Resuscitation of the newborn is required to some extent in nearly 10% of all births. Extensive resuscitation is required in about 1%. Delivery room resuscitation is required for >50% of the high-risk population of very-low-birth-weight (<1500 grams) newborns. Worldwide, nearly 25% of neonatal deaths result from birth asphyxia.¹ With proper antenatal and intrapartum surveillance, the potential need for active resuscitation at birth can often be identified before birth. Unfortunately, the arrival of a newborn to the ED is never planned. This chapter reviews the principles of emergency resuscitation of neonates.

The transition from intrauterine to extrauterine life is a treacherous time. Even the normal laboring process places significant stress on the placental-fetal unit. Blood flow and, therefore, oxygen delivery are transiently impaired during uterine contractions. Compression of the umbilical cord, when it occurs, further impairs circulatory flow. Although antenatal/intrapartum US imaging and fetal heart tone monitoring have permitted better surveillance of fetal well-being, prediction of fetal status at birth remains inexact. Maternal complications of pregnancy can predispose newborns to complications and include infections, chronic or gestational disease (e.g., diabetes, lupus), and illicit or prescribed medication use. Complications of labor, such as preterm delivery and/or prolonged rupture of membranes, maternal fever, breech or transverse fetal position, placental abruption, and umbilical cord problems such as a nuchal cord (cord wrapped around the neck) or true knots in the cord, can significantly heighten the risk to the fetus.

Once delivery occurs, the newborn still faces a variety of risks as the transition to extrauterine life unfolds. Requirements of this transition include the onset of respiration, absorption of lung fluid, reduction of pulmonary vasculature resistance to allow flow to the pulmonary vascular circuit, and closure of the ductus arteriosus and foramen ovale. Premature infants and infants who are small for gestational age are at risk for additional challenges in transitioning from fetal to infant physiology including insufficient pulmonary surfactant, fragile germinal matrices within the cerebral ventricles, and thin skin that impairs thermoregulation. The transition from the sterile intrauterine environment to the extrauterine world teeming with bacteria places yet another burden on the newborn.

HISTORY

Obtain a brief history from the mother, including the date of last menstrual period/estimation of gestational age, number of fetuses, number of previous pregnancies and living children, history of diabetes, hypertension or pregnancy-related problems, prenatal care (including known congenital anomalies), prolonged rupture of membranes, fever, and meconium-stained amniotic fluid.

PHYSICAL EXAMINATION

The need for resuscitation or routine newborn care (see “Treatment” below) is determined by the initial physical examination. For the term infant who is crying or breathing and who has good muscle tone at delivery, provide routine newborn care with the infant skin-to-skin on the mother. A slightly more detailed examination using the Apgar scoring system has been used for generations to assist medical personnel in assessing newborns both for the need for resuscitation and the response to resuscitation. Evaluate the newborn at 1 and 5 minutes after delivery for heart rate (absent = 0, <100/min = 1, >100/min = 2), respiratory effort (absent = 0, weak = 1, crying or normal = 2), muscle tone (limp = 0; some flexion = 1; active, fully flexed = 2), reflex irritability (no response = 0, grimace = 1, crying or active = 2), and color (blue or pale = 0, acrocyanosis = 1, completely pink = 2). If the 5-minute Apgar score is <7, continue Apgar scoring at 5-minute intervals until a score of 7 or more is reached. The expanded Apgar scoring system includes a section to document resuscitative measures.² For infants requiring resuscitation, monitor pulse oximetry with the probe placed on the newborn’s right hand (preductal) (see targets for resuscitation below).

LABORATORY EVALUATION

Routine laboratory studies are not required for most term or preterm deliveries. However, obtain point-of-care glucose testing in infants born to diabetic mothers, infants who are small or large for gestational age, or depressed or irritable infants, or if there is poor response to the initial steps of resuscitation. Obtain a type and screen or crossmatch of blood in infants requiring significant resuscitation in the setting of suspected blood loss.

IMAGING

Routine imaging is not required for most deliveries. In rare circumstances, an x-ray of the chest and abdomen may be useful to confirm endotracheal tube placement, suspected pneumothorax, and some congenital defects (e.g., diaphragmatic hernia).

EQUIPMENT

Table 108-1 lists equipment that may be needed during neonatal resuscitation. A compressed air source, an oxygen blender with flow meter, pulse oximetry for neonatal use, and laryngeal mask airways are standard resuscitation equipment.

UMBILICAL CORD CLAMPING

Do not clamp the umbilical cord of newborns (term or preterm) who do not require positive-pressure ventilation or immediate resuscitation for at least 1 to 3 minutes after birth. Delayed cord clamping reduces the need for blood transfusion, increases neonatal iron stores, and may decrease the risk of requiring treatment for hyperbilirubinemia.¹ For newborns requiring positive-pressure ventilation, the cord may be clamped and cut to allow effective ventilations to be performed.

