neonatal resuscitation in the delivery room

8/13/2019 Neonatal Resuscitation in the Delivery Room

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Neonatal resuscitation in the delivery roomAuthorCaraciolo J Fernandes, MDSection EditorLeonard E Weisman, MDDeputy EditorMelanie S Kim, MDDisclosures

All topics are updated as new evidence becomes available and ourpeer review processiscomplete.Literature review current through:Nov 2013. | This topic last updated:ago 26, 2013.

INTRODUCTIONThe successful transition from intrauterine to extrauterine life is dependent

upon significant physiologic changes that occur at birth. In almost all infants (90 percent), these

changes are successfully completed at delivery without requiring any special assistance. However,

about 10 percent of infants will need some intervention, and 1 percent will require extensive

resuscitative measures at birth [1].

The indications and principles of neonatal resuscitation will be reviewed here. The physiological

changes that occur in the transition from intrauterine to extrauterine life are discussed separately.

(See"Physiologic transition from intrauterine to extrauterine life".)

ANTICIPATION OF RESUSCITATION NEEDBeing prepared is the first and most important

step in delivering effective neonatal resuscitation [1]. Neonates requiring resuscitation are inevitably

born in locations where resuscitation is uncommon because most newborns are healthy and do not

require additional special assistance. In these settings, the need for resuscitation is not anticipated

in most infants who require resuscitation [2]. As a result, at every birthing location, personnel who

are adequately trained in neonatal resuscitation should be readily available to perform neonatal

resuscitation whether or not problems are anticipated.

In all instances, at least one healthcare provider is assigned primary responsibility for the newborn

infant. This person should have the necessary skills to evaluate the infant, and, if required, toinitiate resuscitation procedures such as positive pressure ventilation and chest compressions. In

addition, either this person or another who is immediately available should have the requisite

knowledge and skills to carry out a complete neonatal resuscitation including endotracheal

intubation and administration of medications.

Equipment needed for resuscitation should be available at every delivery area (table 1), and

routinely checked to ensure the equipment is functioning properly [3].

TrainingThe neonatal resuscitation program (NRP) was developed by the American Academy

of Pediatrics (AAP) and American Heart Association (AHA) as a training program aimed at teaching

the principles and skills of neonatal resuscitation [3]. Studies have demonstrated that NRP training

improves the correct sequencing and timing of the resuscitative steps and procedures by healthcareproviders [2], provider knowledge and comfort in performing neonatal resuscitation [4], and five-

minute Apgar scores [5].

By 2005, the NRP had trained two million health care providers in the United States and was a

model for similar neonatal resuscitation programs in over 100 countries [6]. The NRP has been

updated five times since its inception. The most recent version is based upon the 2010 AHA, AAP,

and International Liaison Committee on Resuscitation (ILCOR) neonatal resuscitative guidelines [1].
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In our institution, all healthcare providers who care for newborn infants (clinicians, nurses, neonatal

nurse practitioners, and respiratory therapists) are required to be NRP trained. It is recommended

that all delivery room personnel complete the NRP in an effort to improve their individual and group

performance in neonatal resuscitation.

High-risk deliveryInfants who are more likely to require resuscitation can be identified by the

presence of one or more of the following risk factors (table 2)[3,7]:

Maternal conditionsAdvanced or very young maternal age, maternal diabetes mellitus or

hypertension, maternal substance abuse, or previous history of stillbirth, fetal loss, or early

neonatal death.

Fetal conditionsPrematurity, postmaturity, congenital anomalies, or multiple gestations.

Antepartum complicationsPlacental anomalies (eg, placenta previa), or presence of

either oligohydramnios or polyhydramnios.

Delivery complicationsTransverse lie or breech presentation, chorioamnionitis, foul-

smelling or meconium-stained amniotic fluid, antenatal asphyxia with abnormal fetal heart

rate pattern, maternal administration of a narcotic within four hours of birth, or delivery that

requires instrumentation (eg, forceps, vacuum, or cesarean delivery).

Individuals fully skilled in neonatal resuscitation should be present to care for the high-risk infant. If

time permits, the team should meet with the parents and discuss the anticipated problems and

plans for care of the infant, and address parental concerns to the best of their ability.

