent neurological deficits with
sequelae depending on extent of asphyxial insult, showing no decline in incidence of meconium
aspiration syndrome and seizures due to HIE with no overall decrease in neonatal mortality,
though asphyxial related deaths decreased significantly (p=<0.01) [11,44-49].

The trend in western developed countries indicates rate of asphyxia in 2/1000 births, resulting
in mortality rate of 10-15% in NICU with cerebral palsy rate of 10-15% among survivors and
eventually a rate of over 40% with considerable impairments such as blindness, deafness,
autism, seizures and cognitive impairments, inability to develop fine motor skills, memory and
mood disturbances. Thus the degree of morbidity remains high affecting quality of life in
survivors as the rate of Hypoxic Ischemic Encephalopathy (HIE) has remained the same over
previous decades [44-49].

Perinatal asphyxia mainly due to intrapartum events is estimated to be the fifth largest causes
of under-five child mortality after pneumonia, diarrhoea, neonatal infections and complications
of preterm births, is in reality much higher as non-breathing viable newborns, termed as
stillbirth are left without resuscitative efforts at birth, who are in fact actually early neonatal
deaths [14-17]. Many parts of low income Asian and African countries with limited resource,
still lack skilled birth attendants and well outfitted resuscitation teams and even essential
resuscitation equipment, such as bulb syringes, bag and mask devices etc. may be substandard
or unavailable and ethnic Asian babies deserve better [30]. Despite concerted global and
national efforts to improve child mortality, in the post neonatal phase with key child health
interventions such as oral rehydration therapy, care seeking for acute respiratory infections and
improved immunization rates has however resulted in neonatal mortality gradually increasing
as a percentage of total under-five child mortality with less attention being given to
determinants of perinatal and neonatal mortality despite new found focus on neonatal health
the annual rate of reduction in NMR and ENMR still lags behind IMR and U5MR, with slow
decline in perinatal mortality rates. Although problems in the perinatal and neonatal phases
have been reported in India, little progress has been made towards implementing large-scale
solutions to these problems and effective interventions to address risk factors such as essential
newborn care and their implementation still has not resulted in a rapid reduction in perinatal
and neonatal mortality rates [2,3,7,12].

Effective resuscitation is the need of the hour that is imperative in hypoxic/asphyxiated births
will prove to be the single most significant strategy in reducing both perinatal and neonatal
mortality and morbidity, so children should be normal, consequently reducing under-five years
child mortality rates [16-18]. Sustained oxygenation rather than IPPV is the basis of quick
reversal of hypoxic ill effects with early onset of rhythmic respiration, resulting in improved
neonatal outcome with reduction of adverse life-long ill sequelae, as throughout the world,
around 200 million children do not accomplished their age appropriate development, more
highly prevalent in Asian countries, further compounded by the negative impact of covid19
Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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pandemic with hundreds of thousands more fatalities expected due to lack of medical facilities
more so in developing Asian countries [45,50]. Thus neonatal period within the first 28 days
of life, is the most vulnerable period in the life of a child with the highest risk of mortality per
day than any other period during childhood, constituting 62% of under-five year child mortality
in Africa and South Asia compared to 54% in developed European and Northern American
countries in spite of low neonatal mortality in Sustainable Development Goal (SDG) regions,
thus neonatal health has taken on eminence in reducing under five child mortality rates [14,15].

Problem Definition
1. Resuscitation of hypoxic newborns requires quick intervention to initiate breathing best
adapted to transition from fetal fluid filled lungs to well aerated neonatal lungs, in reducing
hypoxic birth injury so children should be normal

2. Sustained pressure ventilation generates hydrostatic pressure gradient between airways and
lung tissue to overcome the high resistance of moving fetal lung liquid through the airways and
across the alveolar wall into the interstitial tissue is scientifically proven

3. Counteract hypoxia by oxygenation with flow rates 2-15 Liters/min, stimulates central
respiratory centre to initiate respiration and facilitate smooth physiological cardiovascular
transition from fetal to neonatal circulation
4. Continuous assessment of newborn status by Pulse oximeter SpO2 and heart rate monitoring

5. Harmful Intermittent Positive Pressure Ventilation (IPPV) predisposes to lung injury as short
intermittent inflation provides for inadequate ventilation in newly born in transition from fetal
fluid filled lungs to neonatal life considered as physiologically and scientifically weak, hence
best suited in cardiorespiratory arrest of infants, children and adults with previously aerated
lungs

Materials and Methods

The study comprised 1,383 consecutive singleton live births during 14-month period from 1st
April 2016 to 31st May 2017 at Shifa Hospital, a multispecialty centre in the metropolitan city
of Bangalore. I attended 830 (60%) deliveries including vaginal deliveries both vertex and
breech presentation, instrumental-vacuum and low/outlet forceps deliveries as well as surgical
Lower Segment Caesarean Sections (LSCS) both Elective and Emergency surgery. Sources of
data were Labor room records, neonatal charts and NICU register. Data was entered into EPI
data version 3.1 and then exported to SPSS Version 21 for analysis and statistical significance,
the threshold of significance was set at 0.05.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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A sample pilot study was carried out on 30 newborns with the new innovative resuscitation
technique using sustained nasal oxygen inflation at flow rates 2-15 Litres/minute (L/min)
proved eminently successful with uneventful observation in NICU, who were then shifted to
mother’s side for initiation of early breast feeding. A study was then undertaken on 830
newborns whose delivery I attended during the 14 month study period.

The status of all newborns are preferably assessed within 20-60 seconds after birth i.e.
following complete expulsion of newborn, with immediate clamping and cutting of umbilical
cord in hypoxic newborns or may be delayed 1-3 minutes in spontaneously breathing
newborns. The Pulse Oximeter is placed across the foot of newborn to monitor peripheral tissue
oxygen saturation (SpO2), heart rate, plethysmograph waveform noting adequate cardiac
output, the pattern of breathing observed or respiratory rate derived from Photoplethysmogram
(PPG).

Lalana Newborn Resuscitation (LNR) proves ideal and consists of three steps. Step 1 Pulse
oximetry score zero to +5 based on peripheral oxygen saturation (SpO2). Step 2 Classification
as “Normal”, healthy newborns with spontaneous onset of rhythmic respiration while hypoxic/
asphyxiated newborns Graded I-V based on SpO2, pattern of breathing and heart rate. Step 3
includes Protocols I and II, application of continuous positive pressure ventilation by sustained
nasal oxygen inflation at flow rates 2-15L/min determined by Pulse oximetry score, SpO2,
pattern of breathing and heart rate for upto 1-3 minutes or till onset of rhythmic respiration,
SpO2 >96% and heart rate >120 bpm.

Step-1
Newborn Pulse Oximetry Score
Pulse oximeter automatically provides an estimate of newborn health status within seconds.
Zero score Pulse Oximetry score SpO2 96%-100% indicates ‘Normal’ healthy newborns, +1
Pulse Oximetry score, SpO2 94%-95%, mild birth asphyxia, +2 Pulse Oximetry score, SpO2
92%-93%, moderate birth asphyxia, +3 Pulse Oximetry score, SpO2 90-91%, severe birth
asphyxia, +4 Pulse Oximetry score, SpO2 89%-50%,Secondary apnea with absent breathing
and + 5 Pulse Oximetry score Terminal apnea with absent breathing or ‘flat baby’. Zero to +5
Pulse Oximetry score based on SpO2, for all newborns is seen in Table 1.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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Score SpO2 Pulse Oximeter Reading Newborn Status

Zero 96%-100% Normal / Healthy
1 94%-95% Mild Asphyxia
2 92%-93% Moderate Asphyxia
3 90%-91% Severe Asphyxia
4 89%-50% Secondary Apnea
5 <50% Terminal Apnea
Table 1: Newborn pulse oximetry scoring for SpO2.

Step-2
Classification of Newborns as Normal, Healthy or Hypoxic/asphyxia Grade
1 to V
The status of all newborns assessed within 20-60 seconds of birth classified as Normal, healthy
newborns or hypoxic/asphyxiated newborns further graded into I-V based on Pulse Oximetry
Score, SpO2, breathing pattern and heart rate. Normal, healthy newborns, have Zero Pulse
oximetry Score SpO2 96%-100%, with spontaneous onset of rhythmic breathing, respiratory
rate 30-60/min and heart rate 120-160 bpm. Mild birth asphyxia, Grade I newborns +1 Pulse
oximetry Score, SpO2 94% -95%, with regular/irregular breathing pattern, respiratory rate ±20-
30/ min and heart rate 100 - 119 bpm, Moderate birth asphyxia, Grade II newborns +2 Pulse
oximetry Score, SpO2 92-93%, with irregular breathing, respiratory rate ±15-20/min and heart
rate 100 - 80 bpm,. Severe birth asphyxia, Grade III newborns +3 Pulse oximetry Score, SpO2
90-91%, irregular or gasping breathing, respiratory rate 10-15/min and heart rate 80-60 bpm.

Secondary apnea Grade IV newborns +4 Pulse oximetry Score, SpO2 89%-50%, absent
respiration and heart rate 60-35 bpm, while Terminal apnea Grade V newborns +5 Pulse
oximetry Score, SpO2 <50%, absent respiration and heart rate < 35 bpm is also referred to as
“flat baby”. However grading of hypoxic newborns into Grade I-V by criteria of +1 to +5 pulse
oximetry score, SpO2 <96%, respiratory rate <30/ min and heart rate <120 bpm, may vary as
real time assessment of newborn’s SpO2 is constantly changing due to continuous monitoring.
The classification of newborns at birth based on Pulse oximetry score, SpO2, respiratory rate
and heart rate is seen in Table 2.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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Normal Grade I Grade II Grade III Grade IV Grade V

Healthy Mild Moderate Severe Secondary Terminal
newborn Asphyxia Asphyxia Asphyxia Apnea Apnea
Zero Pulse +1 Pulse +2 Pulse +3 Pulse +4 Pulse +5 Pulse
oximetry oximetry oximetry oximetry oximetry oximetry
Score - SpO2 Score - SpO2 Score - SpO2 Score - SpO2 Score - SpO2 Score -
96%-100% 94% - 95%, 92-93%, 90-91%, 89%-50%, SpO2 <50%,
Spontaneous Regular/ Regular/ Irregular Absent Absent
onset irregular irregular /gasping respiration. respiration
respiration, Respiration, Respiration, respiration, Heart Rate ‘Flat baby’.
rate 30- rate 20- rate 15- rate 10-15/ 60-40 bpm Heart Rate
60/min, 30/min. 20/min. min. Heart <40 bpm
Normal Heart Heart Rate Heart Rate Rate 80-60
Rate 120-160 100 - 119 100 - 80 bpm.
bpm bpm. bpm.
Table 2: Classification of newborns within 20-60 seconds of birth.

Step-3
Effective aeration of the newly born’s lung is a function of applying an elevated pressure over
sustained periods of 1-3 minutes that results in significant improvement of lung mechanics in
efficiently overcoming the high resistance of moving liquid from lungs to interstitial with
uniform lung aeration and prompt increase in heart rate monitored continuously by pulse
oximetry with circulation of oxygenated blood throughout the body.

Newborns timed at birth at complete expulsion of fetus, the umbilical cord ligated and cut
immediately in hypoxic/asphyxiated newborns, which may be delayed upto 1-3 minutes in
“Normal” newborns with spontaneous onset of respiration. The pulse oximeter is placed on the
baby’s foot to monitor superficial oxygen saturation (SpO2), heart rate and the plethysmograph
tracing records how well heart is pumping oxygenated blood throughout the body indicated by
pulsatile changes. All newborns are classified as ‘Normal’ or hypoxic who are further Graded
I to V, based on pulse oximeter score +1 to +5 respectively, SpO2, pattern of respiration and
heart rate within 20-60 seconds of birth.

Majority are ‘Normal’ Healthy newborns, active, pink in color, moving all four limbs with
vigorous cry initiate spontaneous rhythmic respiration within 20-60 seconds of birth with Zero
Pulse oximetry Score, SpO2 >96% respiratory rate 30-60/min and heart rate of 120-160 bpm.
Routine newborn care based on regional NICU protocol, baby wiped dry under radiant warmer
to prevent hypothermia, nasal and oral suction maintaining asepsis, Vitamin K 0.5-1mg
intramuscularly, stomach wash if delivered by LSCS, baby wrapped in warm clothing and cap,

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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is transferred to mother’s side for early feeding, breast feeding instituted within an hour after
normal vaginal delivery or four hours after LSCS.

Lalana Newborn Resuscitation (LNR) for hypoxic newborns are further graded into Grade I -
V based on +1 to +5 Pulse oximetry score, peripheral oxygen saturation (SpO2) <95%, pattern
of breathing and heart rate. Mild birth asphyxia, Grade I newborns, +1 Pulse oximetry Score,
SpO2 94%-95%with regular/irregular respiratory rate ±20-30/ min and heart rate 100 - 119
bpm, require resuscitation by sustained nasal oxygen inflation at flow rate 2-4 L/min (FiO2
28% to 36%), upto 60 seconds till rhythmic pattern of respiration, oxygen is discontinued with
normal pulse oximeter reading SpO2 >96%. If however SpO2 decreases to <94% oxygen flow
rate is increased to 5-8 L/min or more (FiO2 up to 50%), for upto 1-3 minutes till Zero Pulse
oximetry Score, SpO2 >96%, and heart rate >120 bpm.

Moderate birth asphyxia, Grade II newborns have +2 Pulse oximetry Score, SpO2 92%-93%,
regular/ Irregular respiration, rate ±15-20/min and heart rate 100 - 80 bpm, resuscitated by
sustained nasal oxygen inflation at flow rate of 5-8 L/min, (FiO2 40% to 52%) for upto 60-90
seconds till onset of rhythmic respiration, oxygen is discontinued with normal pulse oximeter
reading SpO2 >96% % and heart rate >120 bpm.

Severe birth asphyxia, Grade III, +3 Pulse oximetry Score, SpO2 90%-91%, irregular/gasping
respiration, rate ±10-15/min and heart rate 80-60 bpm, resuscitation by sustained nasal oxygen
inflation at flow rate of 10-12 L/min, (FiO2 56% to 64%) applied for 90-120 seconds till onset
of rhythmic respiration, oxygen is then discontinued with normal pulse oximeter reading SpO2
>96 and heart rate >120 bpm.

Secondary apnea Grade IV, +4 Pulse oximetry Score, SpO2 89%-50%, absent respiration and
heart rate 60-40 bpm, ventilation by sustained nasal oxygen inflation at flow rate of 12-14
L/min, (FiO2 64% to 76%) up to 120-180 seconds till onset of rhythmic respiration, rate 30-
60/min and heart rate >120 bpm, oxygen is discontinued with normal pulse oximeter reading
SpO2 >96%. However if heart rate is <45 bpm, endotracheal intubation undertaken with
continuous distending pressure ventilation by sustained oxygen at flow rate of 15 L/min (FiO2
100%) for 120-240 seconds or more till onset of breathing and heart rate increases to > 100bpm
extubate and continue with nasal oxygen inflation flow rate of 10-12 L/min (FiO2 60-68%).
Grade IV newborns are usually subjected to severe perinatal asphyxia and are at greater risk of
intrauterine (stillbirth) or early neonatal death often delivered by judicious quick obstetric
intervention by emergency LSCS, may be effectively resuscitated by sustained nasal oxygen
with tactile stimuli, back rubs, nasal and oral suctioning till onset of rhythmic respiration.
Oxygen discontinued at Zero pulse oximetry score, rhythmic pattern of respiration, rate 30-
60/min SpO2 >96% and heart rate >120 bpm.

Terminal apnea, Grade V newborns +5 Pulse oximetry score, SpO2 <50%, with absent
respiration and heart rate <40 bpm ‘flat baby’ may respond to continuous distending pressure
ventilation by sustained nasal oxygen inflation up to 15 L/min (FiO2 64% to 76%) for 120-240
Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 12

seconds or more till onset of rhythmic respiration or if no recording on pulse oximeter of SpO2
or heart rate, immediately intubate with endotracheal tube and resuscitate by positive airway
distending pressure with oxygen flow at rate of 15 L/min upto 25 L/min (FiO2 100%), if no
breathing or heart beat within 60 seconds give cardiac compression about 120/min with
medication of epinephrine, volume expander 5% dextrose saline at 10 ml/kg and Carbicarb
2.5meq/kg, a mixture of Na2CO3/NaHCO3 which does not generate CO2 slow infusion over
one hour. If heart rate increases > 100 bpm with onset of breathing, shift to sustained nasal
oxygen inflation up to 12 L/min (FiO2 64%) for 60-120 seconds and oxygen discontinued with
rhythmic breathing, rate 30-60/min, normal SpO2 >96% and heart rate >120 bpm.

