preparation for resuscitation and organization of personnel, particularly assignment of roles is critical
Approximately 10% of in hospital delivered newborns require resuscitation assistance to breathe at birth. Less than 1% require extensive resuscitation.
The aim of resuscitation is to prevent neonatal death and adverse longterm neurodevelopmental sequelae associated with perinatal asphyxia.
Substantial physiologic changes occur in the transition from fetal to extrauterine life including
the role of the placenta in gas exchange is taken over by the lungs
changes from fluid-filled to air filled lungs
dramatic increase in blood flow to the lungs with reversal, then closure of intra and extra cardiac shunts
Failure or disruption of these changes may result in further difficulties with resuscitation in the newborn infant. For example, failure to increase alveolar oxygen and reduce pulmonary vascular resistance may lead to persistence of fetal circulation or pulmonary hypertension.
The need for resuscitation of the newborn infant at birth cannot always be anticipated nor predicted. Therefore, at every birth, no matter how "low risk", suitable equipment and staff must be available and prepared to resuscitate the newborn infant.
The steps of evaluation and intervention are often simultaneous processes. Evaluation begins immediately after birth assessment of tone, breathing, and heart rate and continues throughout the resuscitation process until vital signs have normalized. Key features in ongoing evaluation are
The newly born infant should establish regular respirations in order to maintain HR > 100 bpm
During labour the uncompromised infant has oxygen saturations of about 60% which after birth usually take 75-10 minutes to reach 90%.
The well newly born infant should then be able to maintain a central pink colour in room air. Assessment of of colour is a poor proxy for oxygenation. Assessment of oxygenation can be aided by use of a pulse oximeter with neonatal probe attached to the infant's right hand
A warm draft free environment should be available. Drying the infant with prewarmed towels will help minimise heat loss in addition to use of a radiant warmer.
Infants less than 28 weeks gestation should be placed immediately after birth in a polyethylene bag or wrap (appropriate size, food grade, heat resistant) with their head out and the body completely covered. Drying the infant's body prior to covering is not recommended.
Aim for normothermia (36.5 to 37.50C) in all newborn infants and avoid iatrogenic hyperthermia
If meconium is present in a non-vigorous infant immediate suction below the vocal cords under direct vision may be appropriate. Delay tactile stimulation to avoid gasping in the infant with an oropharynx full of particulate meconium. Repeated suctioning of the trachea is not recommended and may unnecessarily delay commencement of active resusciation
Suction is rarely required and should not exceed -100 mmHg. It should be limited in depth to 5 cm below the lips.
The rate for assisted ventilation is 60 inflations per minure.
Positive pressure ventilation should be commenced in air (21% oxygen) initially. Supplemental oxygen administration should be guided by pulse oximetry. Hyperoxia should be avoided as even brief exposure to excessive oxygenation can be harmful to the newborn during and after resuscitation. Regardless of gestation, aim for oxygen saturations that resemble those of healthy term babies. Wean supplemental oxygen once the saturations reach 90%.
Time from birth Target saturations during resuscitation 2 minutes 65 - 85% 3 minutes 70 - 90% 4 minutes 75 - 90% 5 minutes 80 - 90% 10 minutes 85 - 90%
Effective ventilation is confirmed by observing three signs
- Increase in the heart rate to about 100/min
- A slight rise in the chest and upper abdomen with each positive pressure inflation
- Oxygenation improves
Few infants require immediate intubation. The majority of infants can be managed with positive pressure ventilation via a face mask. With improve ment in the infant's condition the inflation pressures and breath rate can be progressively reduced.
See intubation section for technical details
In the majority of infants establishment of adequate ventilation will restore circulation.
Begin chest compressions for either
- HR < 60 fdespite effective positieve pressure ventialiton for at least 30 seconds.
Aim for approximately a ratio of 90 chest compressions to 30 breaths per minute (3:1). (120 events per minute) - count one-and-two-and-three-and-breath etc
Supplemental oxygen should be increased to 100% when compressions are commenced
The "two thumb" technique is preferred. Both thumbs meet over the sternum with fingers around the chest wall. The sternum should be compressed to one third of the antero-posterior chest dimension.
Route of Delivery
- umbilical venous catheter - preferred route
- ET - for adrenaline only
- peripheral intravenous line - difficult to cannulate in the collapsed infant
- intraosseous needle for failed or unsuccessful umbilical venous catheterization
- umbilical arterial catheter should not be used fordrug administration during resuscitation
For HR < 60 for > 30 sec despite compressions and positive pressure ventilation
Dosage: 0.1 -0.3 ml/kg 1 in 10,000 as a quick push IV repeated at 3-5 minutely intervals. It should be followed by a small saline flush.
0.5 - 1.0ml/kg 1in 10,000 ET(if no IV access).
10 - 15 ml/kg normal saline repeated 2 or 3 times
This may need to be followed with O negative red blood cells in the setting of massive blood loss, especially in babies who are not responding to resuscitation interventions.
Naloxone does not form part of the initial resuscitation of newborns with respiratory depression in the delivery room.
Dosage - 0.1mg/kg of 0.4mg/ml solution
Contra-indication - may result in rapid withdrawal with seizures if given to infants of narcotic dependent women
Not indicated for routine use
Argument for correction of acidosis includes theoretical concerns about hypoxia and elevated pulmonary vascular bed pressure and poor cardiac contractility with acidosis.
Argument against correction includes concerns regarding hyperosmolarity and CO2 generation with intracellular acidosis from alkali infusion.
Infants require careful observation and management in a special or intensive care nursery following active resuscitation. Attention to management of temperature, cardio-respiratory status (oxygenation, heart rate, respiratory pattern, blood gas analysis), blood glucose sugars and infection risk are required
Term infants at risk of hypoxic ischemic encephalopathy should be considered for therapeutic hypothermia therapy ("cooling") . Prompt discussion with NETS is recommended as cooling must be initiated within 6 hours of birth
PEEP has been shown to be very effective for establishing and maintaining lung volume and improving oxygenation, especially in preterm babies. If suitable equipment is available, PEEP of at least 5cm H2O should be used during resuscitation. It is possible to provide PEEP either by use of
o A T-piece device (eg Neopuff or similar). This technique can be easily applied but the device requires a flow of gas to operate
o An anaesthetic bag and mask. Considerable practice is required to develop competence with this technique.
Section 13 Neonatal Guidelines Australian Resuscitation Council On Line http://www.resus.org.au/ December 2010
The updated online guidelines for neonatal resuscitation
The Victorian Newborn Resusciation Project: NeoResus http://www.neoresus.org.au 26 January 2011
A great learning resource for neonatal resuscitation