Necessary equipment should be assembled prior to the birth of at-risk newborns as follows [3]:

The radiant warmer is turned on and is heating.

The oxygen source is open with adequate flow through the tubing.

The suctioning apparatus is tested and is functioning properly.

The laryngoscope is functional with a bright light.

Testing of resuscitation bag and mask demonstrates an adequate seal and generation of

pressure.

In high-risk deliveries of multiple gestations, each infant will require a full complement of personnel

and equipment.

Preterm infantsPreterm infants pose a greater challenge than term infants because they are

more likely to require resuscitation and develop complications from the resuscitative process. If a

preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to

delivery to a perinatal center that has fully trained staff with expertise and experience in the care of

these infants [8,9].

The following factors make the preterm infant more likely to require resuscitation and to be more

susceptible to sequelae [3]:

HypothermiaThe risk of heat loss leading to hypothermia is increased in infants with a

large body surface area to mass, thin skin, and decreased subcutaneous fat. The smaller

the infant, the more difficult it is to prevent hypothermia. (See'Provide warmth'below.)

Inadequate ventilationImmature lungs may be deficient in surfactant, and therefore

difficult to inflate and ventilate. Immature respiratory drive and weak respiratory muscles

increase the likelihood of apnea and inadequate respiratory effort. The greater the degree
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of prematurity, the more likely the infant will require intubation and positive pressure

support. (See'Next steps'below.)

InfectionMaternal infection is associated with premature delivery, and offspring of

infected mothers are at risk for antenatal infection. Premature infants also have immature

immune systems, which increases the risk of acquiring postnatal infection.

(See"Pathogenesis of spontaneous preterm birth", section on 'Bacteria'.)

Organ damageImmature tissues and capillaries (eg, retina or germinal matrix) are more

vulnerable to injury resulting in complications (eg, retinopathy of prematurity and intracranial

hemorrhage, respectively). (See"Clinical manifestations and diagnosis of intraventricular

hemorrhage in the newborn"and"Retinopathy of prematurity", section on 'Risk factors'.)

Reduced antioxidant functionImmature antioxidant defense systems may be unable to

counteract the effects of free radicals. Free radicals and reactive oxygen species are

speculated to contribute to many of the morbidities of prematurity (eg, bronchopulmonary

dysplasia and necrotizing enterocolitis) [10]. The very preterm infant may be particularly

susceptible to oxidant injury from the use of excess supplemental oxygen in the delivery

room [11]. (See"Pathogenesis and clinical features of bronchopulmonary dysplasia",

section on 'Oxygen toxicity'and"Pathology and pathogenesis of necrotizing enterocolitis in

newborns".)

Additional resources and personnel should be present when a preterm birth is anticipated. These

include:

Equipment to keep the infant warm. In infants less than 28 weeks gestation, the use of

polyethylene bags and wraps have been used to maintain body temperature. (See"Short-

term complications of the premature infant", section on 'Hypothermia'.)

Personnel skilled in intubation are especially important for the extremely low birth weight

infant (birth weight


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If there is no chance of survival, resuscitation should not be initiated. (See'Withholding

resuscitation'below.)

When a good outcome is considered very unlikely, the parents should be given the choice

of whether resuscitation should be initiated, and clinicians should respect their preference.

If a good outcome is considered reasonably likely, clinicians should initiate resuscitation

and, together with the parents, continually reevaluate whether intensive care should be

continued. (See'Postresuscitation'below.)

OVERVIEW OF RESUSCITATIVE STEPSAlthough there is increasing emphasis to incorporate

the highest quality of evidence (ie, randomized clinical trials) into the American Heart

Association (AHA)/American Academy of Pediatrics (AAP) and International Liaison Committee on

Resuscitation (ILCOR) neonatal resuscitative guidelines [1], this is not always possible.

Randomized trials are difficult to perform in the delivery room because of difficulties in obtaining

consent before resuscitation, difficulty in blinding care providers regarding intervention, and the

relatively uncommon occurrence of a poor neonatal outcome to measure the effectiveness of an

intervention. As a result, many of the guideline recommendations are based upon extensive clinical

experience [1].

