1 What physiologic changes take place during the transition from intrauterine to extrauterine life?

The cardiopulmonary systems undergo a rapid change from fetal to extrauterine life. At birth the umbilical cord is clamped, and systemic vascular resistance rises. With the newborn’s first breaths (increasing the neonate’s PaO₂ and pH), pulmonary vascular resistance decreases, thereby causing an increase in pulmonary blood flow. Blood flow through the foramen ovale and the ductus arteriosus reverses direction, and then these structures eventually close. The ductus arteriosus is usually closed functionally by 15 hours of age.

If the pulmonary vascular resistance does not fall adequately, a persistent right-to-left shunt will occur (persistent pulmonary hypertension). Inability to expand alveolar spaces can cause intrapulmonary shunting of blood (hypoxia). Disruption of fetal maternal circulation (placenta previa, abruption placentae) can result in acute blood loss and hypovolemia in the newly born infant.

2 What preparation is necessary for the unexpected emergency department (ED) delivery?

Preparation is key, as most ED deliveries are “unexpected.” A prearranged plan should be set in motion as soon as birth is imminent. That plan should include the assembly of personnel who are best able to take care of the newly born infant. A brief history should be obtained if possible because it may affect the resuscitation. Equipment and medications specifically for a neonatal resuscitation should be kept in a designated tray so they are quickly available (Table 2-1). Periodic inspection of this equipment for proper functioning and expiration dates of medication should become part of the routine upkeep of the neonatal resuscitation tray.

Table 2-1 Equipment and Drugs for the Neonatal Resuscitation

Equipment

Gowns, gloves, and masks

Warm towels and blankets

Bulb syringe

Meconium aspirator

Suction catheters (sizes 5–10 Fr)

Face masks (sizes premature, newborn, and infant)

Oral airways (sizes 000, 00, 0)

Anesthesia bag with manometer (preferably 500 mL, no larger than 750 mL)

Laryngoscope with straight blades (sizes 0 and 1)

Spare bulbs and batteries

Stethoscope

Endotracheal tubes (sizes 2.5, 3.0, 3.5, 4.0) and stylet

Tape

Umbilical catheters (3.5 and 5 Fr)

Oxygen source with flow meter

Umbilical catheter tray

Three-way stopcocks

Nasogastric feeding tubes (8 and 10 Fr)

Needles and syringes

Chest tubes (8 and 10 Fr)

Magill forceps

Radiant warmer

Cardiorespiratory monitor with electrocardiography leads

Pulse oximeter with neonatal probes

Suction equipment and tubing

Pulse oximeter with newborn probe

End-tidal CO2 detector

Laryngeal mask airway (optional)

Drugs

Epinephrine 1:10,000

Naloxone

Sodium bicarbonate

Dextrose in water 10%

Normal saline, lactated Ringer’s

Resuscitation drug chart

3 What problems should be anticipated for a preterm delivery (< 37 weeks’ gestation)?

Preterm babies have immature lungs that may be more difficult to ventilate and more prone to injury by positive-pressure ventilation. Premature infants are also more prone to intracranial hemorrhage because they have immature blood vessels in the brain. In addition, these infants are at risk for rapid heat loss because of their thin skin and large surface area. Finally, premature infants are at increased risk for infection and hypovolemic shock caused by small blood volume.

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.

4 What are the critical facts in the history that should be elicited, if possible, prior to delivery?

The standard maternal history is important but may need to wait until after delivery because of the imminent birth of the infant. Critical information may need to be narrowed to facts that may affect the immediate preparation (equipment and personnel) for the delivery:

Hazinski MF (ed): Textbook of Pediatric Advanced Life Support. Dallas, American Heart Association, 2002.

5 What steps should be taken initially to care for the newly born infant?

Since newly born infants do not tolerate cold, and hypothermia can prolong acidosis, prevent heat loss as much as possible. Dry the infant of the amniotic fluid and place the newborn in slight Trendelenburg position, on his or her back with the neck slightly extended, under a prewarmed radiant warmer. Suction the mouth and then nose with the bulb syringe or catheter. Duration of the suctioning should not exceed 5 seconds, and the tip should not be passed farther than 5 cm. Vigorous suctioning will cause bradycardia. Usually by drying and suctioning the infant, he or she is adequately stimulated to begin effective respirations. Gently flicking the heels and rubbing the back are additional stimulation methods. Avoid vigorous stimulation. Wrapping the newly born infant in warmed blankets will reduce heat loss.

6 How can a very–low-birthweight premature newborn infant (< 1500 gm) be kept warm in the ED?

Drying and swaddling, warming pads, increased environmental temperature, covering with a blanket, and placing the baby skin-to-skin with the mother have all been used to keep newborns warm. These techniques have not been evaluated in controlled trials and may not be enough to warm very small newborns. Very–low-birthweight infants may need additional warming techniques, such as covering the infant in plastic wrapping (food-grade, heat-resistant plastic) and placing him or her under radiant heat.