However Grade V newborns are at high risk of intrauterine death (fresh stillbirth) or if born
with signs of life who are often un-responsive to resuscitative intervention and dying shortly
after birth termed early neonatal deaths, are usually delivered by emergency LSCS, which
impacts the more mature, larger newborns with birthweight around 3500-4000 g, born 39
weeks or later, most of whom on survival may be associated with high incidence of HIE and
serious neurological sequelae with lifelong disability, cerebral palsy etc. Hence it is
recommend that resuscitative efforts may be aborted if neonate unresponsive after three to five
upto ten minutes of resuscitation with sustained nasal oxygen inflation at 15 L/min (FiO2 76%)
or through endotracheal tube, FiO2 (100%).

Preterm <32 weeks and <1250g with incidence of 1% among 830 deliveries attended. Among
total nine preterms, VLBW, five were 28-32 weeks gestation and four were 28 weeks gestation.
Three preterm weighed <1000g and remaining six between 1000-1250 g. Five delivered
normally and three by emergency LSCS and one preterm 32 weeks gestation, weighing 1180
g born by assisted breech delivery had placenta previa. Of the two deaths, one preterm 28 weeks
gestation weighing 740 g died on2nd post-natal day due to extreme immaturity and RDS.
Another preterm 28 weeks weighing 960 g had obstetric complications of MSAF and PROM
died on 3rd post-natal day of RDS and sepsis, the remaining seven preterm VLBWs survived.
However one preterm 28 weeks gestation and 1010g birthweight had polyhydraminos with
duodenal atresia was surgically corrected at a referral hospital.

LNR Protocol II for resuscitation of preterm newborns, gestational age <32 weeks and
birthweight <1250g by CPPV by sustained nasal oxygen inflation at flow rates of 2 L/min up
to 12 L/min (FiO2 28-60%), through wide bore oxygen tube or nasal prongs till heart rate
improves and regular respiration established following which bubble CPAP with blender and
FiO2<30% through nasal prongs started, to maintain oxygen saturation around 95%, if less
than 28 weeks gestation the SpO2 maintained between 88-95%, the preterm is then transferred
to NICU for observation and further management/treatment of complications if any. In preterm
with secondary or terminal apnea endotracheal intubation with sustained oxygen flow at rate
of 12 L/min (FiO2 100%) is administered for 2-3 minutes or more till breathing established and
heart rate >120 bpm, continued with CPAP (FiO2<30%) through nasal prongs and baby shifted
to NICU for observation and management/treatment of any complications.
Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 13

Delivery room use of sustained nasal oxygen inflation during resuscitation triggers
physiological transition of fetal fluid filled lungs to well ventilated neonatal lungs initiating
rhythmic breathing. In spontaneously breathing preterm <32 weeks and <1250 g birth weight,
Continuous Positive Airway Pressure (CPAP) with blender and FiO2 <30%,with oxygen
bubbling through 5 cm water in a bottle producing small airway pressure oscillations which on
reaching the newborn’s lung results in improved gas exchange and lung function. Preterm <32
weeks and VLBW <1250 g CPAP (FiO2<30%) maintain oxygen saturation around 95%,
preterm <28 weeks gestation the SpO2 maintained between 88-95%. Preterms are more prone
to birth asphyxia as opposed to term babies and extremely immature preterms are at greater
risk of cerebral palsy, delay in development, hearing and sight problems, hence it is recommend
that resuscitative efforts may be aborted in terminal apnea.

The present study all 178 hypoxic newborns Grade I-V were effectively resuscitated with onset
of rhythmic breathing by Lalana Newborn Resuscitation (LNR) outlined in Protocol I and II
resulted in the wellbeing of neonates with normal pulse rate, respiratory rate and oxygen
saturation during observation in NICU, blood glucose checked as well as blood gas study for
acid base balance with temperature control to prevent hypothermia and minimize oxygen
consumption and shifted to mother’s side for institution of early breast feeding if uneventful
stay NICU during observation for four hours.

Lalana Newborn Resuscitation (LNR) provides for quick and safe resuscitation by application
of continuous positive airway pressure by sustained nasal oxygen inflation monitored by Pulse
oximetry SpO2 in determining oxygen flow rates of 2 L/min up to 15 L/min (FiO2 28%-76%),
blown to the baby’s nostrils through wide bore oxygen tube for up to 60-180 seconds to initiate
rhythmic respiration, SpO2>96% and heart rate 120-160 bpm. Higher FiO2 stabilizes hypoxic
newborns at birth, reducing risk of hypoxia-induced inhibition of breathing and leading to a
more stable breathing pattern with better aeration of the lung and increased lung volume,
pulmonary compliance with Functional Residual Capacity (FRC), facilitating reflex
cardiovascular changes compatible with adult life. The primary measure of adequate initial
ventilation is the prompt improvement of heart rate and adequate cardiac output noted on
plethysmograph waveform with circulation of oxygenated blood throughout the body resulting
in aerobic cellular metabolism and removal of lactic acid, mitigating hypoxia positively
impacts postnatal adaptation of newborns with minimal ill effects thus decreasing the morbidity
and mortality associated with hypoxic ischemic tissue (brain, heart, gut and kidney) injury and
untoward long-term sequela.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 14

LNR METHODOLOGY
Protocol I
Lalana Newborn Resuscitation (LNR) Protocol I, provides quick and safe resuscitation by
sustained nasal oxygen inflation oxygen flow rates 2 L/min up to 15 L/min (FiO2 28% to 76%)
determined by Pulse oximetry score (L/min-Litres per minute, HR / beats per minute-Heart
Rate/bpm, ET- Endotracheal Tube) (Table 3).

Classification Protocol I
Zero Pulse oximetry Score - SpO2 96% - 100%, spontaneous onset of
rhythmic breathing, rate 30-60/min and HR±120-160 bpm. Routine newborn
‘Normal’ care maintaining asepsis and thermo-control.
Healthy Shift newborn to mother’s side and initiate early nutrition, by breast-feeding
within an hour in normal delivery and four hours after LSCS.
+1 Pulse oximetry Score - SpO2 >96%, regular/ irregular respiration, ± rate
20-30/min and HR ±100–119 bpm. Sustained nasal oxygen at flow rates 2-4
L/min (FiO2 28% to 36%), directed towards the nostrils through the wide
bore tube for up to 60 seconds. Newborn wiped dry under radiant warmer
with tactile stimuli, nasal and oral suction. Discontinue oxygen with Zero
Grade I Pulse oximetry Score SpO2> 96%, with rhythmic breathing pattern, rate 30-
Mild Asphyxia 60/min and HR 120-160 bpm.
Shift newborn to NICU for observation for 4 hours and then to mother’s side
and institute breast-feeding.
Grade II +2 Pulse oximetry Score - SpO2 92-93%, irregular/ respiration ± rate 15-
Moderate 20/min and HR ±100–80 bpm. Sustained nasal oxygen flow rate 5-8 L/min
Asphyxia (FiO2 40% to 52%), directed towards the nostrils through the wide bore tube
for up to 60-90 seconds. Neonate wiped dry under radiant warmer with
tactile stimuli, nasal and oral suction. Discontinue oxygen with Zero Pulse
oximetry Score SpO2> 96 with rhythmic breathing pattern, respiratory rate
30-60/min and HR >120 bpm.
Shift to NICU for observation for 24 hours or management and treatment of
complications if any.
+3 Pulse oximetry Score - SpO2 90-91%, gasping respiration, ± rate 10-
15/min and HR ± 80 - 60 bpm. Sustained nasal oxygen flow rate 8-12 L/min
(FiO2 52% to 64%) directed towards the nostrils through the wide bore tube
for up to 90-120 seconds or more. Neonate wiped dry under radiant warmer
Grade III with tactile stimuli, back rubs, nasal and oral suction. Discontinue oxygen
Severe

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 15

Asphyxia with Zero Pulse oximetry Score SpO2>96% with rhythmic breathing pattern,
respiratory rate 30-60/min and HR >120 bpm.
Shift newborn to NICU for observation, management and treatment of
complications if any.

+4 Pulse oximetry Score - SpO2 89%-50%, absent respiration and HR ±60-

40 bpm. Sustained nasal oxygen flow rate 12-15 L/min (FiO2 64% to 76%),
directed towards the nostrils through the wide bore tube for up to 120-180
seconds or more. Neonate wiped dry under radiant warmer with tactile
Grade IV Secondary stimuli, back rubs, nasal and oral suction. Discontinue oxygen with Zero
Apnea Pulse oximetry Score, SpO2>96%, with rhythmic breathing pattern,
respiratory rate 30-60/min and HR >120 bpm.
Shift newborn to NICU for observation, management and treatment of
complications if any.
+5 Pulse oximetry Score - SpO2 <50%, absent respiration and HR <40 bpm,
‘Flat baby’ or no recording on pulse oximeter of SpO2 and heart rate and
occasional heart beats on auscultation, immediately intubate with
endotracheal tube and ventilate with continuous distending airway pressure
by oxygen flow at rate of 15 L/min (FiO2 100%) for 120-240 seconds or
more, if no onset of breathing within 60 seconds start cardiac compression
around 120/min and medications of epinephrine or volume expanders, 5%
dextrose saline at 10 ml/kg also combats hypoglycemia and Carbicarb 2.5
meq/kg (a mixture of Na2CO3/NaHCO3) but without the generation of CO2
slow infusion over one hour to combat metabolic lactic acidosis secondary to
hypoxemia and cardio pulmonary disturbances or Sodium bicarbonate if
Grade V newborn is breathing diluted at 8 ml eq/kg. If onset of rhythmic respiration
Terminal and heart rate increases to > 100bpm, remove ET tube and continue with
Apnea sustained nasal oxygen inflation at flow rate 12-15 L/min ( FiO2 64% to
76%) directed towards the nostrils through the wide bore tube till onset of
rhythmic breathing under radiant warmer with tactile stimuli, back rubs,
nasal and oral suction. Discontinue oxygen with Zero Pulse oximetry Score,
SpO2>96%, rhythmic breathing pattern, respiratory rate 30-60/min and HR
>120 bpm.
Shift newborn to NICU for observation, management and treatments of any
complications. OR abort resuscitation after 5-10 minutes if unresponsive
either fresh stillbirth or early neonatal death.
Table 3: Classification of newborns within 20-60 seconds of birth.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 16

Protocol II
Protocol II-Lalana Newborn Resuscitation (LNR) of preterm newborns with gestational age
<32 weeks and birthweight <1250g followed by bubble CPAP with blender and FiO2<30%
through nasal prongs to maintain SpO2 around 95-96% (Table 4).

CLASSIFICATION PROTOCOL II

Zero Pulse oximetry Score - SpO2 > 96% with onset of with rhythmic
breathing pattern, respiratory rate 30-60/min, HR 120-160 bpm. Routine
newborn care given. Start Bubble CPAP at 5 cm H2O, FiO2<30% with
Normal Healthy
blender through nasal prongs or Oxygen Hood with oxygen flow rate to
Preterm maintain SpO2 at 88-95%.

Shift to NICU for observation, management and treatment of

complications if any.

+1 Pulse oximetry Score - SpO2 94% - 95%, regular /irregular breathing,

respiratory rate ± 20-30/min, HR ± 100-120 bpm. Sustained nasal
oxygen at flow rate at 2-4 L/min (FiO2 28% to 36%), directed towards
the nostrils through the wide bore tube for up to 60 seconds, gently wipe
dry with tactile stimuli, nasal and oral suction under radiant warmer till
Grade I Mild
SpO2 ~ 95%, with rhythmic breathing pattern, respiratory rate 30-
Asphyxia 60/min and Heart Rate 120-160 bpm. Start Bubble CPAP at 5 cm H2O,
FiO2<30% with blender through nasal prongs or Oxygen Hood with
oxygen flow rate to maintain SpO2 between 88-95%.

Shift to NICU for observation, management and treatment of

complications if any.

+2 Pulse oximetry Score - SpO2 92-93%, regular/ irregular breathing,

respiratory rate ± 15-20/min and HR ± 100 – 80 bpm, Sustained nasal
oxygen flow rate 4 -6 L/min (FiO2 36% to 44%), directed towards the
Grade II Moderate nostrils through the wide bore tube for up to 60-90 seconds, gently wipe
Asphyxia dry with tactile stimuli, nasal and oral suction under radiant warmer.
Discontinue oxygen flow when SpO2 ~ 95%, with rhythmic breathing
pattern, respiratory rate 30-60/min and Heart Rate >120 bpm. Start
Bubble CPAP at 5 cm H2O, FiO2<30% with blender through nasal
prongs or Oxygen Hood with oxygen flow rate to maintain SpO2
between 88-95%.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 17

Shift to NICU for observation, management and treatment of

complications if any.

+3 Pulse oximetry Score - SpO2 90-91%, irregular/gasping breathing,

respiratory rate ± 10-15/min and Heart Rate ± 80 - 60 bpm. Sustained
nasal oxygen flow rate 6 -8 L/min (FiO2 44% to 52%) directed towards
the nostrils through the wide bore tube for up to 90-120 seconds, gently
wipe dry with tactile stimuli, nasal and oral suction under radiant
warmer. Discontinue oxygen flow when SpO2 ~ 95%, with rhythmic
Grade III Severe breathing pattern, respiratory rate 30-60/min and Heart Rate >120 bpm.
Asphyxia Start Bubble CPAP at 5 cm H2O, FiO2<30% with blender through nasal
prongs or Oxygen Hood with oxygen flow rate to maintain SpO2
between 88-95%.

Shift to NICU for observation, management and treatment of

complications if any.

+4 Pulse oximetry Score - SpO2 89%-50%, absent respiration and HR

60-35 bpm. Sustained nasal oxygen flow rate of 8 - 10 L/min (FiO2 52%
to 60%), directed towards the nostrils through the wide bore tube for up
to 120-180 seconds or more, gently wipe dry with tactile stimuli, back
rub, nasal and oral suction under radiant warmer. Discontinue oxygen
Grade IV Secondary flow when Pulse oximetry SpO2 ~ 95%, with rhythmic breathing
pattern, respiratory rate 30-60/min and Heart Rate >120 bpm. Start
Apnea
Bubble CPAP at 5 cm H2O, FiO2<30% with blender through nasal
prongs or Oxygen Hood with oxygen flow rate to maintain SpO2
between 88-95%.

Shift to NICU for observation, management and treatment of

complications if any.

+5 Pulse oximetry Score - SpO2 <50%, absent respiration and HR <35

bpm ‘Flat baby’ or no reading on pulse oximeter of SpO2 and heart rate,
with occasional heart beats on auscultation, immediately intubate with
Grade V endotracheal tube and ventilate with continuous distending airway
pressure by oxygen flow at rate of 12-15 L/min (FiO2 100%) if no
Terminal breathing attempts by 60 seconds start cardiac compression around
Apnea 120/min and medications of epinephrine or volume expanders, 5%
dextrose saline at 10 ml/kg and start Carbicarb 2.5meq/kg, a mixture of
Na2CO3/NaHCO3 safer with no generation of CO2 slow infusion over
one hour that does not affect cerebral blood flow. If onset of rhythmic
respiration and heart rate increases to >100bpm, remove ET tube and

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 18

continue with sustained nasal oxygen inflation at flow rates of 4-6 L/min
(FiO2 36% -44%), directed towards the nostrils through the wide bore
with tactile stimuli, back rubs, nasal and oral gently wipe dry with tactile
stimuli, back rub, nasal and oral suction under radiant warmer.
Discontinue oxygen flow when SpO2 ~ 95%, rhythmic breathing
pattern, respiratory rate 30-60/min and HR>120 bpm. Start Bubble
CPAP at 5 cm H2O, FiO2<30% through nasal prongs or Oxygen Hood
with oxygen flow rate to maintain SpO2 between 88-95%.

Shift to NICU for observation and management / treatment of

complications.

However resuscitative efforts may be aborted after 5-10 minutes in the

event the preterm is unresponsive due high incidence of neurological,
deficits cerebral palsy etc. or other organ deficits and untoward ill life-
long sequelae.

Table 4: Classification of preterm <32 weeks and <1250g within 20-60 seconds of birth.

Results
The incidence of birth asphyxia was 21.4% among 1,383 consecutive singleton live births,
during 14-month period from 1st April 2016 to 31st May 2017, I attended 60% (n=830/1383)
deliveries, including vaginal deliveries both vertex and breech presentation, instrumental-
vacuum and low/outlet forceps deliveries and surgical lower segment caesarean sections
(LSCS) both emergency and elective. All newbons were assessed and classified within 20-60
seconds of birth as normal, healthy neonates or hypoxic/asphyxia Grade I-V who were all,
successfully resuscitated utilizing continuous positive pressure ventilation by sustained nasal
oxygen inflation at varying flow rates of 2-15 L/min for upto 1-3 minutes or more based on
pulse oximetry readings.
Among 830 deliveries attended, a majority 78.5% (n=652/830) were ‘Normal’, healthy
newborns with zero Pulse oximetry score, SpO2 96% -100%, heart rate 120-160 bpm with
spontaneous onset of rhythmic respiratory rate of 30-60/min. There was a high incidence 21.4%
(n=178/830) of birth asphyxia. The distribution of 830 deliveries attended revealed 78.5%
Normal, healthy newborns and 21.4% hypoxic/asphyxiated newborns Grade I to V is seen in
Table 5.