The following discussion and our own practice are in compliance with the

2010 AHA/AAP/ILCOR guidelines for neonatal resuscitative care [1,13,14].

The 2010 AHA/AAP/ILCOR guidelines include a rapid assessment of the neonate's clinical status

based on the following questions:

Is the infant full-term?

Is the infant breathing or crying?

Does the infant have good muscle tone?

If the answer to all three questions is yes, the newborn does not need resuscitation, should not be

separated from the mother, and is managed by routine neonatal care. (See"Overview of the routinemanagement of the healthy newborn infant".)

The basic steps ("ABCDs") in resuscitation in any age group still apply in the newborn period.

However, there are aspects of neonatal resuscitation that are unique and lead to differences in the

initial resuscitative steps. (See'Initial steps'below.)

The 2010 AHA/AAP/ILCOR guidelines recommend the following approach (algorithm 1)[1,3]:

Initial steps (provide warmth, clear Airway if necessary, dry, and stimulate)

Breathing (ventilation)

Chest compressions

Administration of Drugs, such asepinephrineand/or volume expansion

The decision to progress from one step to the next is determined by the time-dependent response

of the infant to the applied resuscitative effort based upon his/her respirations and heart rate

(algorithm 1). A time allocation of 30 seconds is given to apply the resuscitative procedure,

evaluate, and decide whether to proceed to the next intervention. Monitoring of oxygen saturation

by using pulse oximetry should be performed in infants who are gasping, apneic, have labored

breathing, have persistent cyanosis, or have a heart rate less than 100 beats per minute (bpm). No
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further resuscitative actions are required if the infant responds with adequate spontaneous

respirations and a heart rate above 100 beats per minute. (See'Pulse oximetry'below.)

It is vital that each step be performed optimally because subsequent resuscitative efforts are

dependent on the success of previous steps. Thus, more time should be spent if 30 seconds is not

sufficient to effectively complete the components of an intervention. Inadequate attention to

ensuring completeness and effectiveness of earlier steps will jeopardize the utility of subsequentactions and unnecessarily expose infants to more aggressive intervention when they only required

the earlier steps of resuscitation.

Apgar scores are not used to guide resuscitation but are useful as a measure of the newborn's

overall status and response to resuscitation. When the five-minute Apgar score is less than seven,

additional scores should be assigned every five minutes for up to 20 minutes. Apgar scores are not

good predictors of outcome. Scores may be determined using the Apgar score calculator (calculator

1).

The following discussion will describe each resuscitative action in depth.

INITIAL STEPSInitial care steps in the delivery room are started within a few seconds of birth

and should be applied throughout resuscitation.

Provide warmthHypothermia in the delivery room or immediate newborn period is

independently associated with an increase in mortality [15,16]. Thus, maintaining body heat is the

initial step in neonatal resuscitation. Hypothermia in the newborn increases oxygen consumption

and metabolic demands, which can impair subsequent resuscitative efforts, especially in the

asphyxiated or extremely low birth weight (ELBW) infant. Low birth weight and preterm infants are

particularly prone to rapid loss of body heat because of their large body surface area relative to their

mass, thin skin, and decreased subcutaneous fat.

To minimize heat loss, the delivered infant is first placed in a warmed towel or blanket and then

under a prewarmed radiant heat source, where he/she is dried with another warmed towel or

blanket. The infant should remain uncovered to allow full visualization and permit the radiant heat toreach the patient. The radiant warmer also allows easy access to the infant for multiple members of

the resuscitative team.

As soon as possible after the infant is placed on the warmer, the temperature control of the warmer

should be regulated by servo-control to avoid hyperthermia; the servocontrolled temperature of the

warmer is set to maintain the infant's temperature at 36.5C, which is monitored by a temperature

skin probe placed upon the infant's abdomen. Healthcare providers should understand how the

warmer and temperature probe work, since a malfunctioning warmer and/or temperature probe may

lead to inadvertent underheating or overheating of the infant.

Although studies have not examined the effects of postnatal hyperthermia in the delivery room on

neonatal outcome, there are data demonstrating that maternal fever is associated with neonatalrespiratory depression, neonatal encephalopathy, cerebral palsy, and increased mortality [17]. It is

unclear whether hyperthermia directly contributes to morbidity or whether it is a marker for an

underlying pathological process (eg, chorioamnionitis). Nevertheless, until further data are

available, it is prudent to avoid neonatal hyperthermia, as well as hypothermia, in the delivery room.

