The vast majority of newly-born term infants will respond adequately to tactile stimulation and warming. Very few will require significant resuscitation.
Neonatal resuscitation is focused chiefly on respiratory support, not on cardiac support, unlike resuscitation for adults.
Healthy term newborns may take 10 minutes or longer to reach normal extra-uterine oxygen saturations.
The use of preductal pulse oximetry is recommended because skin color may correlate poorly with oxygen saturation.
The use of 3-lead electrocardiogram (ECG) is the best secondary method to rapidly and accurately monitor the heart rate.
The use of oxygen/air blenders is recommended to decrease exposure to 100% oxygen which has been increasingly shown to have toxic effects.
When meconium-stained amniotic fluid is present, mouth and nasal suctioning after delivery of the head is not recommended for vigorous infants.
Chest compressions are only initiated if there is no pulse or if the heart rate remains less than 60 beats/min after adequate positive-pressure ventilation (PPV) for 30 seconds.
The ratio of chest compressions to ventilations during resuscitation should be 3:1, with 90 compressions and 30 ventilations per minute.
Chest compressions are performed using the two-thumb–encircling hand technique.
Auscultating for heart rate is more accurate than palpation of the umbilical cord base.
The umbilical vein is the best site for intravenous (IV) access, but intraosseous access may be considered in the emergency department setting.
Only isotonic crystalloid or packed red blood cells should be used for initial volume resuscitation.
Epinephrine is indicated for a heart rate less than 60 beats/min after 30 seconds of adequate ventilation and chest compressions.
The dose of epinephrine for the newly born infant is 0.1 to 0.3 mL/kg of 1:10,000 solution given intravenously. Higher doses are not recommended.
Therapeutic hypothermia instituted after resuscitation may improve neurologic outcomes for term infants with hypoxic-ischemic encephalopathy (HIE).
Of the nearly 4 million infants born in the United States each year, more than 90% successfully transition from intrauterine life with little or no intervention. Roughly 10% require some assistance and 1% require more extensive resuscitation.1 Because of the large number of births nationwide, it is inevitable that the emergency medicine practitioner will eventually be faced with a newly born infant who may require resuscitation. As in any critical situation in medicine, preparation and anticipation play a key role in neonatal resuscitation. This includes equipment (Table 22-1) and personnel to be ready as soon as a newly born infant presents to the emergency department. Current American Heart Association (AHA) and American Academy of Pediatrics (AAP) guidelines recommend that at least one skilled provider should attend every birth in the delivery room and at least two skilled providers should be present for deliveries in the higher risk emergency department setting.2
| Warm | Preheated radiant warmer Warm towels or blankets Hat Plastic bag or plastic wrap (<32 weeks’ gestation) Thermal mattress (<32 weeks’ gestation) |
| Clear airway | Bulb syringe 10F or 12F suction catheter attached to wall suction at 80–100 mmHg Meconium aspirator |
| Auscultate | Stethoscope |
| Ventilate | Flowmeter set to 10 L/min Oxygen blender set to 21% (21%–30% if <35 weeks) Positive-pressure ventilation (PPV) device Term- and preterm-sized masks 8F feeding tube and large syringe |
| Oxygenate | Equipment to give free-flow oxygen Pulse oximeter with sensor and cover Target oxygen saturation table |
| Intubate | Laryngoscope with size-0 and size-1 straight blades (size 00, optional) Stylet (optional) Endotracheal tubes, sizes 2.5, 3.0, 3.5 End-tidal CO2 detector Measuring tape and/or endotracheal tube insertion depth table Waterproof tape or tube-securing device Scissors Laryngeal mask airway (size 1) and 5-mL syringe |
| Medicate | Access to 1:10,000 epinephrine and normal saline Supplies for administering medicines and placing emergency umbilical venous catheter Electrocardiogram (ECG) monitor leads and ECG |
| Thermoregulate | Plastic bag or plastic wrap Chemically activated warming pad Transport incubator ready |
Successful neonatal resuscitation depends on anticipation, preparation, and immediate support of infants who are not successfully transitioning to extrauterine life.1 Because births that occur outside of the delivery room are more frequently complicated by lack of prenatal care, trauma, or prematurity, it is vital to take a focused history to anticipate the degree of resuscitation that may be required. Key antepartum factors to focus on include the gestation of the pregnancy, the last menstrual period, multiple gestation, amniotic fluid color, and history of previous fetal or neonatal death. Maternal diabetes, hypertension, and intrapartum fever also have been associated with increased perinatal morbidity. Other risk factors that should be addressed include prolonged rupture of membranes (>18 hours), prolonged labor (>24 hours), foul-smelling amniotic fluid, bleeding, and prolapsed umbilical cord (Table 22-2).