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Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 19

Distribution Live Deliveries Normal Birth asphyxia

Births attended Healthy Newborns Grade I to V
Number 1,383 830/1383 652/830 178/830
Percentage 100% 60.0% 78.5% 21.4%
Table 5: Distribution of live births.

Majority 78.5% (n=653/830) of births attended, were normal, healthy newborns who
established spontaneous rhythmic respiration at birth, while 15.1% (n=126/830) Grade I
suffered from mild asphyxia, and 3.7% (n=31/830) Grade II had moderate asphyxia, only 2.1%
(n=17/830) Grade III newborns had severe asphyxia while 0.4% (n=3/830) Grade IV had
secondary apnea. Just 0.1% (n=1/830) Grade V newborn had terminal apnea. Sex distribution
revealed five females to four males. The distribution of 830 births attended according to Grade
I-V is seen in Table 6.

Distribution Normal Grade I Grade 1II Grade III Grade IV Grade V Total
Healthy Mild Moderate Severe Secondary Termina Birth
Newborns Asphyxia Asphyxia Asphyxia Apnea l Apnea Asphyxia
Number 652/830 126/830 31/830 17/830 3/830 1/830 830

Percentage 78.5% 15.1% 3.7% 2.1% 0.4% 0.1% 100%

Table 6: Distribution among 830 deliveries attended as normal and grade I to V.

Distribution of 21.4% (n=178/830) hypoxic/asphyxiated newborns among births attended,

revealed a majority 70.8% (n=126/178) Grade I newborns had mild birth asphyxia, +1 Pulse
oximetry score, SpO2 94%-95%, while17% (n=31/178) Grade II newborns with moderate
asphyxia, +2 Pulse oximetry score, SpO2 92%-93% and only 9.5% (n=17/178) Grade III
newborns had severe asphyxia, +3 Pulse oximetry score, SpO2 90-91% while 1.7% (n=3/178)
Grade IV newborns suffered from secondary apnea, +4 Pulse oximetry score, SpO2 89%-50%,
with absent respiration and Heart Rate <50 bpm while 0.5% (n=1/178) with Grade V had
terminal apnea, +5 Pulse oximetry Score, SpO2 <50%, with absent respiration and Heart Rate
<30 bpm or ‘Flat baby’. Distribution of 178 newborns with birth hypoxia/asphyxia, Grade I to
V is seen in Table 7.

Grade I Grade 1I Grade 1II Grade IV Grade V Total

Distribution Mild Moderate Severe Secondary Terminal Birth
Asphyxia Asphyxia Asphyxia Apnea Apnea Asphyxia
Number 126 31 17 3 1 178
Percentage 70.8% 17.4% 9.5% 1.7% 0.5% 100%
Table 7: Distribution of newborns with birth asphyxia Grade I to V.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 20

In the present study all 178 hypoxic newborns Grade I-V were effectively resuscitated with
onset of rhythmic breathing, by Lalana Newborn Resuscitation (LNR) outlined in Protocol I
and Protocol II based on birthweight and gestation with wellbeing of the newborns during
observation in NICU for four hours to monitor pulse, respiratory rate and oxygen saturation on
pulse oximeter, temperature maintained to prevent hypothermia and minimize oxygen
consumption, blood glucose checked as well as blood gas study for acid base balance etc
newborn then shifted to mother’s side and breast feeding instituted with uneventful early
neonatal period.

Discussion
Lalana Newborn Resuscitation (LNR) with effective resuscitation proves ideal for hypoxic
newborns in improving neonatal health and reducing perinatal mortality and neonatal mortality
and morbidity rates. India with a population of over 1.3 billion has 124, 419, 96 thousand births
each year, approximately 10% of newborns require assistance to breathe with incidence of birth
asphyxia ranging from 2 to 28 per 1000 live births with 6.61 lakh newborn dying in the
neonatal period of whom 5.1 lakhs die within the first week of life with Early Neonatal
Mortality Rate (ENMR) 20 per 1000 live births and Neonatal Mortality Rate (NMR) 26 per
1000 live births is concerning, Nigeria ranked second with 270, 000 newborn deaths being
almost one half neonatal deaths reported in India, indicating that strategies aimed at reduction
of early neonatal deaths will substantially reduce under-five chid mortality rate, perinatal
mortality rate being a sensitive indicator for monitoring health care status (51, 52).

The incidence of Birth asphyxia was 21.4% with all 178 hypoxic/asphyxiated Grade I-V
newborns successfully resuscitated by Lalana Newborn Resuscitation (LNR), the most safe
resuscitative method that is proven both scientifically and physiologically that application of
continuous positive pressure ventilation by sustained nasal oxygen inflation because lungs are
filled so fluid, studies have shown that high pressure 25-30 cm H2O is needed for the first
inflation for about five seconds so whole lung becomes inflated and foetal lung fluid has been
displaced from the alveoli then lungs continued to be inflated at lower 10-15 cm H2O (38-40).
Thus oxygen at flow rates of 2-15 Litres/min (FiO2 21% to 76%), is key to effective
resuscitation in quick reversal of hypoxia with onset of rhythmic respiration with prompt
increase in heart rate as being a sign of adequate lung aeration based on the concept that a low
heart rate indicates vagal-induced bradycardia in response to perinatal asphyxia facilitates
smooth physiological cardiovascular changes transiting from fetal to neonatal life monitored
continuously by Pulse oximetry SpO2 achieve aim of effective resuscitation with reduction in
perinatal and neonatal mortality and morbidity in reducing adverse long-term hypoxic
neurodevelopmental ill sequelae, so children should be normal.

In contrast non-physiological resuscitation by NRP by bag and mask or invasive endotracheal

intubation with short intermittent inflation lacks scientific clarity regarding transition of fluid
filled fetal lungs to well aerated neonatal lungs, as short intermittent bursts of air/oxygen does

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 21

not generate adequate intrapulmonary pressure but also proves potentially harmful as entire
tidal volume will only enter previously aerated regions due to the much lower airway resistance
predisposes to lung injury with overexpansion and intermittent collapse of alveoli causing
ventilation perfusion (V/Q) mismatch, persistent pulmonary hypertension and bradycardia that
further perpetuates hypoxia with delay in onset of breathing [29,30,35,37]. Thus continuous
distending airway pressure by sustained oxygen inflation is the key to mitigating hypoxia-
induced inhibition of breathing [53,54].

LNR Includes 3 Steps:

Step1: Assessment of newborn by continuous Pulse oximetry monitoring that automatically
and within few seconds provides an estimate of newborn’s health status. The pulse oximeter is
clamped to baby’s foot within 20-60 seconds after birth timed at complete expulsion of fetus.
In hypoxic newborns with immediate clamping and cutting of umbilical cord, however
umbilical cord ligation may be delayed up to 3 minutes in healthy newborns with spontaneous
onset of respiration and heart rate >120 bpm [54].

Step 2: Classification of newborns based on zero pulse oximetry score by SpO2, as ‘Normal’,
healthy newborns. ‘Normal’ healthy newborns have zero pulse oximetry score, SpO2 96%-
100%, spontaneous onset of rhythmic breathing pattern, respiratory rate 30-60/min and heart
rate of 120-160 bpm. Hypoxic/asphyxiated newborns are further graded into Grade I to V based
on +1+5 Pulse oximetry score, SpO2 <96%, presence or absence of breathing and heart rate.
However grading of hypoxic newborns into Grade I-V by criteria of +1 to +5 pulse oximetry
score, SpO2 <96%, respiratory rate <30/ min and heart rate <120 bpm, to determine sustained
nasal oxygenation may vary as real time assessment of newborn’s SpO2 is constantly changing
due to continuous monitoring, oxygen is however discontinued at SpO2 96%.

Step 3: Lalana Newborn Resuscitation Protocol I and II, by continuous positive pressure
ventilation by sustained nasal oxygen inflation, flow rates determined by Pulse oximetry score,
facilitate onset of rhythmic breathing with effective resuscitation maintaining thermo-control
and asepsis.

Among 830 deliveries attended, majority 78.5% (n=653/830) were normal, healthy newborns
who established spontaneous rhythmic respiration, rate 30-60/min at birth with zero Pulse
oximetry score, SpO2 96%-100%, heart rate of 120-160 beats per minute (bpm). While among
newborns with birth asphyxia, Grade I newborns, 15.2% (n= 126/830) had mild birth asphyxia
+1 Pulse oximetry Score, SpO2 94% -95% with regular/irregular respiration, rate ±20-30/ min,
heart rate ±100 - 119 bpm, Grade II newborns comprised 3.7% (n=31/830) had moderate birth
asphyxia +2 Pulse oximetry Score, SpO2 92-93% with regular/ irregular breathing, respiratory
rate 15-20/min, ± heart rate 100 - 80 bpm and Grade III newborns 2.1% (n=17/830), had severe
birth asphyxia +3 Pulse oximetry Score, SpO2 90-91% with irregular or gasping respiration,
rate 10-15/min, heart rate 80-60 bpm and Grade IV newborns 0.4% (n=3/830), with secondary
apnea +4 Pulse oximetry score, SpO2 89-50%, heart rate < 60 bpm with absent respiratory
effort. Grade V newborns constituted 0.1% (n=1/830) with terminal apnea +5 Pulse oximetry
score, SpO2 <50%, absent breathing and heart rate < 30 bpm, in the event of no recordable
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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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pulse oximeter readings for SpO2 and heart rate within 60 seconds continuous distending
pressure ventilation through endotracheal intubation of sustained oxygen flow at 15 L/min
1(FiO2 100%) with cardiac compression of 100-120/min and medications of epinephrine or
volume expanders, 5% dextrose saline at 10 ml/kg, to also combat hypoglycemia, Sodium
carbonate in ventilating newborns or Carbicarb 2.5meq/kg (a mixture of Na2CO3/NaHCO3) for
metabolic lactic acidosis secondary to hypoxemia and cardio pulmonary disturbances which
does not generate CO2, newborn is extubated at onset of breathing and resuscitation continued
with sustained nasal oxygen flow at 8-12 L/min (FiO2 52% to 60%), till Zero Pulse oximetry
score, SpO2 96%-100%, regular breathing pattern respiratory rate 30-60/min and heart rate of
120-160 beats per minute (bpm), oxygen flow is discontinued [56].

Grade V newborns with terminal apnea are often subjected to severe perinatal asphyxia
especially after prolonged labour due to failed trial with undetected cephalo-pelvic
disproportion often associated with high risk of intrauterine death i.e. fresh stillbirths and
usually delivered by quick obstetric intervention by emergency LSCS, termed as fresh stillbirth
if born without signs of life or early neonatal death with signs of life with failed resuscitation
including endotracheal intubation upto 5-10 minutes with CPPV and 100% oxygen flow at 15
L/min (FiO2 100%) may abort resuscitative efforts due to high incidence of HIE with lifelong
untoward neurological sequelae.

However though introduction of Neonatal Resuscitative Program (NRP) resulted in significant

worldwide reduction in asphyxial neonatal deaths but nearly half of survivors suffered from
permanent neurological deficits depending on the extent of insult, varying from mild ill effects
to severe hypoxic ischemic encephalopathy or multi-organ complications and death within the
first few days [11,13,31,44-49]. Since mild perinatal hypoxia occurs more frequently than
severe events, it is associated with substantial long-term effect on the population, who are at
increased risk of low intelligence or Intelligent Quotient (IQ) scores <80 affects a large
proportion of adults with poor scholastic performance and other deficits include impaired
cognition, mild autism, lack of development of fine motor skills, memory and mood
disturbances etc. with over 200 million children not attaining age appropriate development
while severe perinatal asphyxia in survivors may result in hypoxic ischemic encephalopathy
which over past few decades has remained the same [45,47-49].

Fetal asphyxia first evokes gasping but prolonged asphyxia depresses central nervous system
including respiratory centre, such that newborns do not respond to normal stimuli augmenting
onset of breathing. However dramatic transition takes place at birth, as organ of gas exchange
switch from placenta in the fetus to the lungs in the newborn occurring at onset of rhythmic
breathing, often within 10 seconds of birth or even after 60-90 seconds at time of clamping of
cord which however predisposes to hypoxia that acts as a major stimulus to breathing including
chilling of the skin at birth and stimulation of receptors near larynx when airways are cleared
of liquid as well as the increased sensitivity of carotid chemoreceptors to hypoxia have all
shown to augment breathing [57-59].

The more severe the perinatal asphyxia the longer it will take longer for the newborn to breathe
more so with Neonatal Resuscitation Program (NRP) that requires a team of usually four or
more skilled birth attendants administering IPPV resuscitation with bag and mask or

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 23

endotracheal intubation if heart rate remains below 60 beats per minute for external cardiac
massage using two fingers to depress the lower sternum at approximately 120 times a minute
while continuing with respiratory assistance in a ratio of 1:5. Medications such as Epinephrine
or volume expanders at recommended dose of 10ml/kg of saline is administered, which can be
repeated to increase cardiac output [29,30].

Resuscitatory efforts aborted after 10-20 minutes with NRP justified due to association of high
mortality or morbidity in survivors with severe neuro-developmental disability and hence a
coordinated approach by obstetrician, neonatal team and parents is important. Resuscitation
may also be withheld in extremely immature newborns with gestational age <23 weeks and
birth weight below 400g or in newborns with lethal congenital malformations, not compatible
with life, e.g. anencephaly etc. [29,30].

In contrast resuscitation by LNR methodology by three simple steps may be administered by a

single birth attendant, is dramatic due to impact of oxygenation with onset of regular breathing
as continuous positive pressure ventilation with varying oxygen flow rate (Litres per minute)
that not only helps keep airway open but also maintains ventilation perfusion, by improving
oxygenation prevents hypoxic pulmonary vasoconstriction decreasing right to left
intrapulmonary shunting, significantly reduces fraction of cardiac output passing through
unventilated alveoli [53]. Air has 21% oxygen or FiO2 0.21 which mixes with oxygen,
increasing concentration of oxygen, approximately by 4% per litre. At the first breath the peak
inspiratory flow is 20-30 L/min, thus CPPV with oxygen at flow rate of 10 L/min, mixes with
20 L/min of air, with FiO2 0.60, hence pure 100% oxygen is never administered [55,56].
However in NRP, use of tight fitting mask or endotracheal intubation can increase FiO2 up to
100%. In addition oxygen saturation stated by NRP seems unacceptable with long delay in
hypoxic new-borns to achieve SpO2 >90%, as stated in protocol, oxygen saturation at 1 min
40-45%, 2 min 65-75%, 3 min 70-75%, 4 min 75-85%, 5 min 80-85% and 10 min 85-95%
[29,30]. In LNR even oxygen flow rate of around 2 L/min creates continuous distending
pressure throughout respiratory cycle with onset of breathing neonates provides intrinsic
Positive End Expiratory Pressure (PEEP), helps keep alveoli open to achieve optimal gas
exchange facilitating quick physiological transition from fetal to neonatal life soon after birth,
monitored by pulse oximeter requires minimal training of birth attendants in contrast to highly
trained birth attendants a prerequisite in NRP [60].

NRP recognizes several significant gaps in knowledge related to neonatal resuscitation as

current recommendation are based on weak evidence lacking well designed large well
controlled trials (RCTs) as opposed to a large controlled study of LNR versus NRP that may
be undertaken in the delivery room [29]. In LNR the quick reversal of hypoxia by
supplementary oxygenation is the key to successful resuscitation in perinatal asphyxia. Lack
of oxygen causes anaerobic glycolysis and metabolic acidosis that result in primary energy
failure or deprivation of high energy phosphate, causing cellular damage and multi-organ
failure with renal failure, hypoxic myocarditis and neurological damages etc. Also severe
hypoxia causes interference with the production of clotting factors from the liver and may
initiate DIC also a strong association between hypoxia and intraventricular hemorrhage as
cause of death in preterm as increase in intravascular pressure ruptures vulnerable vessels in

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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the germinal matrix. Hypoxia is also a major factor in necrotizing enterocolitis with
interference of blood to the gut [61,62].