The following methods of warming infants are also used depending upon the condition of the

neonate and the need for further resuscitative efforts:
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Swaddling the infant after drying

"Skin to skin" contact with mother and covering the infant with a blanket

Use of polyurethane bags or wraps in infants with birth weights less than 1500 g

Raise the environmental (room) temperature to 26C (78.8F)

Warming pads

In infants who require respiratory support, the use of humidified and heated air versus nonheated

air decreases the rate of both mild (36 to 36.4C) and moderate hypothermia (


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StimulationTactile stimulation of the newborn should be initiated promptly after birth, except in

the case of the "nonvigorous" infant born with meconium-stained amniotic fluid who first requires

endotracheal intubation. Drying and suctioning the infant, which is performed as part of the initial

steps, may provide adequate stimulation. Safe, appropriate ways of providing additional stimulation

include briefly slapping or flicking the soles of the feet, and rubbing the infant's back. More vigorous

stimulation is not helpful and may cause injury. If, after one or two attempts of additional stimulation,

the infant still remains apneic, positive pressure ventilation (PPV) should be initiated. (See'Positive

pressure ventilation'below.)

Given that most infants will be stimulated from the moment of birth, efforts at stimulating the infant

should not be prolonged. The time elapsed from the baby's birth to placing the baby under the

warmer, positioning, suctioning, and providing additional stimulation should be no more than 30

seconds (algorithm 1)[3].

Pulse oximetryThe 2010 AHA/AAP/ILCOR guidelines recommend the use of pulse oximetry to

determine oxygen saturation (SpO2) in the following settings because oxyhemoglobin saturation

may normally remain in the 70 to 80 percent range for several minutes following birth, which may

result in the appearance of cyanosis, and the assessment of skin color is a poor indicator of

oxyhemoglobin saturation during the immediate neonatal period [1]:

When resuscitation is anticipated

Positive pressure ventilation is used for more than a few breaths

Persistent cyanosis

Use of supplementary oxygen

For these infants, the oximeter probe should be attached to a preductal location on the right upper

extremity, usually the wrist or medial surface of the palm, as soon as possible.

The targeted SpO2levels for term infants born at sea level are as follows based on the time after

delivery [1,20]:

1 minute60 to 65 percent

2 minutes65 to 70 percent





Data on targeted levels for premature infants and term infants born at other altitudes are lacking,

and the above levels are thought to be reasonable for these patients.

NEXT STEPSThe initial steps delineated above are applied in every newborn delivery.

Subsequent resuscitative care depends on the evaluation of the infant while performing these initial

steps (algorithm 1). No further resuscitative actions are required if the infant responds with

adequate spontaneous respirations (eg, sustained regular respirations) and a heart rate above 100

beats per minute, and achieves targeted SpO2levels.

Supplemental oxygenOver the last few decades, the standard practice of initial use of 100

percent oxygen, whenever supplemental oxygen is needed, has been challenged, as increasing

evidence has shown that hyperoxia due to oxygen supplementation may result in tissue and organ
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injury [21-23]. Hyperoxia is thought to raise cellular oxygen contents, which leads to an increased

generation of free oxygen radicals causing cellular and tissue injury [21-24].

In addition, several studies including meta-analyses have shown improved survival and outcome in

primarily term infants resuscitated with room air compared with those who received 100 percent

oxygen.

Two meta-analyses demonstrated a reduction in mortality in primarily term infants with the

use of room air compared with 100 percent oxygen, and no difference in the risk of hypoxic

ischemic encephalopathy or changes in neurodevelopmental outcome at 18 to 24 months

of age [25,26].

Two trials of asphyxiated term infants demonstrated that infants resuscitated in room air

compared with those resuscitated with 100 percent oxygen more quickly achieved

sustained respirations and had lower concentrations of markers or oxidative stress (ie,

glutathione, superoxide dismutase, catalase, and glutathione peroxidase) [22,27].