Costeloe K, Hennessy E, Gibson AT, et al: The EPICure study: Outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics 106:659–671, 2000.

7 How do you assess the condition of a newly born infant?

The basic principles for the newly born infant are the same as for any patient. However, there are particular problems of the neonate that bear special attention. After placing the neonate under the prewarmed radiant warmer on his or her back, dry and suction the baby (see Question 5). Carefully observe the respiratory effort and rate. If cyanosis or other signs of distress are noticed, administer oxygen. If the respiratory response is inadequate, stimulate the infant again and reposition. Adequacy of respirations is based on the rate (usually 35–60 breaths per minute), the effort (lack of retractions and grunting), and breath sounds. If the respiratory effort continues to be suboptimal (absent, slow, shallow), begin positive-pressure ventilation. If the respiratory effort is adequate, then evaluate the heart rate.

The heart rate is a critical measurement in determining the condition of the infant. Determine the heart rate by listening to the apical area with a stethoscope or palpating the pulse at the base of the umbilical cord. The normal heart rate of the newly born infant is above 100 beats per minute and is generally 120–150 beats per minute. If the heart rate is less than 100 beats per minute, begin positive-pressure ventilation. If the heart rate is greater than 100 beats per minute with spontaneous respirations, continue the assessment.

Assess the newborn’s color for the presence of pallor and cyanosis. Pallor could indicate hypovolemia, anemia, hypoglycemia, decreased cardiac output, or acidosis. Cyanosis of the distal extremities or acrocyanosis is common and not a sign of hypoxia. Central cyanosis requires oxygen administration. If the neonate is still cyanotic despite oxygen therapy and positive-pressure ventilation, begin an organized workup for life-threatening illnesses, such as heart disease, sepsis, congenital anomalies, and diaphragmatic hernia.

Finally, assign an Apgar score at 1 minute and at 5 minutes of life (Table 2-2). The Apgar score assesses heart rate, respirations, muscle tone, reflex irritability, and color. It indicates how the infant is doing or the responsiveness to the resuscitation. If the Apgar score is less than 7 at 5 minutes, continue scoring every 5 minutes. Do not delay resuscitative efforts to obtain an Apgar score.

Owen CJ, Wyllie JP: Determination of heart rate in the baby at birth. Resuscitation 60(2):213–217, 2004.

8 When does the newly born infant need assistance with ventilation?

Approximately 10% of newly born infants require some assistance to begin breathing at birth, and 1% require extensive resuscitation measures. After the infant has been quickly assessed and found to have apnea or gasping respirations, initiate positive-pressure ventilation with oxygen. Also, initiate positive-pressure ventilation if the heart rate is less than 100 beats per minute because bradycardia in a newborn is usually due to hypoxia. Persistent central cyanosis despite 100% oxygen is another indication to begin positive-pressure ventilation.

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.

9 What is the proper technique to assist ventilations in the newly born infant?

The mask should fit around the nose and mouth but not cover the eyes or go below the chin. Assisted ventilations should be at a rate of 40–60 breaths per minute (30 breaths per minute when chest compressions are being performed), but controversy exists over the rate. The initial breaths may require higher inflation pressures and longer inflation times. The effectiveness of the assisted ventilations is judged by the movement of the chest, adequacy of breath sounds, and the heart rate. If the condition of the neonate does not improve, then reposition the head, check for patency of the airway, improve the seal of the mask on the face, and increase the inflating pressure of the bag.

10 What are the indications for tracheal intubation of the newly born infant?

Indications for intubation vary but are based on the degree of respiratory depression, the success of ventilation efforts, the presence of meconium, the degree of prematurity, and the skill of the health care provider. There is controversy at every turn. For instance, some neonatal experts feel that early intubation in infants younger than 28 weeks is indicated, while others suggest that these infants can be handled with mask or nasal prong continuous positive airway pressure.

Endotracheal intubation is indicated if a neonate:

Laryngeal masks may be used as an alternative airway method by trained providers when bag-mask ventilation is ineffective or attempts at endotracheal intubation have been unsuccessful.

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.

11 How should endotracheal intubation of the newborn be performed?

Perform the tracheal intubation by the oral route, using an uncuffed endotracheal tube and a laryngoscope with a straight blade (size 0 for premature baby, size 1 for term baby). If a stylet is used, it should not protrude beyond the end of the tube. Cricoid pressure may be needed. After the endotracheal tube is passed through the vocal cords, check the position by observing symmetrical chest wall movement, listening for breath sounds at the axillae, and noting the absence of breath sounds over the stomach. Confirm the absence of gastric inflation; watch for condensation in the endotracheal tube during exhalation; and note the improvement in heart rate, color, and activity of the newborn. A prompt increase in heart rate is the best indicator that the tube is in the tracheobronchial tree and providing effective ventilation. Confirm tube placement with a CO₂ monitor. Exhaled CO₂ detection is effective for confirmation of endotracheal tube placement in infants, including very–low-birthweight infants. Confirmation of tube placement by radiograph is also recommended. The guide for the proper size of the endotracheal tube size is:

The proper depth of insertion can be estimated by:

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.