The longer hypoxemia, the more severe the sequelae, combating with oxygen supplementation
results in prompt increase in heart rate with circulation of oxygenated blood throughout the
body improving cellular function by conversion of anaerobic metabolism to aerobic with
utilization glucose and generation of 38 mols of Adenosine Triphosphate (ATP) instead of 2
mols of ATP with the removal of lactic acid from tissues [63,64]. Thus Lalana Neonatal
Resuscitation (LNR) with oxygenation is a safe resuscitative method physiologically and
scientifically proven utilizing continuous positive pressure ventilation by sustained nasal
oxygen inflation with higher fraction of inspired oxygen (FiO2), determined by Pulse oximetry
SpO2 score, quickly reverses hypoxial injury while initiating rhythmic respiration with
circulation of oxygenated blood throughout the body, as well as reducing adverse hypoxic
neurological or organ deficits so that children should be normal serves to achieve the aim of
effective resuscitation.

When oxygen/air enters the lungs, the normal fetal partial pressure of oxygen (PAO2) levels
of 25mmHg rises sharply to above 60 mmHg, resulting in dilation of pulmonary vasculature at
birth facilitated by development of surface tension forces in the alveoli that exert radial traction
on blood vessels with increase in blood flow through the lungs and pressure in left atrium rises,
along with cessation of umbilical circulation, the right atrial pressure falls slightly resulting in
closure of foramen ovale and ductus arteriosus constricts in response to increasing PO2 once
breathing has started with the entire cardiac output must flow through the lungs allows for full
oxygenation of blood [65-67].

Hypoxia is a potent inhibitor of spontaneous respiration and lack of oxygen causes anaerobic
glycolysis and metabolic acidosis due to accumulation of lactic acid, hypoxia and acidosis
therefore impairs cardiac function and increases pulmonary vascular resistance. The low pH
worsens pulmonary vasoconstriction with right to left shunting through foramen ovale and
ductus arteriousus and venous blood bypasses lungs to enter aorta with serious consequences
causing life threatening hypoxial injury in newborns [63,65,67]. Continuous positive pressure
ventilation with sustained nasal oxygen inflation facilitates lung fluid reabsorption at birth,
enabling smooth transition from fetal to extra uterine life. Thus oxygen therapy in hypoxic
newborns is the only specific treatment to prevent or mitigate the effects of hypoxia to decrease
central apnoea and promote regular breathing pattern that is the key to successful resuscitation
[38-40]. Oxygen flow rate is determined by grading of hypoxic newborns into Grade I-V,
varying from 4 L/min up to 15 L/min with approximate FiO2 36% to 75% respectively, creates
continuous distending pressure to achieve optimal gas exchange that stimulates the central
respiratory centre to initiate rhythmic respiration, avoiding hypoxemia and hypercapnia that is
associated with rise in arterial carbon dioxide causing reduced blood flow to the brain and
ischemia with altered mental status [40,53,54].

Some newborns who remain short of breath or have transient tachnpnoea (wet lung) for a few
hours or occasionally one to two days later after birth due to delayed removal of fetal lung fluid
as IPPV with bag and mask provides insufficient transpulmonary pressure for clearance of lung
fluid that remains in the alveolar walls and adequate oxygenation is required for reversal of

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 25

hypoxia being the only specific treatment [68]. Randomized controlled trials show sustained
oxygen inflation decreases need for intubation and mechanical ventilation [69,70]. Animal
studies have suggested that a longer sustained inflation may be beneficial for establishing
residual capacity during transition from fluid filled to air filled lungs after birth and randomized
controlled trials have also demonstrated benefit of sustained inflation decreases need for
intubation and mechanical ventilation as well, because lungs are filled so fluid, high pressure
25-30 cm H2O is needed for the first inflation applied for five seconds so whole lung becomes
inflated and foetal lung fluid has been displaced from the alveoli then lungs can be inflated at
lower 10-15 cm H2O [39,66].

In LNR despite oxygen FiO2 1.0 or 100% blown through the oxygen tube to baby’s nostril,
first breath requires a peak inspiratory flow of around 20-30 L/min or 8 L/kg/min, for e.g. a
baby weighing 3500 g, requires approximately 28 L/min, to meet inspiratory flow in addition
to oxygen at flow rate of 10 L/min, therefore another 18 L/min of air is sucked in from
surrounding atmosphere with FiO2 of 21%, hence (10 x 100) + (18 x 21) =1378%, 1378 divided
by 28 = gives FiO2 49%. Therefore the air/oxygen mixture inhaled has a FiO2 0.49 or 5%
obviating both hyperoxia and mitigating hypoxia [53,54,60].

In contrast NRP with tight fitting mask or endotracheal intubation increases FiO2, to 1.0 or
100% predisposes to hyperoxia with its deleterious effect of slowing cerebral blood flow in
both term and preterm infants, as also even brief periods of supplemental, uncontrolled
exposure of 100% oxygen results in generation of oxygen free radicals, which have a role in
reperfusion injury, contributing to eye (ROP), causing blindness, lung injury and altered mental
status in preterm [70-73]. In addition intermittent inflation with bag and face mask does not
generate adequate intrapulmonary pressure to displace alveolar fluid and also because gastric
distension occurs and satisfactory oxygenation in fetal fluid filled lungs is not possible, studies
have detected un-even alveolar ventilation during a single breath even with oxygen resulting
in decreased pulmonary perfusion, V/Q mismatch further perpetuating hypoxia, hypercarbia
and acidosis since pulmonary arterioles remain constricted with right to left shunt through
foramen ovale and ductus arteriousus interfering in transition of fetal to neonatal
cardiopulmonary circulation [32,35-37]. Newborns remain extremely vulnerable to reopening
of fetal right to left shunts for several days to even weeks after birth due to pulmonary
vasoconstriction and if PO2 of lung tissue falls, further compounded by low pH, that worsens
pulmonary vasoconstriction has serious consequences with bypass of venous blood into the
aorta being probably the single most life threatening result of hypoxia in the neonatal period as
anatomical closure usually takes place by about two weeks of age [34,67]. As such the
peripheral oxygen saturation stated by NRP with IPPV seems unacceptable with long delay in
hypoxic new-borns to achieve normal SpO2 96%, advocating oxygen saturation at 1 min with
SpO2 40-45%, 2 min 65-75%, 3 min 70-75%, 4 min 75-85%, 5 min 80-85% and at 10 min
SpO2 85-95% [29,30].

In the fetal lungs surfactant is secreted by the 7th month of gestation and Type II pneumocytes
in neonatal lungs, secrete a thin lining of alveolar fluid that combines with surfactant to form
an aqueous protein containing hypophase with overlying phospholipid film composed mainly
of dipalmitoyl phosphatidylcholine to create a moist surface conducive to gas exchange by
lowering surface tension, open alveoli and prevent atelectasis, gases first dissolve in the

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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alveolar lining fluid and then diffuse across type I, extremely thin squamous alveolar cells and
pulmonary arteriolar capillary membrane to combine with haemoglobin [34,74]. Thus
oxygenation is the process of taking oxygen from inspired air that diffuses passively from the
alveoli to pulmonary capillaries where it binds to haemoglobin forming oxyhaemoglobin and
a small amount dissolves in plasma. In the newborn gas exchange occurs in the lungs by two
mechanisms for oxygen delivery to the body, 98.5% oxygen is bound to haemoglobin, which
is assessed by Pulse oximetry SpO2, being almost similar to SaO2 measured by Arterial Blood
Gas (ABG) analysis, while some oxygen is dissolved in the plasma, accounts for only 1.5%
transport to tissues.

Each haemoglobin molecule carries four molecules of oxygen bound to the iron of the heme
prosthetic group. There are about 270 to 300 million haemoglobin molecules present in one-
third of erythrocyte cytoplasm which are relatively short lived about 100 to 220 days. As the
first oxygen molecule binds to haemoglobin tetramer, it induces a change in shape of
haemoglobin that increases its ability to bind to three other molecules of oxygen, reflecting
cooperative interaction between haemoglobin and oxygen molecules, thus each haemoglobin
tetramer binds to four molecules of oxygen and a gram of haemoglobin can combine with 1.34
ml of oxygen. Hence blood with normal haemoglobin concentration of 15g/dl, 100 ml carries
approximately 20 ml of oxygen in addition a small quantity of oxygen is dissolved in blood. If
haemoglobin tetramer binds to only three molecules of oxygen instead of four, it leads to
hypoxia and deoxyhaemoglobin. However if the partial pressure of oxygen in the alveoli is
high, then four molecules of oxygen binds haemoglobin binds to form oxyhaemoglobin [74].

However a lack of oxygen in the blood means that body tissues will not be oxygenated properly
causing damage to the organs is an indication of serious pulmonary tissues [74]. While oxygen
delivery is the rate of oxygen transported from the lungs to the peripheral tissue and oxygen
consumption is the rate at which oxygen is removed from the blood for use by the tissues.
Oxygenated blood sustains aerobic cellular metabolism throughout the body, wherein oxygen
is used to convert glucose to Adenosine Triphosphate (ATP). Insufficient oxygenation is
termed hypoxemia, causes low partial oxygen tension that refers to abnormally low oxygen
content in tissue or organ with residual neurological and organ deficits.
Arterial blood flows from the heart to parts of the body laden with oxygen where it diffuses to
the surrounding tissues with low partial pressure of oxygen and oxyhaemoglobin releases
oxygen to cells to form deoxyhaemoglobin. Diffusion of oxygen is related to partial pressure
of oxygen (PAO2) from the alveoli into the pulmonary capillaries (PaO2), depends on the
Alveolar-arterial (A-a) gradient, normal range of difference between PAO2 PaO2 being 5-10
mmHg, but collapsed, fluid filled or unventilated alveoli with VQ mismatch shunt, reflects a
rising A-a gradient, that impairs oxygen diffusion across the alveolar - pulmonary arteriolar
capillary membrane into the blood stream [74].

The normal partial pressure of oxygen in the alveoli (PAO2) is FiO2 0.21 or 21% at atmospheric
pressure of 760mmHg, breathing in room air at sea level is around 80 to 100 mmHg, therefore
about 90% of oxygen in healthy lungs makes it to the blood. However when PAO2 is >90%,
the increase in PAO2 has relatively little impact on oxygen saturation by haemoglobin, as there
can be no further increase in saturation however high the PAO2 rises with supplemental oxygen.
If however the alveolar partial pressure (PAO2) falls to 60 mmHg, less oxygen binds to

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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haemoglobin with rapid fall of oxygen in red blood cells. Hence alveolar partial pressure of
oxygen at 100mmHg is much better than the alveolar partial pressure of oxygen of 80 mm Hg
even though oxygen saturation of haemoglobin in blood will not change very much despite
increments in oxygen supplement [74].

The relationship between the partial pressure of oxygen and oxygen saturation is shown by the
oxygen disassociation curve. The sigmoid shape of the disassociation curve reflects the
cooperative interaction between haemoglobin and oxygen molecules is initially steep and then
flattens out, is a graphical representation of haemoglobin affinity to oxygen or the percentage
of saturation of oxyhemoglobin at various alveolar partial pressures (PAO2) of oxygen. The X
axis of the oxygen disassociation curve represents the dissolved oxygen in linear relationship
to its partial pressure resulting in a straight line on the horizontal axis and the proportion of
haemoglobin in its saturated (oxygen-laden) forms the vertical Y axis against the prevailing
oxygen tension.

Oxygen at high alveolar partial pressure (PAO2) 100 mmHg drives oxygen on to the
haemoglobin until 95-100% saturated. Haemoglobin releases oxygen as the blood passes
through the tissues and partial pressure of oxygen (PvO2) returning from the tissues (mixed
venous blood) 40 mmHg is much lower than arterial blood. The most important aspect of the
oxygen disassociation curve is that if the Pulse oximeter reading falls below 90%, the partial
pressure of oxygen in the blood (PaO2 or SaO2) drops very rapidly and oxygen delivery to
tissues is reduced that may lead to cardiac arrest, requiring quick resuscitative intervention.
Pulse Oximeter provides a rapid tool in assessing adequate peripheral oxygenation or
percentage of hemoglobin that is saturated with oxygen. In addition the plethysmograph
indicates cardiac function by pulsatile changes as prompt increase in heart rate being a sign of
adequate lung aeration is based on the concept that a low heart rate is due to vagal-induced
bradycardia in response to perinatal asphyxia. Continuous Pulse Oximetry therefore empowers
one to respond quickly and confidently to abnormal readings to determine supplemental nasal
oxygen flow if SpO2 falls < 96% [41,42,74].

Various factors affect haemoglobin’s affinity for oxygen. Right shift with decrease in oxygen
affinity is influenced by lower pH, higher temperature, PCO2 as well as high concentration of
2,3 diphosphoglycerate (2,3 DPG) produced from phosphoglyceraldehyde in response to
hypoxia in red blood cells, an intermediate metabolite in the glycolytic pathway that binds to
the beta chains of deoxyhaemoglobin and rearranges it into the T state by decreasing affinity
for oxygen, hence more oxygen is released into tissue, indicating that haemoglobin allows more
oxygen to be available to tissues but is also more difficult for oxygen to bind with haemoglobin
in lungs. Fetal haemoglobin is the main oxygen transport protein in the human fetus during the
last seven months of development and persists in newborn until six months of age to later form
adult haemoglobin which has two alpha and two beta subunits, while fetal haemoglobin is
composed or two alpha and two gamma subunits which shifts oxygen disassociation curve to
the left compared to that of adult haemoglobin, resulting in greater affinity for oxygen, allowing
the fetus to extract oxygen from maternal circulation, however oxygen disassociation curve in
relation to partial pressure of oxygen is lower than normal adult haemoglobin based on lower
P50 value or 6-8 mm Hg (Torr), difference due to decrease affinity for 2,3 Diphospoglycerate

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in that oxygen released from red blood cells requires a lower PaO2 with left shift when
compared to adult Hb [74,75].
Also hypoxia with anaerobic metabolism produces lactic acid causing metabolic acidosis that
decreases pH and shifts the curve to the right, referred as Bohr effect, as the higher hydrogen
ion concentration causes an alteration in amino acid residues that stabilises deoxyhaemoglobin
in a T (taunt or tense) state that has lower affinity for oxygen, thus further promotes hypoxia.
While left shift indicates increase affinity of haemoglobin for oxygen binding at any given
PAO2 with increase oxygen transport to tissues, as blood passing through the lungs gives CO2
and H+ ions in the form of carbonic acid that increases oxygen binding to haemoglobin. Tissues
have low oxygen concentration and oxyhemoglobin releases oxygen to form
deoxyhaemoglobin, thus diffusion of oxygen from haemoglobin to tissue cells is enhanced by
this process and corresponds to the steep portion of the ‘S’ shaped curve [74,75].

Oxygenation in LNR is from high pressure sources such as cylinder or piped wall supply that
first passes through a pressure regulator to a lower pressure which then flows through the flow
meter, controlled by a valve for litre flow per minute. Sustained positive pressure is maintained
according to the flow rate of oxygen dialled on flow meter usually between 1-15 Litres per
minute (L/min) while FiO2 is defined as the percentage concentration of oxygen inhaled or
fraction of inspired oxygen. Air gives 21% oxygen equivalent to FiO2 0.21 and flow rate of 1
L/min gives an oxygen increment of approximately 4% or FiO2 0.04 for each increased in
litre/min flow i.e. FiO2 24% when 1 L/min oxygen flow is mixed with air. Thus flow rate of 6
L/min gives oxygen concentration of 45% or FiO2 0.45 or volumetric fraction of oxygen that
mixes with air during inhalation. Therefore even though 100% oxygen or FiO2 1.0 through
flow meter which is connected to either medical wall supply or oxygen cylinder at varying flow
rates between 1-15 L/min dialled on flow meter, is bubbled through a bottle containing 5 cm
water for humidification, passes through the wide bore oxygen tube, mixes with room air on
inspiration resulting in FiO2 of 0.24 up to 0.72 i.e. 24% to 72% oxygen but never 100% oxygen
on inspiration by the neonate. In addition a wide bore oxygen tube proves advantageous in
allowing for quick adjustment of varying oxygen flow rates between 2 L/min to 15 L/min
without the requirement for changing from low to high flow oxygen delivery devices
[53,54,60,69].

Low flow oxygen delivery devices allows oxygenation of FiO2 <35%, while moderate oxygen
flow delivery devices allows FiO2 35% -60% and high oxygen flow delivery devices allows
FiO2 >60. Low flow oxygen delivery devices includes paediatric nasal cannula consisting of a
thin tube with two small nozzles that inserts into the nostrils and allows oxygen at flow rate of
2-4 L/min with approximate FiO2 0.28-0.36. Simple face mask allows oxygen flow of 5-6
L/min with FiO2 0.32-0.36. Higher oxygen flow rate require humidification with minimum 5
L/min to flush carbon dioxide (CO2) from mask in breathing patients and to protect mucosa of
nostrils from drying. Partial rebreather allows oxygen flow of 6-8 L/min sufficient to keep
reservoir bag from deflating during inspiration, does not have a one way valve [69].