A retrospective population-based Swedish study compared the outcome of severely

depressed infants (defined as a one-minute Apgar score less than four) who were

resuscitated at one of four tertiary centers that used either 40 percent oxygen or 100percent oxygen during neonatal resuscitation. There were no differences in rates of

neonatal death, hypoxic ischemic encephalopathy, or seizures between infants resuscitated

with 40 percent oxygen and those who received 100 percent oxygen [28].

Data are more limited in premature infants, but suggest that room air may be insufficient to achieve

targeted oxygen levels and 100 percent oxygen results in excessive oxygen exposure [29]. As a

result, in our practice, blended oxygen with concentration starting at 30 percent is used in the

resuscitation of preterm infants below 30 weeks gestation, and oxygen concentration adjusted

based on a predetermined SpO2target range. (See'Our approach'below.)

In one observational study of preterm infants less than 30 weeks gestation, infants

resuscitated with room air had median oxygen saturations of 31 and 54 percent at two and

five minutes, and almost all of the infants required supplemental oxygen (91 of 106

patients) [30]. In contrast, the median oxygen saturations of the 20 infants resuscitated with

100 percent oxygen at two and five minutes were 84 and 95 percent.

A small trial randomly assigned 42 premature infants (gestational age 28 weeks) who

required resuscitation to initially receive either 30 percent oxygen, which was increased in a

stepwise manner every 60 to 90 seconds by 10 percent if bradycardia (85 percent [31].

There were no differences in mortality rate and the oxygen saturation values obtained by

pulse oximeter from 1 to 20 minutes of life between the two groups. By five to seven

minutes of life, the mean oxygen was 45 percent in both groups. In one small trial, preterm infants (24 to 28 weeks gestation) resuscitated with 30 percent

oxygen, when compared with those resuscitated with 90 percent oxygen, needed fewer

days of oxygen supplementation and mechanical ventilation, and had a lower incidence of

bronchopulmonary dysplasia (15 versus 32 percent) [32].

The following 2010 American Heart Association/American Academy

of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) guidelines reflect
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the lack of data needed to establish evidence-based guidelines for a specific initial oxygen

concentration for resuscitation [1]:

Resuscitation should be initiated with blended oxygen. If blended oxygen is not available,

room air should be used.

The oxygen concentration should be adjusted to achieve targeted SpO2levels, which are

monitored by pulse oximetry. (See'Pulse oximetry'above.)

If the heart rate is below 60 bpm after 90 seconds of resuscitation, the oxygen

concentration should be increased to 100 percent until recovery of a normal heart rate.

Our approachAt our institution, we currently utilize 21 percent oxygen for resuscitation of

neonates >30 weeks gestation. For infants 30 weeks gestation, because of the increased risk of

hyperoxia-related complications associated with prematurity [10], we initiate resuscitation with 30

percent oxygen by use of a blender. In all infants, pulse oximetry guides further adjustments of the

delivered supplemental oxygen in an effort to achieve and maintain the oxygen saturation based on

target SpO2. (See'Pulse oximetry'above.)

However, the optimal target SpO2levels in the delivery room are unknown in preterm infants [33].Target SpO2for premature infants is discussed in detail separately. (See"Oxygen monitoring and

therapy in the newborn", section on 'Oxygen target levels'.)

Positive pressure ventilationPositive pressure ventilation (PPV) is required in the following

clinical settings after administering the initial steps of resuscitation:

If the infant is gasping or apneic.

If the heart rate is


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opened at 35 to 40 cm H2O, oxygen concentrations fell to levels of 30 and 45 percent at

flow rates 2L/min. With a 100 percent oxygen source and a reservoir, oxygen delivery is

generally 90 to 100 percent oxygen. These findings are significant given the concern for

potential oxygen toxicity and episodes of hyperoxia with high concentrations of delivered

oxygen. They also demonstrate that pulse oximetry is required when supplemental oxygen

and positive pressure ventilation are used. (See'Supplemental oxygen'above.)

Flow-inflating bagThe flow-inflating bag (also referred to as an anesthesia bag) fills only

when gas from a compressed source flows into it. It is technically more difficult to master

than the self-inflating bag because a tight face-mask seal is needed for the bag to inflate;

however, this feature may be considered an advantage because it assures an optimal face-

mask seal is obtained, which is necessary for effective positive pressure ventilation.