Aziz HF, Martin JB, Moore JJ: The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol 19:110–113, 1999.

12 When are chest compressions indicated in the resuscitation of the newly born infant?

Effective ventilation usually restores vital signs to normal in a newborn, and chest compressions are generally not needed. Because chest compressions make effective ventilations more difficult and the heart rate usually responds to assisted ventilation, chest compressions are not initiated until assisted ventilation has been started. The indications for the initiation of chest compressions during the resuscitation of the newly born infant are absent heart rate, or heart rate less than 60 beats per minute despite adequate assisted ventilation for 30 seconds.

13 What is the proper technique for chest compressions in the newborn?

The two acceptable techniques for performing chest compressions are applying two thumbs superimposed or next to each other on the sternum with the fingers surrounding the chest, or two fingers placed on the sternum at a right angle to the chest with the other hand supporting the back. Data suggest that the two-thumb method may have the advantage of generating peak systolic and coronary perfusion, and it is preferred by providers. Placement on the chest is at the lower third of the sternum. The rate should be approximately 90 times per minute at a 3:1 ratio with assisted ventilations. Take care not to simultaneously provide a breath while compressing the chest. Compress the chest to one-third of the anterior–posterior diameter of the chest. Compressions must be adequate to generate a pulse. Reassess the heart rate every 30 seconds during this time and continue compressions until there is a spontaneous heart rate over 60 beats per minute.

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.

David R: Closed chest cardiac massage in the newborn infant. Pediatrics 81:552–554, 1988.

14 How does the resuscitation of the newly born infant differ if meconium is present in the amniotic fluid?

Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. If the newborn has meconium-stained fluid and is not vigorous (decreased tone, absent or depressed respirations, or a heart rate less than 100 beats per minute), intubate the trachea immediately to suction out meconium. This is accomplished by suctioning while withdrawing the endotracheal tube from the airway. Repeat intubation with suctioning until no more meconium is suctioned. If the heart rate falls below 60 beats per minute, keep the endotracheal tube in place and initiate positive-pressure ventilation. Newer research indicates this technique is of no value if the infant is vigorous. Delay gastric suctioning until the initial resuscitation is complete. Meconium-stained newborns who develop respiratory depression should receive tracheal suctioning prior to positive-pressure ventilation.

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.

Wiswell TE, Gannon CM, Jacob J, et al: Delivery room management of the apparently vigorous meconium stained neonate: Results of the multicenter, international collaborative trial. Pediatrics 105:1–7, 2000.

15 What are the most common drugs used in a neonatal resuscitation, and when are they indicated?

Drugs are rarely used in neonatal resuscitation as most problems are improved by addressing airway, breathing, and circulation. Bradycardia in the newborn infant is usually due to inadequate lung inflation and hypoxemia, so adequate ventilation is most important.

Gibbs J, Newson T, Williams J, et al: Naloxone hazard in infants of opioid abusers. Lancet 2:159–160, 1989.

Lokesh L, Kumar P, Murki S, Narang A: A randomized controlled trail of sodium bicorbonate in neonatal resuscitation—effect on immediate outcome. Resuscitation 60:219–223, 2004.

Oca MJ, Nelson M, Donn SM: Randomized trial of normal saline versus 5% albumin for the treatment of neonatal hypotension. J Perinatol 23:473–476, 2003.

Perondi MB, Reis AG, Paiva EF, et al: A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med 350:1722–1730, 2004.

16 Where is the best place to obtain IV access?

The easiest and most direct access is the umbilical cord. Any medication, as well as volume expanders, can be given through the umbilical vein. Note that it is not recommended to administer resuscitative drugs via the umbilical artery. Peripheral veins in the extremities and the scalp can also be used but generally require more skill to access. Intraosseous lines can be used when no other access can be obtained. Drugs (e.g., epinephrine) can also be given via the endotracheal tube.

17 Are there circumstances when resuscitation of the newly born infant may not be the appropriate action?

Since all ED deliveries are considered “unexpected” and the ED physician rarely has a previous relationship with the delivering mother, conversations about withholding resuscitation are difficult at best. Antenatal information can be incomplete or inaccurate. In the ED, it may not be possible to gather this information quickly with precision and reliability. Guidelines should be developed after discussion with local resources and review of the most recent literature. Review the guidelines regularly and modify them on the basis of changes in resuscitation and neonatal intensive care practices.

If gestational age, birthweight, or congenital anomalies are associated with almost certain early death or high morbidity, resuscitation is not indicated. Examples include extreme prematurity (gestational age < 23 weeks, birthweight < 400 gm), anencephaly, and chromosomal abnormalities incompatible with life (trisomy 13).

American Heart Association: Part 13: Neonatal Resuscitation Guidelines. Circulation 112:IV-188–195, 2005.