High oxygen flow device, the Venturi mask has a one way valve over port that limit
entrainment of room air with humidified oxygen flow rate of 6 L/min upto 15 L/min and
approximate FiO2 0.44 to 0.78. The non-breather mask is high flow device with one-way valves
to exit exhaled air and draw oxygen from attached reservoir bag with oxygen flow rates of 10

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

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L/min to15 L/min, delivers approximate FiO2 0.70 up to 1.0, if mask is properly fitted to 100%
oxygen as with endotracheal intubation. An aerosol generating device will deliver FiO2
anywhere from 0.21 to 1.0, depending on the set up usually at 10 L/min and desired FiO2 is
selected by adjusting an entrainment collar located on the top of the aerosol container with
humidity device connected to the flow meter through wide bore tubing that connects to
patient’s mask [53,54,69].

While Continuous Positive Airway Pressure (CPAP) is a non-invasive nasal type of respiratory
support in spontaneously breathing preterm newborns, CPAP with blender to maintain <30%
FiO2 in delivery room is recommended for early rescue of preterm babies <32 weeks and
<1250g for respiratory acidosis, respiratory distress syndrome, recurrent apnoea, atelectasis
etc. [76-80]. Bubble CPAP with blender allows for increase in FiO2 with increasing oxygen
saturation in newborn but not in oxygen flow rate, preterm < 32 weeks have periodic breathing
and may have short attacks of apnea due to immaturity and inadequate control of breathing.
Prolonged apnea results in hypoxia, so instead of breathing air by CPAP, increasing PaO2 by
23%-25% or 50 mmHg raises PAO2 to about 70-80 mmHg. Oxygen bubbled through 5 cm
water in a bottle with FiO2 <0.3 or <30% produces small airway pressure oscillations that
improves gas exchange and lung function to maintain oxygen saturation between 90%-96%
avoids routine intubation in management of respiratory distress syndrome, as well as decreases
surfactant need by 50% and provides post extubation respiratory support effectively reducing
broncho-pulmonary dysplasia [76-81]. However in low income Asian countries with limited
resources, oxygen hood may also be used instead of CPAP machine, the oxygen flow rate
adjusted to maintain preterm SpO2 around 95% managed with parenteral fluids and treatment
of any complications.

CPAP titrated pressure is prescribed pressure of steady oxygen flow rate between 4-8 L/min
ensures bubbling through 5 cm H2O to deliver constant air pressure into the baby’s nose
through nasal prongs, enabling air sacs to stay open by increasing Functional Residual Capacity
(FRC) and maintaining lung volume during expiration, prevents atelectasis by building up
Positive End Expiratory Pressure (PEEP) or alveolar pressure above atmospheric pressure that
exists till the end of expiration preventing alveolar collapse and apnea, making it easier for the
baby to breathe independently. Also any decrease in lung volume (FRC) decreases surface area
for gas exchange with intrapulmonary shunting or V/Q mismatch perpetuating hypoxia [76-
80].

While extrinsic PEEP is applied by ventilator, intrinsic PEEP is facilitated by sustained nasal
oxygen flow with higher FiO2 as well as by incomplete expiration. Pressure support PEEP or
pressure applied during inspiration causes progressive air trapping (hyperinflation). This
accumulation of air increases alveolar pressure at the end of expiration. Alveolar gas equation
used to calculate alveolar pressure with any given FiO2 is PAO2=FiO2 (PBAR-PH2O) -
PACO2/RQ. If PH2O at 37oC = 47 mm Hg, PBAR or barometric pressure at sea level varies
from 745 to 765mmHg or 747mmHg, PACO2 = arterial PaCO2 = 40 mmHg and RQ = 1, then
PAO2= PAO2 (700)-PaCO2. Infant breathing 30% O2, (FiO2= 0.3) has arterial CO2 of 40
mmHg then Alveolar oxygen tension: PAO2 = 0.3(700)-40mmHg = 170mmHg [53,54,69].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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Pre-oxygenation is dangerous and an ineffective practice [81]. Effective oxygen therapy is

delivering the lowest FiO2 to achieve normal oxygen saturation based and heart rate assessed
according to Grade II -V, based on Pulse oximetry SpO2 thus preventing hypoxia and
hyperoxia, LNR with sustained positive pressure ventilation establishes an ideal approach in
resuscitating hypoxic/asphyxiated newborns, transiting from fluid filled fetal lungs to
uniformly well aerated neonatal lungs by avoiding inappropriate supplemental oxygen therapy
based on Pulse oximeter SpO2, oxygen flow discontinued at zero score SpO2 >96% [60]. The
dangers of Neonatal Resuscitation Program (NRP) in that tight fitting face mask or
endotracheal intubation predisposes to hyperoxia with FiO2 upto 0.8-1.0 has deleterious effect
of slowing cerebral blood in both term and preterm infants and reperfusion injury with
generation of oxygen free radicals, may cause injury to eye (ROP) and lungs in preterm, high
regional cerebral oxygen saturation may predispose to periventricular haemorrhage with
increased incidence of necrotizing enterocolitis [29,30,71-73]. However randomized trials
(SUPPORT) and benefits of oxygen saturation targeting (BBOT), the best oxygen profiles to
reduce ROP while optimizing the health of preterm and their development remain unknown
[71,72,82-86].

Neurodevelopmental impairment may be observed among extremely premature infants at 18-

22 months of age [82]. However SpO2 85-89% in extremely preterm was associated with
increased mortality at the time of discharge compared to higher 91-95% (19.9% vs 16.2%;
p=0.045), preferably preterm newborns should not be exposed to either damaging hyperoxia
with SpO2 100% or hypoxia SpO2 <95% [71-73,85,89].

Initiation with room air remains controversial as current Neonatal Resuscitation Program
(NRP) guidelines suggest using air or blended oxygen to titrate oxygen to meet preductal
saturation SpO2 at 85-94%, but there are no studies to justify any particular starting oxygen
concentration [86-90]. In LNR maximum FiO2 of upto 68% id administered through sustained
nasal inflation and at no time is 100% oxygen administered except with endotracheal intubation
in Grade V preterm with poor circulation and low arterial oxygen saturation in asphyxiated
babies, who are subject to high mortality rates [60]. Though to date no randomized trials of
strategies to achieve the NRP recommended interquarteli range of preductal saturations have
been conducted in preterm neonates, perhaps maintaining SpO2 around 95-96% would be ideal
in preventing both hypoxia and hyperoxia [86-90].

Pulse oximetry SpO2 readings follow the Gaussian curve of normal distribution and equipment
bias, within ± 1 Standard Deviation (S.D.) of true arterial oxygen saturation 68% of the time,
then SpO2 90% is 1% on equipment bias then true arterial saturation will be 89%, 90% or 91%.
If monitor has 3% bias then SpO2 90% will be between 87% and 93% for 68% of the time and
as such, a difference of 1-2% may be inconsequential. The alarm limits should preferably be
set at 1% or 2% above or below the chosen target range, high alarm should be set at 95% to
avoid PaO2 of >80 mmHg and lower limits should be set at ≥85% when breathing supplemental
oxygen with FiO2 > 0.21 with careful attention on averaging and sensitivity of monitors. Since
there is no definite conclusive evidence for ideal oxygen saturation in extremely premature
newborns, it is perhaps best to avoid both hypoxia as well as hyperoxia by maintaining oxygen
saturation of SpO2 around 95% to 96% [87-91].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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The assessment of peripheral oxygen saturation specifically in peripheral arterial blood by

Pulse Oximeter was developed by Takuo Aoyagi in 1935, is a small non-invasive portable
device is of particular value in neonatal units to prevent hypoxia and hyperoxia, is also known
as the fifth vital sign, the first four being Temperature, Pulse, Respiratory rate and blood
pressure (TPR and +BP) [41]. The Pulse oximeter probe consists of two parts, Light Emitting
Diodes (LEDs) and light detector called photo-detector which notes how much light at each
red and infrared wave length has been absorbed and determines the ratio of the two wave
lengths.

Light emitted from light source passes through the body part to a photo detector that measures
amount of light absorbed according to Beer’s law that states that the amount of light absorbed
is proportional to the concentration of light absorbing substance and Lambert’s law, which
states that the amount of light absorbed is proportional to the length of the path light has to
travel in the absorbing substance. Red light is absorbed by deoxyhemoglobin and infrared light
by oxyhemoglobin. The ratio of the absorbed red light and infrared light differs and the
microprocessor calculates a value for the oxygen saturation in the pulsing arterial blood
excluding venous blood, skin, bone, muscle fat etc. providing percentage of haemoglobin
saturated with oxygen within seconds, being almost similar to arterial oxygen saturation (SaO2)
measured by Arterial Blood Gases (ABG) analysis [41,42].

Pulse oximeter also provides reading of heart rate, the increase in heart rate indicating adequate
lung aeration and circulation of oxygenated blood. Also pulsatile change in absorbance due to
pressure changes in arteriolar blood volume in the skin represented in graphical form is called
plethysmography trace. The variation of pulsatile changes in transmission of light signal
received by the sensor indicates cardiac function and how well the heart is pumping oxygenated
blood through the body. The perfusion index quantifies the amplitude of the peripheral
plethsmograph waveform and helps to predict early adverse respiratory outcome in neonates,
also any irregularity of cardiac rhythm improves detection of critical congenital heart disease
in newborns, is implemented as screening test for critical congenital heart diseases [91,92].
Pulse oximetry Photoplethysmogram (PPG) is measurement of respiratory rate by application
of digital band filters to allow the removal of cardiac component on the PPG waveform. PPG
signal should have two distinct peaks, one low frequency corresponding to respiratory rate and
another higher frequency corresponding to heart rate. A recent method titled ‘ARspec’ (Acute
Regressive specral median) yielded most reliable respiratory rate estimation [93,94].

Apgar’s simple clinical practical score at 1, 5 and 10 minutes of birth, 0-3 severe asphyxia, 4-
7 as moderate asphyxia and 8-10 in normal healthy newborns in terms of cardio-respiratory
status, reflex irritability, muscle tone and colour of newborn, is now rendered redundant and
obsolete as it is subjective and poorly reproducible and as such the need for active resuscitation
being a specific sign of delayed onset of respiration could therefore indicate recent cerebral
injury especially hypoxic-ischemic [95-97]. Also umbilical blood gases for metabolic acidosis
is difficult, as pH below 7.18 and a base excess more negative than -8 despite being indications
of oxygen deprivation in newborn is a poor predictor of significant perinatal brain injury [98].
While Pulse oximetry automatically provides condition or status of newborns within seconds,
significantly detecting more cases of hypoxia requiring immediate resuscitative measures [41].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 32

Pulse oximeter also guides the flow rate of supplemental oxygen based on grading I-V among
hypoxic newly borns [60].

Hence birth asphyxia is best defined as lack of oxygen during antepartum, more so intrapartum
period or just before birth, Graded I-V as mild, moderate, severe birth asphyxia, secondary
apnea and terminal apnea respectively assessed within 20-60 seconds of birth, as delayed onset
of respiration indicate recent cerebral injury especially hypoxic-ischemic. Pulse oximetry
scoring of SpO2 <96% is also an accurate indicator of hypoxia in newborns. Resuscitation best
achieved by sustained positive airway pressure with nasal oxygen inflation at flow rates 1-15
L/min, results in uniform aeration and increased pulmonary compliance with prompt increase
in heart rate and cardiac output with rhythmic breathing. Alternatively birth asphyxia maybe
defined as Pulse oximetry score +1 to +5 with SpO2 <96% due to lack of oxygen in newborns
causing failure to initiate or sustain rhythmic breathing at birth necessitating immediate
resuscitative intervention by LNR.

The practice of resuscitation IPPV with bag and mask or endotracheal intubation was
undertaken at Christian Medical College and Hospital, (CMCH), Vellore, South India, the then,
premier institution in South East Asia, decades earlier to my post graduate residency in early
eighties at the neonatal unit, that was later implemented world-wide with the introduction of
‘Neonatal Resuscitation Program’ (NRP) published in 1988 [29,30]. I immediately resuscitated
severely asphyxiated newborns with endotracheal intubation and intermittent positive pressure
ventilation with adjunct therapy of epinephrine as well as sodium bicarbonate administered in
ventilated breathing newborns for severe perinatal asphyxia with Apgar score of 0-3 at 1 min
to 5-10 min. However if newborn is properly oxygenated, metabolic acidosis due to anaerobic
glycolysis will rapidly resolve, precluding use of hypertonic bicarbonate solution that may
overload circulation causing increase risk of cerebral haemorrhage [99]. It wasn’t until 2016
that I discovered the application of continuous positive pressure ventilation by sustained nasal
oxygen inflation at flow at rates of 8-15 litres/min resulted in almost immediate revival of the
central respiratory centre in initiating rhythmic respiration with no residual adverse sequelae
in hypoxic newborns who on observation for four hours in Neonatal Intensive Care Unit
(NICU) fared well, were then shifted to mothers side, breast feeding initiated and discharged
3-5 days later. I have since used LNR with supplemental nasal oxygen flow successfully in all
asphyxiated newborns till date with success, without the resort to IPPV with bag and mask
ventilation or endotracheal intubation with good neonatal outcome.

I earlier published a study from CMCH, Vellore, that reported high perinatal mortality rate
(PMR) of 40.7/1000 among 21,585 consecutive total live-births births during 1979-1983, being
one-half contemporary national PMR of around 80/1000 total births, in spite of CMCH being
a tertiary referral centre for high-risk cases. The Stillbirth Rate (SBR) 23.6, featured one and a
half times higher than Early Neonatal Mortality Rate (ENMR) of 17.5 per 1000 live births.
There were 509 stillbirths accounting for 58% of 878 perinatal deaths with 369 Early Neonatal
Deaths (ENDs), indicating that most asphyxiated babies died before birth as fresh stillbirths
and nearly half 48% (n=119/369) as early neonatal deaths dying within two hours of life from
severe perinatal asphyxia instead as fresh term stillbirth as a result of obstetric intervention and
skilled resuscitation with IPPV using bag and mask or endotracheal intubation etc. could
therefore constitute a total 72% stillbirths of perinatal deaths [21]. The adage “masterful

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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inactivity and watchful expectancy” proves detrimental in ethnic Asian-Indian population with
high perinatal mortality rates, hence active management of labour with quick obstetric
intervention is important to rescue endangered foetuses, which has however resulted in a sharp
increase of LSCS from 14% in the eighties to 42% in twenties, as fetal distress was the
commonest indication for emergency LSCS indicating undetected CPD with prolonged labor
[100,101].

Among 369 early neonatal deaths within the first seven days of life, birth asphyxia in 116
(31.4%) was the leading cause during 1979-1983 at CMCH Vellore. However majority 41.7%
(154/369) severely asphyxiated newborns had Apgar scores 0-3 at 1 min of birth, most 38 of
whom had lethal congenital malformations, constituting an absolutely unavoidable cause of
perinatal deaths, 10 died later of intracranial haemorrhage, 9 hyaline membrane disease, 5
fulminant sepsis, 2 massive meconium aspiration syndrome and 1 second birth, infant had
hydrops fetalis [8].

Nearly two-thirds 67.2% (n=248/369) of ENDs, took place within the first 24 hours of life.
The main cause of death was severe birth asphyxia 30% (n=74/248), lethal malformation
(LM) 24% (n=59/248) and Respiratory Distress Syndrome (RDS) 21% (n=52/248) ranked as
second and third causes respectively, followed by intracranial haemorrhage (ICH) 7.6%
(n=19/248), neonatal infections 3.2% (n=8/248) and ‘miscellaneous’ 14.5% (n=36/248) which
included extreme prematurity, pulmonary haemorrhage, liquor aspiration and Rh iso
immunization, constituted the remaining first day deaths [9].

Time of death among 248 first day deaths, nearly half 48% (n=119/248) took place within two
hours of birth and 29% (n=72/248) >2-12 hours with less than a quarter 23% (n=57/248) within
12-24 hours [9]. Other studies have noted that more than half, 57 % of neonatal mortality
occurred within 24 hours [102]. Seven out of every eight stillbirths is due to severe birth
asphyxia, with stillbirth rate figuring one and a half times that of early neonatal mortality rate,
reveals the magnitude of asphyxiated stillbirths [21,103]. Emphasizing that birth asphyxia
continues to be a major cause of preventable proportion perinatal and neonatal and that the
neonatal period, more so the first one week, especially within the first 24 hours of life being
critical for survival in the life of a child with prevailing high mortality rates predominately in
developing Asian countries [5-10].