Provide routine newborn care to term infants who are breathing or crying with good tone. Leave the newborn with the mother, provide warmth (skin-to-skin or blankets), clear the nose and mouth with bulb suction only if signs of obstructed breathing are noted, dry the baby, and provide ongoing assessment of respiratory effort and tone. Even before initiation of the ABCs (airway, breathing, circulation) of resuscitation, provide a neutral thermal environment for the newborn. Although vigorous term infants may be placed skin-to-skin with their mother for warmth, preterm or depressed newborns should be placed under a preheated radiant heat source. Place the infant on his or her back in the warmer. Then, gently dry the newborn with a warm towel while preparing to initiate resuscitation. Very-low-birth-weight newborns and those <29 weeks of estimated gestational age should be placed in polyethylene bags that have been developed for that purpose (plastic food wrap or a food-grade 1-gallon plastic bag may also be used). Avoid hyperthermia, which may precipitate apnea and worsen hypoxic-ischemic injury.

Newborn resuscitation almost exclusively involves care of primary respiratory compromise (Table 108-2). Consensus guidelines³ recommend a timed sequence of steps (30, 60, and >60 seconds). Most important is the rapid establishment of effective ventilation and determining the heart rate before initiating CPR.^4,5

INITIAL STEPS (FIRST 30 SECONDS)

Within the first 30 seconds of birth, provide warmth, and dry and stimulate the baby. Current guidelines³ no longer advise the routine suctioning of the newborn nose and mouth. Infants who are spontaneously breathing, whether delivered through clear or meconium-stained amniotic fluid, do not require tracheal suctioning because tracheal suctioning can cause reflex bradycardia and apnea. If the infant is not breathing initially, dry and provide stimulation by rubbing the back two to three times; if there is no response, open the airway using jaw thrust and towels beneath the shoulders to provide a sniffing position. If there appears to be obstruction from amniotic fluid, gently suction the nose and throat with a bulb or 8F catheter.

After these initial steps, assess the respiratory effort and heart rate.

ONGOING RESUSCITATION (30 TO 60 SECONDS)

After warming, drying, and stimulating, reassess the respiratory effort and the heart rate. If the infant begins breathing without significant effort and with good color, return to the mother for routine care. If the heart rate is >100 beats/min but there is persistent cyanosis or labored breathing, open the airway and suction the nose and mouth if there is a visible obstruction; attach pulse oximetry to the right hand or wrist (preductal) and apply supplemental oxygen to achieve targeted preductal oxygen saturation goals as per Table 108-3.

Apneic or depressed newborns delivered through meconium are at risk for meconium aspiration syndrome, but current evidence indicates that tracheal suctioning does not reduce morbidity or mortality.³ Naloxone is not recommended for treatment of neonatal respiratory depression, even after maternal opioid exposure or use.³ Provide usual respiratory support and ventilation.

Initiate positive-pressure ventilation using a bag and mask for infants with a heart rate of <100 beats/min or who are gasping or remain apneic after the initial steps of newborn resuscitation. Begin resuscitation using room air because newborn blood oxygen levels, even in healthy newborns, take time to reach extrauterine values and excessive oxygenation is associated with increased mortality.⁶ Table 108-3 provides subsequent oxygen saturation goals throughout neonatal resuscitation.

POSITIVE-PRESSURE VENTILATION

Provide positive-pressure ventilation with a self-inflating or flow-inflating infant bag or a T-piece resuscitator for all newborns with an HR <100 beats/min or who are gasping or apneic after 30 seconds. Bradycardia, even extreme, is typically the result of respiratory failure, and chest compressions or medications should not be initiated until effective ventilations have been provided. Administer positive-pressure ventilation if available. Use a manometer to monitor peak inspiratory pressures: a peak inspiratory pressure of 20 cm H₂O is usually sufficient, although initial peak inspiratory pressures as high as 30 to 40 cm H₂O may be required. Generally, flow-inflating bags are preferred, because they allow better control of inflation pressures. Self-inflating bags are superior if supplemental air or oxygen is unavailable. Be careful when using a self-inflating bag, because pop-off valve pressures, usually set at 30 to 40 cm H₂O, can be exceeded if excessive pressure is applied. T-piece resuscitators have the advantage of delivering a consistent pressure with each artificial breath. Excessive inflation pressures can cause pneumothorax and compromise resuscitation. Provide 40 to 60 breaths/min. Good chest rise and an increase in heart rate (usually within 5 to 10 breaths) are the best indicators of effective ventilation.

Most infants will respond to initial positive-pressure ventilation as outlined above. The most likely reason for a poor response to positive-pressure ventilation is inadequate positive-pressure ventilation, and corrective steps should be taken to assure effective ventilation prior to further resuscitation measures. The American Heart Association recommends use of the pneumonic “MR SOPA,” which stands for Mask (adjust to improve the seal), Reposition the head to open the airway, Suction the mouth then nose, Open the mouth with a jaw thrust, and increase the Pressure until chest rise is noted (maximum peak inspiratory pressure 40 cm H₂O), and if none of these is effective, proceed to definitive Airway control (endotracheal intubation).

Infants with significant labored breathing may benefit from continuous positive airway pressure ventilation if the necessary equipment and expertise are available.

ENDOTRACHEAL INTUBATION

In the absence of improvement with bag-mask ventilation, endotracheal tube insertion and ventilation are indicated. Other potential indications for endotracheal intubation in the newborn include (1) concomitant need for chest compressions, (2) administration of endotracheal medications, (3) known or suspected congenital diaphragmatic hernia (to avoid inflating stomach/bowel situated in the chest), and (4) extremely low birth weight (<1000 grams).⁷

The technique for endotracheal intubation is discussed in detail in chapter 111, Intubation and Ventilation in Infants and Children. Tables 108-4 and 106-5

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