Because the flow-inflating bag does not have a pressure release valve, a pressure

manometer should always be used to minimize the risk of overinflation resulting in

pulmonary air leak. (See"Pulmonary air leak in the newborn".)

T-piece resuscitatorThe T-piece resuscitator is similar to the flow-inflating bag, but with

the addition of an adjustable flow-control valve, which more precisely controls the peak

inflating pressure applied to the infant's lungs, decreasing the risk of pulmonary air leak

complications. Like the flow-inflating bag, it requires a compressed gas source. In term infants and preterm infants with birth weights greater than 1500 g, laryngeal mask

airway (LMA), which fits over the laryngeal inlet, has been found to be effective when BMV

or endotracheal intubation is unsuccessful, or endotracheal intubation is not possible [35].

The LMA is a soft mask with an inflatable cuff attached to a silicone rubber airway, which is

inserted through the mouth by the clinician using his/her index finger to guide insertion

along the hard palate "blindly" without the use of visualizing instruments. Following insertion

and inflation of the cuff, the LMA covers the laryngeal opening and its rim conforms to the

contours of the hypopharynx occluding the esophagus with a low-pressure seal. LMA

should be considered only i f BMV is unsuccessful in providing adequate ventilation, and

endotracheal intubation is unsuccessful or not feasible. [1,35-37].

ProcedureThe following steps are required to effectively provide assisted positive pressure bag-

mask ventilation (BMV):

PositionThe infant should be positioned with the neck in a neutral to slightly extended

position to ensure an open airway (figure 1). The clinician should stand at the head or side

of the warmer to view the chest movement of the infant to assess whether ventilation is

effectively delivered. (See'Airway'above.)

SuctionThe nose and mouth should be suctioned as needed to clear any mucous to

prevent aspiration prior to delivery of assisted breaths.

SealAn airtight seal between the rim of the mask and the face is essential to achieve the

positive pressure required to inflate the lungs. An appropriately sized mask is selected and

positioned to cover the chin, mouth, and nose, but not the eyes of the infant. The mask is

held on the face by positioning the hand of the clinician so that the little, ring, and middle

fingers are spread over the mandible in the configuration of the letter "E" and the thumb and

index are placed over the mask in the shape of the letter "C". The ring and fifth fingers lift

the chin forward to maintain a patent airway. An airtight seal is formed by using light

downward pressure on the rim of the mask and gently squeezing the mandible up towards

the mask (picture 1).
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Initial breathsThe initial administered breaths often require pressures of 30 to 40 cm H2O

to inflate the lungs of the newly born term infant. In most preterm infants, an initial inflation

pressure of 20 to 25 cm H2O is usually adequate. Adequacy of ventilation is demonstrated

by improvement in heart rate. Chest wall movement should be assessed if heart rate does

not improve. The infant should be ventilated at a rate of 40 to 60 times per minute to

achieve a heart rate >100 bpm.

When initiating ventilation, the care provider should try to avoid excess volume or pressure,

which can result in volutrauma resulting in lung injury or pulmonary air leak, especially in

the premature infant [38]. To minimize volutrauma, the positive pressure should be adjusted

to deliver a tidal volume of 4 to 5 mL/kg. In addition, positive end-expiratory pressure

(PEEP) of 4 to 5 cm H2O should be used to prevent atelectasis [38]. The self-inflating bag

does not provide PEEP. (See"Prevention of bronchopulmonary dysplasia", section on

'Noninvasive mechanical ventilation'and"Pulmonary air leak in the newborn".)

Next stepsFurther resuscitative efforts are based upon the heart rate response of the

infant after the initial 30 seconds of BMV.

If the heart rate is greater than 100 beats per minute (bpm) and spontaneous effectiverespiration has begun, BMV can be discontinued and free-flowing oxygen administered

as needed, based on the target oxygen saturations for minutes after birth. The infant is

observed closely (heart rate and SpO2) to determine whether his/her spontaneous

respiratory effort is adequate without need for further intervention.