I also observed during my neonatal residency at CMCH, Vellore that more babies born by
normal vaginal delivery were hypoxic when compared to those delivered by LSCS, though
those delivered by outlet forceps delivery, cutting short second stage had least perinatal
mortality rate [100]. However during 1982 increased sensitization of obstetrician to fetal
hypoxial injury by avoiding prolonged labor with active management and judicious obstetric
intervention, reduced incidence of birth asphyxia which ranked fourth with lethal congenital
malformations ranked as the first cause, being an absolutely unavoidable proportion of
perinatal mortality, followed by respiratory distress syndrome and Intracranial haemorrhage
as second and third cause of early neonatal deaths an increase in outlet forceps deliveries
cutting short second stage of labor was also noted with least PMRs [8,9,100.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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The low ethnic Asian mean birth weight in the 1983 cohort was 2881 g, compared to three
decades later was almost similar to 2873 g, in 2015-’17 cohort. The decrease of -8 g is attributed
to a shift in demography with small family norm and over 50% young primigravida mothers
having lower birth weight babies [101,104]. The distribution of birth weight between Asian
and Caucasian newborns is remarkable, Caucasian newborns have higher mean birth weight of
3470g reported in a British study, most 82.7% weighed above 3000 g with only 17.3%
weighing below 3000 gm that contrasted to low Asian mean birth weight of 2874 g with around
one-fourth 27.7 % weighing more than 3000 g and a high 72.3 % weighing 3000 g and below
[105]. In fact almost two thirds 65.6% of Asian Indian births weighed between 2000-3000g,
while almost similar 68% Caucasian births weighed higher 3000-4000 g, indicates why ethnic
Asian population have to set standards and perinatal definitions of their own for international
comparison [101,105,106].

Norway reported highest mean birth weight of 3575 g being statistically significant (p=0.001)
when compared to other Asian countries such as D.R. Congo, Egypt and Thailand with 400g
less birth weight median, while Argentina, Brazil and France had birth weight less than 200g
and Denmark, Germany with mean birth weights approximately 100 g less. WHO has also
observed that differences in birth weight when adjusted to gestational age at birth between
other countries is highly significant for all percentiles at birth, p=0.0018 at 5th percentile to
p<0.001 for 10th, 25th, 50th, 75th, 90th and 95th percentiles, reveals the wide variation in human
fetal growth across ethnic Asian and Caucasian population, indicating that Asian and Caucasian
perinatal definitions are mandated, taking into consideration the wide variation in mean birth
weight gestation at birth and intrauterine growth pattern based on ethnicity that will result in
improved perinatal and neonatal outcome among ethnic Asian population, presently
comprising a majority four-fifths of world’s nearly 8 billion population [106-109].
The Asian Indian peak births 32.6 % in 1983 cohort occurred at 39 weeks gestation with mean
gestation of 38.86 weeks S.D. ± 1.29 weeks while peak births 27.4% among 2015-’17 cohort
took place at 38 weeks with mean gestation of 38.2 S.D. ± 2 weeks, contrasted with Caucasian
births which peaked 31% at 41 weeks gestation, mean gestation of 41.03 weeks S.D. ± 1.32
weeks, with a highly statistically significant difference of 3-4 weeks (p=0.001), while Norway
reported mean gestation of 40 weeks 3 days [101,104,105,108]. The shortened gestation of 38
weeks at peak births among Asian-Indian babies results in smaller babies with lower average
birth weight 2881g when compared to Caucasian newborns who with a longer gestation upto
42-44 weeks continue to gain weight by deposition of subcutaneous fat have birth weight
around 3500g [101,105,106,108,110].

The early peak births at 38 weeks gestation in 2015-17 study compared to 39 weeks in 1983
study is due to judicious quick surgical obstetric intervention in rescuing jeopardized foetuses
that resulted in increased incidence of LSCS deliveries 41.6 %, when compared to low 14.8%
during the 1979-1983 [100,101]. Not only shortened gestation but also decreased intrauterine
fetal growth potential contributes to the low mean birth weight in ethnic Asians as intrauterine
growth curves for Asian- South Indian newborns, constructed for 1983 cohort when compared
three decades later to 2015-‘17 cohort revealed almost similar low growth potential for 10th,
25th, 50th, 75th and 90th percentile curves till 32 weeks gestation, thereafter the 2015-’17 study
gained 100-300 g weight from 32 to 37 weeks, following which there was catch-up growth by
the 1983 cohort at 40 weeks with 200-300 g growth spurt 40-42 weeks gestation and thereafter

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 35

500 g in 2015-’17 study demonstrating an inherent genetic predisposition at play rather than
environmental factors despite vast increase of socioeconomic reforms and technological
advances in the country [101,104].

The comparison of national and international intrauterine growth chart revealed that the 10th
percentile in the 2015-’17 South Indian cohort and the All India National Neonatal Perinatal
Data base (NNPD) study with Lubchenco’s were closely related, thereafter the Lubencho curve
diverged from 32-33 weeks gestation with rapid weight gain of around 500 g at 37 weeks, then
decreased by 200- 300g weight gain at 40 weeks gestation. However the 50th percentile curve
in 2015-’17 study and 50th percentile NNPD study revealed low growth potential corresponded
to the 10th percentile International WHO curve [104,111,112].

However though the 90th percentile growth curve in 2016-‘17 Indian study was similar only till
32 weeks gestation to 90th percentile World Health Organization (WHO) curve, it thereafter
declined to below the 50th percentile WHO curve at 40 weeks in contrast the 90th percentile
WHO curve continued to gain more than 1000g at 40 weeks gestation [104,108]. Also the 90th
percentile all India NNPD had the least growth potential corresponding to 50th percentile WHO
curve up till 37 weeks gestation and thereafter fell by over 250 g less but had a catch-up growth
to the 90th percentile South Indian 2015-17 curve at 40 weeks gestation [104,108,111].

Comparison of the 10th percentile intrauterine growth curve reported in UK study corresponded
to the 50th percentile of 2015-’17 South Indian curve till 36 weeks, which thereafter flattened
by almost 800 g to meet the 10th percentile of 2015-’17 South Indian curve at 41-42 weeks
gestation. However the 50th percentile South Indian curve was lower by around 200 g compared
to 50th percentile UK curve at all gestation, though the 90th percentile South Indian curve
corresponded to 90th percentile UK curve till 38 weeks, the UK curve thereafter increased by
almost 500 g greater weight gain by 41-42 weeks gestation [104,113]. The 50th percentile US
curve though similar to the 50th ercentile South Indian curve till 30 weeks, thereafter diverged
with rapid intrauterine fetal growth up to 34 weeks corresponding to 90th percentile Indian
growth curve and gaining more than 1000 g at 40 weeks gestation [104,114].

Birth weight for gestational age is a commonly assessed perinatal outcome parameter and Small
for Gestational Age (SGA) defined as weighing less than 10th percentile of birth weight for
that gestation is also an indicator for Intrauterine Fetal Growth Restriction (IUGR), its
importance is due to high associated perinatal and infant morbidity and mortality as well as
future adult chronic non-communicable diseases such as cardiovascular disease, stroke, type II
diabetes, obesity, other endocrine and metabolic disorders prominently linked to Small for
Gestational Age (SGA) [115,116]. Invalidating international reference WHO percentile
intrauterine growth curves which differs from the Indian intrauterine growth curves such that
the 10th percentile is almost 800 g below WHO 10th percentile curve, while 50th percentile
South Indian curve corresponds to 10th percentile WHO curve, that would mistakenly identify
a large proportion of Appropriate for Gestational Age (AGA) Indian babies as small for
Gestation Age (SGA) who have differing morbidity and mortality, emphasizing further why
ethnic Asians require specific intrauterine growth charts to avoid inaccurate labeling of SGA
newborns and their management, however these small for dates after birth feed avidly and gain
weight [104,107,108,112].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 36

Pooling of data as in the international WHO intrauterine growth curves do not represent
variations among populations in a single intrauterine growth chart but only partially reflect the
individual population included, hence ideally two separate ethnic Asian and Caucasian
intrauterine growth charts are recommended [104,107,108,113,114].

Therefore despite the vast technological and economic revolution that has influenced all
sections of society in India including improved obstetric care, ethnic Asian foetuses will
continue to have low intrauterine growth velocity with low average birth weight as a result of
asymmetrical intrauterine growth retardation as well as shortened gestation when compared to
Caucasian counterparts is primarily due to inherent genetic predisposition [105,114]. Hence
ethnic Asian specific intrauterine growth curves is mandated for accurate identification of small
for dates for institution of early management of treatment of complication for SGA as well as
LGA newborns as well as ethnic specific Asian and Caucasians perinatal guidelines
[104,107,114].

I have also reported 21.2% incidence of birth asphyxia comprising 583 cases among 2750
singleton live births who required resuscitation at birth to establish rhythmic respiration,
majority delivered at 39 weeks by emergency LSCS births OR 4.91, [CI 95%] 3.94-6.10 times
compared to normal delivery being highly statistically significant P=0.0001. In contrast
elective LSCS deliveries was associated with low risk 9.1% of birth asphyxia with OR 1.67
[CI 95%] 0.84-1.63, not statistically insignificant P=0.358. Though vacuum extraction
comprised 11% of births, it was associated with a significantly higher risk of birth asphyxia,
OR 8 [CI 95%] 5.58- 11.69, being highly statistically significant P=0.0001 [10].

Also, Meconium Staining Of Amniotic Fluid (MSAF) was associated with 84% asphyxiated
newborns, OR 8.42 [CI95%] 5.1-14 being 30 times higher compared to newborns with clear
liquor (P=0.0001) (117). One-fifth 21% newborns with MSAF develop MAS, one-third
requiring intubation and mechanical ventilation. MSAF is usually present in 8-20% of all
deliveries increasing to 23-52% by 42-44 weeks of gestation but rarely found in amniotic fluid
before 34 weeks gestation. MSAF with increasing gestation beyond 39weeks, predisposes to
maternal complications such as meconium laden amniotic fluid embolism, intra-partum chorio-
aminioitis, puerperal endometritis, wound infection etc. with increasing morbidity and
mortality in both the newborns and their mothers. Peak delivery 38% of newborns with thick
MSAF, 35% MAS, and 32% newborns with thin MSAF occurred at 39 weeks delivered mainly
by emergency LSCS [117-122].

WHO has stated that LSCS performed when necessary can effectively reduce maternal and
neonatal mortality, the ideal rate of LSCS being 10% for a given population with a rise towards
is 10-15%. However if LSCS rates go above 10% there is no evidence to indicate that mortality
rates will improve. Though emergency LSCS is a boon for mothers and babies, there is no
similar evidence for elective LSCS, which in fact could become life threatening. However the
benefits of elective LSCS in high risk cases is associated with improved neonatal and maternal
outcome and other benefits such as decreased perineal pain and urinary incontinence at three
months [123]. In India, the National Family Health Surveys (NFHS) 4 and 5 in 2015 and 2019
respectively reported an overall incidence of 17 5% LSCS, being higher than WHO

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 37

recommended limits with a high 60.7% in Telegana followed by 42.2% in Andhra Pradesh,
41.7% in Jammu and Kashmir, 39.5% in Goa and 37.6% in Ladakh [124,125]. I reported LSCS
of 42% in Bangalore in 2015-’17 with up to 80% in some centres [101,126]. In fact Turkey has
the highest caesarean section rate of 54.9% followed by Korea 45%, Poland 38.9%, US 32%,
UK 28.5%, Canada 27.7% [127]. Thus it may be observed that caesarean section rates are
highest in Asian countries as compared to western countries due to the increased vulnerability
of ethnic Asian foetuses to asphyxial birth injury with prolonged labor due to undetected CPD
during vaginal delivery as compared to Caucasian foetuses who have remarkably low perinatal
mortality rates, having almost eliminated birth asphyxia with low incidence of around 1%
[18,19,101,128].

Planned elective LSCS or active management labor and cutting short second stage of labor
with outlet or low perineal forceps delivery in high risk cases at 38 weeks gestation will obviate
complications of later delivery by 39 weeks and beyond by decreased resort to emergency
surgical intervention, could not only envision reduction in incidence of emergency LSCS but
also improvement in outcome of both mother and baby with resultant significant fall in
perinatal, neonatal and maternal mortality and morbidity [101,104,107].

Intrapartum events with placental insufficiency during labour contractions results in maximum
decrease in fetal oxygen saturation especially during the latter part of the second stage of labour
as fetal blood supply is diminished by uterine contractions or terminated by cord compression,
resulting in asphyxia [129]. Thus intrapartum events have more impact than antepartum factors
as various studies show placental insufficiency with decrease in oxygen supply to the fetus
during contractions, assessed by scalp electrode, an intrauterine pressure catheter and a
specially designed fetal pulse oximetry sensor, that records maximum drop in fetal oxygen
saturation 92 seconds after the peak of a contraction with recovery 1 minute 30 seconds later,
is statistically significant (P=0.036). Also intravascular oxygen electrode measuring
continuous fetal arterial PO2 showed transient fetal hypoxemia following uterine contractions
[130]. Fetal infrared spectroscopy demonstrated a fall in cerebral oxygenated hemoglobin after
a contraction, as well as angiographic studies reveal blocked circulation through the intervillous
space during uterine contractions decreasing oxygen transfer to the fetus with lower oxygen
levels and pH, noted more so, at the end of labor than at the beginning, compounded by
maternal pain, breath holding and maternal metabolic acidosis further reducing oxygen
delivery to the fetus [131-133].

In the fetus deoxygenated blood with low oxygen saturation of 25-40% passes through
umbilical arteries to the placenta which is the organ of gas exchange returns to fetus through
umbilical vein with high oxygen saturation of 80-90% is first delivered to brain and
myocardium as circulation is ‘shunt dependent’, also fetal haemoglobin (HbF) helps to
maintain oxygen delivery due to shift in left of oxygen disassociation curve which after birth
proves disadvantageous with impairment of oxygen extraction at tissue level [63,74,75].

During labor the mean fetal SpO2 decrease to around 45-50%, and during last one hour of
delivery if SpO2 falls below <30% for more than 30% correlates highly with fetal acidosis in
cases of non-reassuring fetal heart rate [133,134]. However after birth, gas exchange shifts to
lungs with 8-10 fold increase in pulmonary blood flow and fall in pulmonary vascular

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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resistance as better oxygenation of neonatal blood increases pulmonary compliance by

reversing pulmonary vasoconstriction caused by hypoxia [34,63]. Therefore a low SpO2 below
50% may be expected if the asphyxiated newborn fails to establish breathing soon after birth
mandating immediate resuscitation with oxygen to quickly reverse hypoxial injury and its
sequelae or death [135].

Bradycardia with weak, irregular beats is indicative of fetal anoxia, usually observed a few
minutes to a few days before delivery associated with sudden increase in fetal activity followed
by diminished activity. Scalp blood analysis may show acidosis with a pH of less than 7.20,
comprising both of respiratory and metabolic components [131,134,136]. Fetal heart rate
monitoring reveals variable late (type II dips) deceleration pattern without any variability in
response to fetal movements or uterine contractions. Consistent slowing or late deceleration of
the fetal heart rate following termination of each uterine contraction is indicative of
uteroplacental insufficiency also considered as positive oxytocin challenge test requires
supplemental oxygen to mother before delivery [134,136]. If fetus is at high risk for asphyxia
due to inadequate supply of oxygen from the placenta detected during labor presenting with
fetal distress, then emergency delivery may be attempted preferably by caesarean section or
alternatively by outlet forceps delivery if head is in perineum.

The longer the hypoxic episode the more severe the sequelae with secondary and terminal
apnea requiring immediate effective resuscitation to avoid death with supplemental oxygen
administration at 16 to 20 cm of H20 for 1 to 2 seconds to counteract hypoxia or upto 1-3
minutes by nasal oxygen inflation at flow rates between 12-15 L/min [38-40]. Due to
hypoxemia and acidosis, the impaired cellular function results in failure of mitochondrial ATP
pump and energy reserves are depleted. Among all sources of energy, glucose alone is capable
of sustaining energy metabolism in the brain under conditions of total cerebral ischemia,
because of its capacity for consumption via anaerobic glycolysis with the production of lactic
acid and ATP. However, during anaerobic conditions, one molecule of glucose yields only 2
mols of ATP as opposed to 38 molecules of ATP during aerobic metabolism. Production of
lactic acid due to the anaerobic metabolism remains in the tissue because of poor perfusion.
The concomitant acidosis leads to decreased heart rate and cardiac output with decreasing
blood pressure leading to cell damage and functional abnormality-such as renal failure in the
kidneys, necrotizing enterocolitis in the gut, hypoxic myocarditis, decreased pulmonary
perfusion, abnormalities of gas exchange and persistent pulmonary hypertension in the lungs
[34,63,64,74].

