Drugs
Drugs are rarely needed and only if there is no significant cardiac output, despite effective lung inflation and chest compressions.
Drugs must be delivered as close as possible to the heart.
This is best achieved by an umbilical venous catheter (UVC).

An alternative to the UVC route is the intraosseous route.
Adrenaline is the only drug that may be given by the tracheal route, although of unknown efficacy at birth.
If this is used, it must not interfere with ventilation or delay acquisition of intravenous access.

After each of the drugs has been given use a small flush of 0.9% sodium chloride to ensure the drug reaches the circulation and a few chest compressions to ensure the drug reaches the heart, then assess the effect.

Adrenaline
Preparation: 1:10,000 (=1g/10,000 mL = 100 mg/L =100 microgram/mL)
Dose: 0.1-0.3 mL kg-¹ of 1:10,000 (10 microgram kg-¹) )
Route: UVC or intraosseous needle or tracheal tube

Sodium Bicarbonate
Preparation: 4.2% (or 8.4% diluted 1:1 with 5% or 10% glucose)
Dose: 1-2 mmol kg-¹ (2-4 mL kg-¹ of 4.2%)
Route: UVC or intraosseous needle
If there is no effective cardiac output, or virtually none, then reversing intracardiac acidosis may be helpful. You are not attempting to correct the baby’s metabolic acidosis; you are merely trying to improve cardiac function by improving the pH of the blood within the heart.
Bicarbonate will normally produce cardiac acceleration within a couple of minutes if it is going to work.
Bicarbonate must never be given down the tracheal tube.

Glucose
Preparation: 10% (=10 g/100 mL=100 mg/mL)
Dose: 2.5 mL kg-¹ of 10% (250 mg kg-¹)
Route: UVC or intraosseous needle
The heart cannot work without glucose and the glycogen stores present in the heart at birth are rapidly depleted during prolonged hypoxia.
Glucose can be tried if there is no response to adrenaline and bicarbonate.
Subsequent symptomatic hypoglycaemia, if present, is better managed with an infusion of 10% glucose rather than with repeated boluses.
Glucose must never be given down the tracheal tube.

Volume
Preparation: 0.9% saline (or a balanced salt solution)
Dose: 10 mL kg-¹ initially
Route: UVC or intraosseous needle
A bolus of about 10 mL kg-¹ is usually sufficient to produce a response and can be repeated if necessary. If blood loss is the cause of the problem, further transfusion with blood may be necessary later. Giving further volume to a severely compromised baby with a myocardium damaged by hypoxia is likely to do more harm than good.
Giving large volumes (more than 40 mL kg-¹) of solutions high in chloride (such as albumin or 0.9% saline) can also exacerbate metabolic acidosis through hyperchloraemiaratio of compressions to inflations in newborn resuscitation is 3:1.

When to stop resuscitation?

• In a newly-born baby with no detectable cardiac activity, and with cardiac activity that remains undetectable for 10 min, it is appropriate to consider stopping resuscitation.

• The decision to continue resuscitation efforts beyond 10 min with no cardiac activity is often complex and may be influenced by issues such as the presumed aetiology of the arrest, the gestation of the baby, the presence or absence of complications, and the parents’ previous expressed feelings about acceptable risk of morbidity.