If the heart rate is between 60 to 100 bpm, continue BMV ventilation and reevaluate

after 30 seconds. Reevaluation includes the following sequence of M-Mask

readjustment, R-Reposition the airway, S- Suction the mouth and nose, and O- Open

the mouth slightly. If these maneuvers fail, consider increasing inflation pressure

because failure of establishing effective positive pressure ventilation is an extremely

common and potentially preventable cause of failed resuscitation.

If the heart rate is below 60 bpm, immediately begin chest compression and reassessthat adequate positive pressure ventilation is being delivered. (See'Chest

compressions'below.)

CPAP or PEEPStudies in animals suggest the addition of continuous positive airway (CPAP) or

end-expiratory pressure (PEEP) may be beneficial for adequate lung recruitment and reduce

subsequent lung injury, especially in very premature animals [39,40].

Data from observational studies and a single clinical trial appear to support the use of CPAP versus

BMV in the initial resuscitation of preterm infants [41-44]. In a randomized controlled Dutch trial of

207 preterm infants born at a gestational age less than 33 weeks, patients who required ventilatory

support were randomized to a single pressure-controlled inflation of 10 seconds followed by CPAP

delivered through a nasopharyngeal tube and T-piece resuscitator versus positive BMV [44]. Infants

treated with single inflation/CPAP, when compared with those who received conventional BMV,were less likely to be intubated, receive more than one dose of surfactant, or develop

bronchopulmonary dysplasia (BPD). However, further studies to confirm these findings are needed

before CPAP verus BMV can be recommended for neonatal resuscitation.

After BMV ventilation as the initial resuscitative intervention, CPAP rather than intubation and

mechanical ventilation may be beneficial in the spontaneously vigorous preterm infants who require

continued respiratory support or at risk for respiratory distress syndrome. (See"Prevention and
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treatment of respiratory distress syndrome in preterm infants", section on 'Assisted ventilation

techniques'.)

In infants who require PPV, PEEP is likely to be beneficial, and should be used if suitable

equipment is available [1].

Endotracheal intubationEndotracheal (ET) intubation allows direct access to the upper trachea

for suctioning (ie, meconium) or delivery of positive pressure ventilation (PPV). Intubation is a skill

that must be learned and takes practice for one to become accomplished. While bag-mask

ventilation (BMV) may suffice in most instances of neonatal resuscitation, there are instances when

ET intubation may be preferred. Thus, when a high-risk delivery is anticipated, at least two

individuals should be present for the birth to assist with resuscitation of the infant, and one should

be skilled in ET intubation.

ET intubation may be indicated if [1]:

Tracheal suctioning for meconium is required

BMV is ineffective or prolonged

Chest compressions are being performed

In addition to the above, ET intubation may be electively chosen in certain special circumstances,

such as congenital diaphragmatic hernia, airway stabilization of the extremely low birth weight

infant, and for administration of surfactant.

All necessary supplies should be readied for intubation, including appropriate size ET tubes (ETT).

The neonatal resuscitation program (NRP) guidelines use birth weight and gestational age to

determine the appropriate ETT size (table 3). An alternate method for selection of ETT size is based

upon the length of the infant [45]. However, its use has only been validated in one study. This

approach cannot be recommended until further studies verify that it can accurately predict

appropriate ETT size for neonates.

Suction device should be available to remove secretions in the posterior oropharynx and

laryngopharynx that may obstruct the view of the trachea and vocal cords.

ProcedureTwo care providers are required for ET intubation, one to perform the procedure and

the other to assist and monitor the status of the infant during the intubation. To minimize

hypoxemia, time needed for intubation should be limited to 20 seconds, and free flowing oxygen is

administered during the procedure.

The following steps are required for successful intubation of the neonate:

Initial stabilizationUnless contraindicated, the patient should be stabilized by BMV.

PositioningThe infant is placed on his/her back with the head in the midline and the neck

slightly extended.

InsertionThe laryngoscope is held in the left hand of the clinician between the thumb and

the first two or three fingers, with the blade pointing away from the clinician. The right hand

stabilizes the head of the infant. The laryngoscope blade is inserted over the right side of

the tongue pushing the tongue to the left and is advanced until the blade lies in the

vallecula, just beyond the base of the tongue. The entire blade is lifted in the direction of the

laryngoscope handle to allow visualization of the vocal cords. It is important not to twist the

laryngoscope like a lever, the so-called "can opener" maneuver, as this can elevate the
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vocal cords out of view and can damage the alveolar ridge. Once the vocal cords are

visualized, an appropriate-sized ETT is inserted through them with the right hand until the

vocal cord guide line (heavy black line near the tip of the tube) is at the level of the vocal

cords.