Birth asphyxia initiates diving reflex; causing shunting of blood to the brain; heart and adrenals
with reduce flow or hypo perfusion in organ system of lungs, gut, liver, kidney, spleen and
skin. In mild hypoxia there is increase in blood pressure and heart rate to maintain cerebral
perfusion-the brain sparing effect [34,35]. In the initial stage of primary apnea, the fetus gasps
in utero, for a short period, heart rate and blood pressure may remain constant or become
slightly elevated, following which, after an interval of a few minutes the fetus commences a
second period of gasping and enters terminal stage or secondary apnea wherein the heart rate
and blood pressure fall quickly and if not immediately resuscitated, will die at birth [135].
Apnea is defined as cessation of breathing greater than 20 seconds and most asphyxiated infants
born with primary apnea will commence spontaneous respiration if given air or supplemental

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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oxygen to breathe, while secondary or terminal apnea requires immediate resuscitative

measures best achieved by LNR to establish rhythmic respiration [34,60,135].

Asphyxia has been demonstrated to cause two patterns of brain damage in animals, firstly acute
total asphyxia produce neuronal necrosis of the brain stem nuclei and secondly partial
prolonged asphyxia results in necrosis of cerebral hemisphere [137]. However pathogenesis of
intrauterine asphyxia in a full term neonate with redistribution of organ blood flow, result in
oxygen debt to brain cells, impaired auto regulation of cerebral blood flow, intracellular
swelling, leading to focal ischemia, generalized brain swelling, increased intracranial pressure,
causing cerebral necrosis and atrophic cortical sclerosis [138]. Autopsy study in preterms with
repeated prolonged apnea more than 20 seconds and cyanosis revealed diffuse neuronal loss
in cerebral cortex, leukomalacia in periventricular watershed zones while full terms with
hypoxic episodes between 2 to 52 weeks of age noted subcortical leukomalacia related to
border zones with tenuous arterial blood supply from anterior , middle and posterior cerebral
arteries and in preterm as auto regulation of smooth muscle tone in vessel is not present is
mainly dependant on systemic blood pressure hence these areas are extremely susceptible to
hypoxic injury [139]. The mechanism of intraventricular haemorrhage is probably that an
asphyxial episode causes vascular constriction followed by vascular dilation with increased
intravascular pressure which ruptures vulnerable vessels in the germinal matrix especially in
the periventricular area in the immature-brain [140].

Various other criteria recommended by AAP and ACOG for severe birth asphyxia include: (I)
Profound metabolic or mixed academia, with an umbilical artery pH <7.00, (II) Apgar score of
0-3 beyond 5 minutes, (III) Neurological involvement such as convulsions, unconsciousness
and hypotonia, (IV) Multi organ system dysfunction involving various systems such as CVS,
GI, kidneys, lungs etc [141]. Hypoxic Ischemic Encephalopathy (HIE) mild, moderate or
severe, classified by Sarnat and Sarnat as stages I, II, or III is based on level of consciousness,
neuromuscular control, tendon and complex reflexes, gastrointestinal motility, presence or
absence of myoclonus, electrography findings and autonomic functions, however these
parameters have no predictive value for long-term neurologic injury after mild to moderate
asphyxia is no longer validated as accurate assessment of birth asphyxia can be monitored by
pulse oximeter [142].

Nearly 20-40 percent of perinatal deaths are attributed to birth asphyxia especially in Asian
countries [5-12,16,17]. Strictly speaking stillbirths are fetal deaths nevertheless even live born
neonate who is apneic and cyanotic with pulse is set aside after birth and left to initiate
respiration, or are inadequately resuscitated and die are classified as stillbirths as unskilled birth
attendants may not be able to distinguish between the two conditions with inaccuracy of
recording these fatalities, often termed stillbirth with high stillbirth rates. Hence
misclassification of stillbirths has significant implications of national health policies and global
strategies for reducing perinatal mortality is actually a poorly resuscitated viable newborn,
would lower stillbirths rate as also a large number are unregistered [16,17]. The disadvantages
of effective neonatal resuscitation by Neonatal Resuscitation Program (NRP) include highly
trained skilled birth attendants and well outfitted resuscitation teams and as such is not
universally applicable in many parts of low income Asian countries with limited resource

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 40

settings who lack essential resuscitation equipment and in addition bulb syringes, bag and mask
devices may be substandard and unskilled birth attendants [29,30].

Lalana Newborn Resuscitation is a new novel non-invasive approach in management of all

cases of birth asphyxia, requires minimal infrastructure for oxygen supply from either piped
oxygen of cylinder with flow meter and wide bore oxygen tube, requires minimal training of
even unskilled birth attendants, help improve individual outcome of newborns suffering from
lack of oxygen resulting from perinatal asphyxia will prove to be of vital importance as quick
oxygenation of tissues, reversing hypoxial insult in initiating regular breathing pattern will save
millions of lives by reducing asphyxial neonatal deaths with minimal residual sequelae or ill
effects as well as reviving viable apneic newborns who otherwise would be termed as stillbirths
[60].

In India current neonatal mortality rate is 28/1,000 live births, with 40 and 49 per 1000 live
births being infant and child mortality rates being 70% of total infant deaths and more than half
of under five deaths and ENMR of 22 per 1000 live births account for 45% of total under five
deaths. Of 25 million global births of children each year, India contributes to one-fifth of total
global live births and more than a quarter of neonatal deaths [12,51,52]. Almost all asphyxia
deaths (97.8%) occur within the first week with 70% within the first 24 hours of life [51]. In
fact India leads with 522 neonatal deaths per 1000 live births followed by Nigeria at 270, Next
Pakistan 248, Ethiopia 99, Democratic Republic of the Congo 97, China 64, Indonesia 60,
Bangladesh 56, Afghanistan 43 and United Republic of Tanzania 43 per 1000 live births
[51,52,143]. However NMR is not uniform across the country with Kerala and Tamil nadu with
low NMRs of below 20/1000, Odisha, Madhya Pradesh and Uttar Pradesh have high NMRs of
more than 35/1000, though Haryana and Gujarat have similar or higher per capita GDP than
Tamil Nadu but almost double NMR. In fact four states, Uttar Pradesh, Madhya Pradesh, Bihar
and Rajasthan alone contribute to 55% of total neonatal deaths in India and up to 15% of global
neonatal deaths occur every year [51,52].

Thus Birth asphyxia is leading preventable cause compounded by the high stillbirth rate, who
would have had a good chance of healthy life on survival with effective resuscitation, however
essential newborn care recommended by WHO reveals inadequacies in mother and child with
only around four antenatal visits and skilled birth attendants is about 50% in 68 count down
countries and neonatal mortality comprising 52% of under five-year mortality [143]. Effective
newborn resuscitation by LNR in many low to middle income Asian countries with limited
resources would require minimal set up with availability of humidified oxygen regulated with
flow meter and pulse oximeter to monitor peripheral tissue oxygenation (SpO2), in fact portable
oxygen cylinders even allows for effective domiciliary resuscitation, equipping even unskilled
birth attendant, who may easily be taught detection of hypoxia/asphyxia of newborn based on
pulse oximetry SpO2 and recording of heart beats per minute obviating the need for a
stethoscope. Simple classification of newborns as ‘Normal’ and hypoxic as Grade I-V
determines sustained nasal oxygen flow rate varying from 2-15 L/min, oxygen flow to be
discontinued with Pulse oximetry, zero score SpO2 96%, while drying the baby, suctioning
nose and mouth to clear the airway passage aided by tactile stimulation in initiating rhythmic
respiration, maintaining body temperature, under asepsis precautions and initiating early breast
feeding practices. In the present study LNR proved eminently effective in all 178 asphyxiated

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 41

newborns resuscitated among 830 deliveries attended, three of whom had secondary apnea
Grade IV and one newborn with terminal apnea Grade V initiated rhythmic respiration,
smoothly transiting from fetal fluid filled lungs to well aerated neonatal lungs with vital
cardiovascular transition to neonatal life.

Advantages of Lalana Newborn Resuscitation (LNR) with

Continuous Positive Pressure Ventilation by sustained nasal
oxygen inflation at flow rates varying from 2-15 litres per
minute assessed by Pulse oximetry score of SpO2

1. Resuscitation of the newly born is unique as the presence of fetal lung fluid
prevents exchange of gases.
2. Sustained nasal oxygen inflatory flow provides continuous distending pressure
that generates hydrostatic pressure to effectively overcome the high resistance of
moving fetal lung fluid through the airways and across the alveolar wall into the
interstitial tissue as well as opposes elevated interstitial pressure during
expiration, preventing lung fluid from re-entering the airways promoting
enhanced reabsorption of lung fluid.
3. Lalana Newborn Resuscitation (LNR) is safe and quick resuscitation of newborn
by non-invasive technique based on CPPV by sustained nasal oxygen inflation
meets the aim of effective resuscitation preventing neonatal death or adverse long
term neurodevelopmental sequelae in survivors, ensuring that children should be
normal.
4. Continuous positive pressure ventilation results in uniform lung aeration,
improved oxygenation with increased pulmonary compliance that increases
Functional Residual Capacity (FRC), prevents atelectasis and maintains lung
volume.
5. Stabilizing newborns with low fraction of inspired oxygen at birth is difficult
since hypoxia is a potent inhibitor of spontaneous breathing; therefore increase
in oxygen flow rate with higher FiO2 determined by Pulse oximetry reading of
SpO2, help to overcome hypoxial insult with quick onset of respiration.
6. Oxygen is the only treatment for hypoxia that facilitates aerobic metabolic
glycolysis and mitigates vagal-induced bradycardia resulting from perinatal
asphyxia that perpetuates hypoxemia with hypercapnia or rise in arterial carbon
dioxide, reducing blood flow to the brain with ischemia causing altered mental
status.
7. The prompt increase in heart rate with improved cardiac output indicate adequate
lung aeration and function resulting in left to right shunting triggering reflex
physiological mechanism that converts fetal circulation to adult type.
8. Continuous Pulse oximetry monitoring gives real time assessment of newborns
in maintaining SpO2 at 96%-98%, mitigates hypoxial injury and cell damage
causing multi-organ failure, neurological deficits or death.

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 42

9. LNR prevents both deleterious effects of hypoxia and detrimental hyperoxia

especially in preterms with sustained nasal oxygen inflatory flow rate determined
by Pulse oximeter SpO2 and discontinued at SpO2 96%.
10. LNR Protocol require minimal infrastructure for supply of humidified oxygen
with flow meter as well as minimal training of even unskilled birth attendants,
proves advantageous more so in low to middle income Asian countries with
limited resources wherein majority of the world’s population reside accounting
for 98% of global perinatal mortality rates.
11. Indications of successful ventilation by LNR is achieved with Zero Pulse
oximetry score, SpO2 >96%, rhythmic pattern of respiration, rate of 30-60/min,
heart rate 120-160 bpm and regular pulsatile changes on plethysmograph with
adequate circulation of oxygenated blood throughout the body.

Disadvantages of Neonatal Resuscitation Program (NRP) with

Intermittent Positive Pressure Ventilation, using bag and
simple mask or invasive endotracheal intubation

1. Short Intermittent Positive Pressure Ventilation (IPPV) is potentially harmful, causing

un-even alveolar ventilation with increased susceptibility to lung injury as the entire
tidal volume will only enter previously aerated regions which has important
implications because during subsequent inflation air will first rapidly flow into and
expand previously aerated lung regions due to much lower airway resistance.
2. IPPV is proven both scientifically and physiologically weak in effectively clearing lung
fluid due to impaired generation of hydrostatic pressure while also permitting fluid to
re-enter the airways with rising A-a gradient, poor oxygenation and circulation of
deoxygenated blood to peripheral tissues.
3. Hypoxia is perpetuated due to increased pulmonary compliance with intermittent
alveolar collapse during IPPV causing V/Q mismatch and right to left shunting of
deoxygenated blood through unexpanded lung.
4. Peripheral oxygen saturation stated by NRP protocol by IPPV seems unacceptable
advocating SpO2 40-45% at 1 min, SpO2 65-75%, at 2 min, SpO2 70-75%, at 3 min,
SpO2 75-85%, at 4 min, SpO2 80-85% at 5 min, SpO2 85-95% at 10 min with long delay
for hypoxic newborns to achieve SpO2 96%. Longer hypoxic episode result in more
severe sequelae often leaving of survivors with permanent lifelong neurological deficits
or multi-organ complications or death within the first few days.
5. Prolonged hypoxia predisposes to anaerobic metabolism and acidosis, impairs cardiac
function resulting in bradycardia and poor peripheral circulation hindering smooth
transition of fetal to neonatal circulation.
6. IPPV with bag and face mask or mouth-to mouth breathing is not effective as adequate
trans-pulmonary pressure for adequate displacement of lung fluid is difficult to achieve
as also because gastric distension occurs.
7. Also simple tight fitting of face mask or endotracheal intubation with FiO2, up to 1.0 or
100% predisposes to hyperoxia with generation of oxygen free radicals, which have a

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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deleterious role causing reperfusion injury contributing to eye (ROP), neurological and
lung injury in preterm.
8. NRP requires the presence of a team of highly trained skilled birth attendants for bag
and mask or invasive endotracheal intubation for Intermittent Positive Pressure
Ventilation, as more severely asphyxiated newborns require cardiopulmonary
resuscitation or medication such as epinephrine or saline volume expanders etc.
9. NRP protocol is best adapted for resuscitation in cardiopulmonary arrest of infants,
children and adults with previously well aerated lungs.
10. Neonatal Resuscitation Program (NRP) has been associated with remarkable decline in
asphyxial deaths worldwide, however the degree of morbidity remains high affecting
quality of life in nearly half of survivors as the rate of Hypoxic Ischemic
Encephalopathy (HIE) has remained the same over the past decades
[4,7,11,29,30,31,48,49].
Thus in spite of vast advances in perinatal care, obstetric management with improved
technology in fetal monitoring etc. birth asphyxia continues to be the leading cause of the
preventable high prevailing perinatal and neonatal morbidity and mortality in most Asian
countries in spite of world-wide reduction in asphyxial deaths following the introduction of
Neonatal Resuscitation Program but with high morbidity with up to 40% of survivors suffering
from ill effects of hypoxial sequelae ranging from mild to severe permanent neurological
deficits etc with incidence of HIE has shown no decrease over the past decades
[7,11,16,17,29,30,49].

I have reported average duration of pregnancy in ethnic Asian-Indian population is 38.2 weeks
and that peak births of healthy, non-asphyxiated newborns born normally with clear liquor took
place at 38 weeks, while most asphyxiated births, majority delivered by emergency LSCS
occurred at 39 weeks (10). In fact 84% of asphyxiated newborns developed complications of
Meconium Staining of Amniotic Fluid (MSAF) and Meconium Aspiration Syndrome (MAS)
[101,117]. This has important significance as increased in emergency surgical intervention at
mean gestation of 39.1 ± S.D. 1.2 weeks, occurring in more mature, high birthweights
newborns weighing around 4000g indicating fetal distress usually after prolonged labor due to
undetected CPD more so in young primigravida mothers, who are at higher risk of dying from
perinatal asphyxia [10,101,104].

Thus the small Asian neonate with average low birth weight around 2800 -3000 g attributed to
asymmetrical intrauterine growth retardation due to inherent genetic predisposition rather than
environmental factors with low energy reserves are less well equipped to cope with any
asphyxial insults resulting from uterine contractions especially when labor is prolonged with
increased mortality and morbidity with adverse long term sequelae [101,104,115,129].
However healthy small for dates, shortly after birth, will feed avidly and gain weight indicating
effective preventive strategies now takes on priority in saving the small Asian babies, that
mandates institution of new ethnic Asian specific guidelines for well-being of Asian newborns
by clinical implementation of peak ethnic Asian births with Asian Due Date (ADD) for delivery
at 38+6 weeks gestation, thus preventing hypoxial birth injury and colossal asphyxial deaths
which are totally preventable [101,104,107].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 44

Other clinical studies from the west report low digit figures perinatal, neonatal and maternal
mortality rates having almost eliminated birth asphyxia with low 1% incidence, yet
demonstrate delivery at 38 weeks by planned or elective LSCS in high risk groups have least
risk of perinatal deaths and that prolonging pregnancy to 39 weeks up to 43 weeks note
increased perinatal risk index due to obstetric events more so in primigravidas with greater risk
of antepartum stillbirth [18,19,144-147]. Also, non-laboring women delivered by caesarean
section before 39 weeks, obviates intrapartum events, reported 83% reduction in moderate to
severe encephalopathy, being one of the leading causes of HIE as well as late fetal death,
signifying that early planned delivery preferably at 38 weeks more so by elective section in
high risk cases before intrapartum events was associated, not only with reduction in birth
asphyxia cases but also fresh stillbirths due to anoxia and neonatal complications such as
respiratory disorders etc, being the most effective strategy than any other so far implemented,
yet still others estimate the lowest cumulative risk of perinatal deaths and advocate delivery by
37 weeks gestation [49,107,144-151].