Antepartum Factors Gestational age less than 36 weeks Gestational age greater than or equal to 41 weeks Preeclampsia or eclampsia Maternal hypertension Multiple gestation Fetal anemia Polyhydramnios |
Oligohydramnios Fetal hydrops Fetal macrosomia Intrauterine growth restriction Significant fetal malformations or anomalies No prenatal care |
Intrapartum Factors Emergency caesarean section Forceps or vacuum-assisted delivery Breech of other abnormal presentation Category II or III fetal heart rate pattern Maternal general anesthesia Maternal magnesium therapy Placental abruption |
Intrapartum bleeding Chorioamnionitis Narcotics administered to mother within 4 h of delivery Shoulder dystocia Meconium-stained amniotic fluid Prolapsed umbilical cord |
Current AHA/AAP neonatal resuscitation guidelines include a rapid observational tool, which can be used to identify which newly born infants will not need to be resuscitated.1 This tool consists of three questions:
Does the baby born appear to be full-term?
Does the baby have good muscle tone?
Is the baby breathing or crying?
If the answer to all of the questions is yes, the infant will likely not require significant resuscitation and should be allowed to stay with the mother with continued monitoring. If the answer to any of these questions is no, then resuscitation may be required. The actions undertaken during resuscitation should occur in an orderly manner as described by the AHA/AAP (Fig. 22-1). These include initial steps in stabilization, ventilation, chest compressions, and administration of epinephrine or volume expansion. The heart rate, respiratory effort, and color are monitored closely and guide the decision to escalate the level of resuscitation. The best indication that the resuscitation is progressing in the right direction is improvement in heart rate.
FIGURE 22-1.
Algorithm for neonatal resuscitation. (Reproduced with permission from Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov;132(18 suppl 2):S543–S560.)
The Apgar score is a method of objectively measuring the newborn’s condition and response to resuscitation. The Apgar score is normally assigned at 1 minute and again at 5 minutes, based on the infant’s respirations, heart rate (by auscultation or umbilical palpation), color, muscle tone, and reflex irritability (Table 22-3). If the 5-minute Apgar score is less than 7, then additional scores should be made every 5 minutes up to 20 minutes. The Apgar score is not used to determine the need for resuscitation or to guide the resuscitation efforts, and the resuscitation must not be delayed for the purpose of tabulating the Apgar score. Neonates with a 1-minute Apgar score >7 require minimal resuscitation other than drying and stimulation. Very few infants with an Apgar score of 0 at 10 minutes will survive without severe neurologic disabilities.3
| Parameter | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Color | Blue, pale | Body pink, extremities blue | Totally pink |
| Muscle tone | None, limp | Slight flexion | Active, good flexion |
| Heart rate (beats/min) | 0 | <100 | >100 |
| Respiration | Absent | Slow, irregular | Strong, regular |
| Reflex irritability (response to nasal catheter) | None | Some grimace | Good grimace, crying |
After delivery, the infant should be dried with warm towels and placed supine under a radiant warmer. The head should be put into a “sniffing” position which aligns the posterior pharynx, larynx, and trachea and allows for unimpeded air entry (Fig. 22-2). A rolled towel may be placed under the infant’s shoulders to help maintain this position. Oral and nasal suctioning should be performed with a bulb syringe or suction catheter only if the infant shows evidence of airway compromise. Indications for suctioning include gasping, not breathing, having difficulty clearing oral secretions, or if positive pressure ventilation (PPV) is anticipated. The mouth should be suctioned prior to suctioning the nose so that the oropharynx is clear of secretions if the infant suddenly gasps during nasal suctioning. One way to remember to suction the mouth before nose is that “M” comes before “N” in the alphabet.2 When suctioning the mouth and posterior oropharynx, it is important not to suction too vigorously or deeply, which may cause a vagal response with resulting bradycardia and apnea.2
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