Thus prolonging pregnancy to 39 weeks and beyond increases the risk of stillbirth, neonatal
and maternal morbidity and mortality with adverse increase in neonatal risk predisposing to
high risk of perinatal asphyxia and higher risk of stillbirth as well as other outcomes such as
PIH that rises with each additional week of gestation [10,49,144-151]. Postdate induction is
typically not recommended prior to 41st week, a dictum followed also by Asian obstetricians
in management of pregnancy in ethnic Asian women, who often experience uterine
contractions by 38 weeks of gestation, labelled as ‘false labor pains’ and instead of attempting
delivery with amniotomy, which is now well accepted in acceleration of labour, or use of
prostaglandin E2, for cervical ripening, instead opt to prolong pregnancy to 40 weeks or
Expected Date for Delivery (EDD) with tocolytic medication to suppress uterine contractions
and/or bed rest increasing risk of neonatal and maternal morbidity and mortality.

Also the later delivery at term questions management of pregnancy at 39-43 weeks associated
with increase obstetric intervention by emergency LSCS more so in ethnic Asian population
[101,104,107,146]. In fact a substantial number of newborns could have perinatal asphyxia
attenuated or removed given timely obstetric intervention and as such elective section at 38
weeks more so in high risk cases would remove the risk of intrapartum asphyxia and reduction
of HIE with improved perinatal outcome and lower term stillbirth rates [10,21,101,107]. Hence
the lowest risk of perinatal deaths was noted at 38 weeks, sharply increased among
primigravida women beyond 39 weeks, because of greater risk of shoulder dystocia, foetal
trauma, meconium staining of liqor, neonatal encephalopathy and intrauterine demise with
higher incidence of HIE [10,49,145,147].
Hence majority of ethnic Asian women who do experience uterine contractions before 40
weeks EDD, should be allowed to progress even from 36 weeks of gestation onwards, though
a blanket policy for induction of labour at 38 weeks would certainly be associated with an
unacceptable general increase in rate of obstetric intervention, it is important to take into
consideration the unique ethnic diversity or genetic predisposition by implementing ethnic due
dates for the two main ethnic races, Asians and Caucasians [107,146]. Thus implementation of
ethnic Asian Due Date at 38+6 weeks gestation will result in improved perinatal outcome as
opposed to a common EDD at 40 weeks well adapted to Caucasian population [152].

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 45

The existing perinatal definitions and guidelines established by World Health Organization
stated in standard medical text books have not taken into consideration ethnic difference that
exists between the two main Asian and Caucasian races [153]. It is this inability to address the
unique ethnic inherent genetic predisposition in Asian population, that resulted in failure of
MDGs - 4 goals with the specific aim of reducing under five child mortality rates by two-thirds,
despite addressing determinants of human health and welfare including poverty, hunger and
disease between 1990 to 2015 that was adopted by United Nations (UN) globally, as majority
under-five child mortality occurs predominantly in ethnic Asian population residing mainly in
low to middle income Asian countries [154-156].

Following years of research and in-depth analysis, I outlined up-to-date ethnic Asian perinatal
standards and definitions, providing appropriate guidelines for ethnic Asian Obstetricians,
Paediatricians/Neonatologists, if implemented will result in improved neonatal and maternal
outcome with reduction in perinatal, neonatal and maternal morbidity and mortality,
consequently infant and under-five years child mortality rates to reach targets set by SDG goals
[152,153]. While extended perinatal team includes radiologists, paediatric surgeons,
genetic/prenatal councillors etc in the event of fetal anomalies for advice or if surgically
correctable with in utero or immediate post-natal surgical intervention.

Hospital based study suggests that 25-62 % of intrapartum stillbirths can be avoided with better
obstetric care and more rapid response to intrapartum complications and the question can
intrapartum-related deaths be reduced as well as disability and can the health system deliver?
as well as reducing the global rate in caesarean section, which is alarmingly increasing
[128,156]. The answer is ‘No’ as so far, all strategies in maternal and child care implemented
all over world has not seen any dramatic reduction in perinatal mortality rates (stillbirths and
early neonatal deaths) due mainly to birth asphyxia which is a preventable cause including
maternal mortality rates as well as reduction of emergency LSCS be envisioned, unless a simple
perinatal guideline of ethnic specific Asian Due Date (ADD) at 38+6 weeks by planned or
spontaneous delivery gestation is implemented by eliminating a common E.D.D at 40+6 weeks
gestation, stated in all standard western text books, best suited for Caucasian population, by
avoiding intrapartum events at 39 weeks and beyond, ensures not only reduction in stillbirths
but also early neonatal deaths due to perinatal asphyxia by decreasing impact of shoulder
dystocia, foetal trauma, neonatal encephalopathy and intrauterine demise and other
complications of labour that occurs more common at delivery by 39 weeks and beyond,
circumventing the problem by delivery in ethnic Asians by 38 weeks gestation [144-152].

In fact only 1.7 percent of Asian women gave birth after 40 weeks EDD, while 90.3% Asian-
Indian women delivered before EDD i.e. 40 completed weeks or 280 days gestation (105). The
Asian Due date at 38+6 weeks is most appropriate for ethnic Asians, most accurately calculated
if menstrual cycles were regular and 28 days interval with ovulation occurring on Day 14,
estimated by Lalana’s rule, Step 1: Determine the first day of last menstrual period, Step 2:
Subtract 1 week, Step 3: Subtract 3 months, Step 4: Add 1 year to arrive at 38+6 weeks or 266
days of gestation, for e.g. if LMP was 15th November, 2021, then ADD is August 8th , 2022
approximately at an interval of 38+6 weeks (or 266 days) from LMP [107].

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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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In contrast only one-third, 32% of Caucasian - British women delivered before Expected Date
of Delivery (EDD) or 40+6 weeks gestation, as significantly more British women, 68 percent
delivered after 40 weeks EDD during 41-44 weeks of gestation [105]. The importance of
addressing inherent genetic or racial differences Asian and Caucasian population cannot be
underestimated as this important criterion has not been addressed world-wide so far, in
formulating ethnic Caucasian and Asian perinatal definition and guidelines that will go a long
way in catering to the well-being of ethnic Asian foetuses and neonates as well as their mothers.
UNICEF, WHO, World Bank and UNDESA reports that sixty million under-five years children
will die between 2017 and 2030, though only 5.6 million children died in 2016 compared to
9.9 million in 2000. Despite a decline in maternal mortality ratio by 37 percent between 2000
and 2015, globally has dropped from 451,000 in 2000 to 295,000 in 2017, a 38% decrease,
that’s around 808 women every day, mostly from preventable causes with aim to reduce global
maternal mortality ratio to less than 70 per 100,000 live births. While Finland, Greece, Iceland
and Poland have 3 women per 100,000 births, thus nearly 95% reduction is to be envisioned
since majority births occur in in Asian countries with nearly two-thirds of maternal deaths with
rate of 130/100, 000 live births during 2016-2018 or 26437 maternal deaths in 2018 mainly
50-98% caused by post-partum haemorrhage, sepsis, PIH and complications of delivery which
may be reduced just by delivering at optimum 38 weeks gestation [14,15,51,157-160].
However I hope that it will not be too frustratingly too long before we finally change practices
in implementing ethnic specific perinatal guidelines and clinically accepted before steep
reduction in perinatal, neonatal and maternal mortality and morbidity becomes a reality.

The current world population of 7.8 billion according to recent United Nations estimates, ethnic
Asians comprise 60% of world population with 4.5 billion residing in Asian countries report
high prevailing perinatal, neonatal, and maternal mortality rates as well as under five years,
morbidity and mortality [109,154-156]. The MDG- 4 set out by World Health Organization
(WHO) significantly reduced under-five mortality rate by 59% between 2000-2015, WHO in
2013 reported that the number of deaths of children under five years fell from 12.7 million in
1990 to 6.3 million in 2013, almost all, 95% of these occur in developing low to middle income
Asian countries [157].

In 2018 WHO reported that over 6 million children and adolescents died globally, of which 5
million died before the age of five, majority of these deaths being preventable occurring mainly
in low-middle income Asian countries despite measures for intervention in the care of newborn
and their mothers such as infant and young child feeding, expanded programme on
immunization with newer vaccines, prevention and case management of pneumonia, diarrhea
and sepsis, malaria control and prevention and care of HIV/AIDS by appropriate home care
and early treatment of complications of newborn, with integrated management of childhood
illnesses in under five years, complimented by interventions for maternal health and nutrition,
especially skilled care during pregnancy and childbirth has not shown further significant
reduction in perinatal and neonatal mortality [158-160].

As in 2019, 5.4 million children under five died of preventable/ treatable causes on an average
means 15,000 young children. While infants comprised 1.5 million, 1-4 years accounted for
1.3 million deaths. The remaining 2.4 million deaths occurred among neonates in the first 28
days of life, highlights importance of reducing neonatal deaths and thereby under-five year

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

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DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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mortality rates occurring mainly in ethnic Asian population. Sustainable Development Goals
(SDGs) 3.2.1, known also as Global Goals stipulate reduction of 11 million under-five child
deaths between 2019-2030, is a huge achievement, currently far away, despite improvement of
global health 4.5 million child deaths will occur by 2030 or 86 million child deaths in SDG era,
aimed at reduction of neonatal mortality to at least 12 per 1000 live births, or that 97.5% of all
newborns would survive, no matter where they are born and child mortality to at least 2.5%
signatory by more than 100 UN Member States as part of the 70th session of UN General
Assembly with renewed commitment to children rights who will grow up to become the future
leaders and pillars of society in protecting their healthy growth and development with
emphasizes shifted to the neonatal period or first 28 days of life as being the most vulnerable
time in the life of a child with high mortality rates [14,15,160].

India with growth rate of 1.11% with 1.35 billion is poised to become the most populated
country in the world by 2027 according to new UN study of global population trends, just
second to China with 1.41 billion, with growth rate 0.39-0.59% (109,161). Thus India could
well set ethnic specific perinatal Asian guidelines and definitions to envision improved
perinatal, neonatal and maternal outcomes, as well as reference intrauterine growth chart for
accurate identification of those at risk neonates SGA and LGA newborns that require special
care. Therefore the most vulnerable time in child survival is during the neonatal period,
especially the first 24 hours of life and within the first week that is critical in the life of
individual and effective strategies are needed to improve outcome by addressing inherent
ethnic diversity in Asian and Caucasian population being the need of the hour. In India among
0.386 million cases of newborn asphyxia occur each year, 75% of newborn deaths are
preventable, birth asphyxia comprising about 20% and other two causes being prematurity 35%
and sepsis 33% with congenital malformation an absolutely unavoidable cause of perinatal
mortality being 9% [12,13,51]. Thus India has highest 522 neonatal deaths per 1000 live births
with Early Neonatal Mortality Rate (ENMR) 20 per 1000 live births and Neonatal Mortality
Rate (NMR) 26 per 1000 live births. Nigeria ranks second with 270 0/00 followed by Pakistan
248 0/00, Ethiopia 99 0/00, and Democratic Republic of the Congo 970/00, China 64 0/00,
Indonesia 60 0/00, Bangladesh 56 0/00, Afghanistan 430/00 and United Republic of Tanzania
43 0/00 live births [14,15,20,51].

The projected NMR of 22/1000 live birth for 2020 in India has not been attained and current
NMR 28/1000 and ENMR 22/1000 live births accounts for 45% of total under-five year child
deaths. This NMR is not uniform across the country, Kerala and Tamil Nadu report low NMR
of below 20/1000, Odisha, Madhya Pradesh and Uttar Pradesh have high NMRs of more than
35/1000 total births. Though Haryana and Gujarat have similar or higher per capita GDP than
Tamil Nadu but doubles NMR, in fact four states, Uttar Pradesh, Madhya Pradesh, Bihar and
Rajasthan alone contribute to 55% of total neonatal deaths and 15% of global neonatal deaths
every year. India contributing to one-fifth global live births but more than a quarter of neonatal
deaths is concerning, indicating strategies aimed at reduction of early neonatal deaths to
substantially reduce under-five child mortality rate depends mainly on India’s progress to meet
the world SDG [13,14,51].

Preventive strategies should be aimed at intrapartum period rather than antepartum or post-
partum, as it has been reported to have a major impact with adverse outcome especially in

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 48

ethnic Asian population, such as active management of labor with judicious obstetric
intervention in rescuing endangered foetuses, that presently lies entirely in the domain of the
obstetrician will be circumvented by the clinical implementation of Asian Due Date (ADD) for
delivery at 38+6 weeks will prove to be the single most eminently suitable guideline for Asian
obstetrician in delivering healthy babies and safe guarding their mothers, given that peak Asian
births do take place at 38 weeks gestation causing improved perinatal, neonatal and maternal
outcome as opposed to a common EDD at 40 weeks gestation [101,104,107].

I am convinced with the aftermath of the covid pandemic affecting all aspects of life, including
non-availability of health care facilities with hundreds of thousands more under-five fatality,
Sustainable Development Goals (SDGs) 3.2.1, known also as Global Goals for target reduction
of under-five child mortality has faced setbacks and requires renewed determination for the
stipulated goal of reduction to 11 million under-five child deaths between 2019-2030 that is
specifically aimed at reduction of neonatal mortality to at least 12 per 1000 live births and
consequently under-five years child mortality to a low 25 per 1000 live births [50,160]. As the
given past endeavors and strategies have met with little or no further fall, it is important that
we implement new approaches and preventive strategies in management of newborns and their
well-being to envision attaining targets by 2030.

WHO is now calling for new sustainable development goals to continue to reduce child
mortality rate to a low 2.5% in all countries by 2030, Goal 3.2 would mean more than 97.5%
of all newborns should survive the first five years of their life, no matter where they are born,
even as UNICEF works to end preventable new-born and maternal deaths. Current trends
indicate that accelerated progress is needed to reach target, as 80% of under five years deaths
globally occur in Asian countries with nearly half, 45% of under-five child deaths being
neonatal deaths, in addition to the colossal stillbirth loss and maternal deaths that occur each
year with almost 95% occurring in low to middle income Asian countries [158-160].

Thus the implementation of two important new criteria aimed at improving the outcome of
newborns and their mothers, thereby reducing perinatal, neonatal and maternal morbidity and
mortality, with focus on intrapartum period precluding events occurring at 39 weeks and
beyond with effective resuscitation of hypoxic newborns, impacting early neonatal period,
especially life within first 24 hours, being most critical to target global fall in infant and under
five mortality rates includes:
Criteria

1. Asian Due Date (ADD) for delivery at 38+6 weeks, as peak births take place at 38.2 weeks
S.D ± 2, will prove to be the single most important strategy in reducing neonatal, perinatal
and maternal mortality and morbidity with focus on intrapartum period, also stemming the
colossal stillbirth loss.

2. ‘Lalana Newborn Resuscitation’ will revolutionize resuscitation of asphyxiated newborns

by sustained nasal inflatory oxygen flow up to 2-15L/min, monitored continuously by Pulse
oximetry for superficial oxygen saturation and successful ventilation is indicated by Zero
pulse oximetry score, SpO2 >96%, with rhythmic respiration, rate 30-60/min and heart rate
120-160 bpm, under asepsis and thermo-control with early institution of breastfeeding will

Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
 49

result in well-being of newborn, so that children should be normal, Thereby ensuring

children be normal with healthy growth and development throughout infancy, childhood
and adolescence, the right of every individual.

Conclusion
Timely delivery of ethnic Asian newborns and effective resuscitation of hypoxic newborns will
not only reduce birth asphyxia which constitutes a leading preventable proportion of perinatal
and neonatal mortality, almost all occurring in Asian countries with focus on events occurring
during intrapartum period having a major impact on mother and child. Therefore the two most
important preventive strategies include clinical implementation of Asian Due Date for delivery
at 38+6 weeks gestation and effective resuscitation by Lalana Newborn Resuscitation (LNR)
based on scientific principle of application of Continuous Positive Pressure Ventilation (CPPV)
by sustained nasal oxygen inflation monitored by pulse oximetry, will save lives, thereby
reducing perinatal, neonatal mortality and consequently under-five child mortality rate.

Conflict of Interest
The authors declare that they have no conflict of interest.

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Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305
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Christopher GL | Volume 2, Issue 3 (2021) | JCMR-2(3)-042 | Research Article

Citation: Christopher GL, et al. Lalana Newborn Resuscitation. Jour Clin Med Res. 2021;2(3):1-55.

DOI: http://dx.doi.org/10.46889/JCMR.2021.2305