Some individuals prefer to use a stylet to provide rigidity and curvature to the tube; if a

stylet is used, care should be taken that it does not protrude out of the tip of the tube, and

when it is removed the tube is not inadvertently dislodged.

Assessment of successful intubationSuccessful intubation following institution of PPV is

associated with a prompt increase in heart rate. Other indicators of successful intubation

include auscultation of audible breath sounds over both lung fields, vapor condensation

inside the ETT during exhalation, and symmetrical chest movement; however, these

findings have not been systematically studied in neonates. Chest radiography is needed to

confirm that the ETT is correctly placed above the carina of the trachea.

Exhaled carbon dioxide (CO2) detectors can be used to confirm ETT placement, especially

in very low birth weight infants [46-49]. At our institution, we use CO2detectors to confirm

ETT placement as endorsed by the 2010 guidelines [1]. Securing ETTIf the ETT is to be used for ventilation, it needs to be secured and taped. A

simple calculation can be used to determine the depth of insertion (referred to as the 7-8-9

or Tochen's rule). The distance measured in cm from the tip of the ETT to the lip of the

infant is calculated as the infant's weight in kg plus "6". So for a 1 kg infant, the depth of

insertion is 7 cm. This rule accurately places the tip of the ETT just above the midtracheal

position in infants with birth weight (BW) 750 g. However, the Tochen's rule is not

adequate for ETT placement in infants with BW


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Resuscitation (AHA/AAP/ILCOR) guidelines in neonates because it generates higher systolic and

coronary perfusion pressure [52-57].

Chest compressions must always be accompanied by positive pressure ventilation (PPV). During

neonatal resuscitation, the chest compression rate is 90 per minute accompanied by 30 ventilations

per minute with one ventilation interposed after every third compression. Thus, the ventilation rate is

reduced from the 40 to 60 breaths per minute used in the absence of chest compression to 30breaths in the presence of chest compression.

After 30 seconds of chest compression and PPV, reassessment of the infant's heart rate, color, and

respiratory rate should determine whether further interventions are required (eg, intubation or

administration of medications).

DRUGSDrugs are rarely required in neonatal resuscitation. Delivering adequate ventilation is

the most important resuscitative step because the most common cause of bradycardia is

inadequate lung inflation or profound hypoxemia.

However, if the heart rate remains


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Volume expansionIn the delivery room, neonatal hypovolemia requiring volume expansion is

rarely needed. Hypovolemia may be suspected if there is ante- or intrapartum hemorrhage, which

could be due to an umbilical cord accident, placenta previa, or trauma, or if there are clinical signs

of hypovolemia seen despite an adequate heart rate, such as pallor, poor perfusion, and weak

pulses.

Because isotonic crystalloid solution is as effective as 5 percent albumin in restoring effectivecirculating volume in neonates [60-62], the current guidelines recommend a 10 mL/kg bolus of

normal saline given over 5 to 10 minutes to correct hypovolemia. This dose can be repeated if

necessary based upon the response to the initial bolus.

Other acceptable solutions include Ringer's lactate or O Rh-negative blood. The latter may be

preferable if severe blood loss and/or anemia is suspected or documented.

NaloxoneIn the 2010 American Heart Association/International Liaison Committee on

Resuscitation (AHA/ILCOR) guidelines, administration ofnaloxone,a narcotic antagonist,

is notrecommended as part of initial resuscitation in the delivery room because data are lacking

demonstrating its efficacy, and there remains uncertainty regarding its dosing, routes of

administration, and safety [1,63]. Although, maternally administered opioids in the perinatal periodmay cause neonatal respiratory depression, attention to ventilation and oxygenation as described

earlier is generally adequate for neonatal resuscitation.

Sodium bicarbonateThere is insufficient evidence to determine whethersodium bicarbonateis

beneficial or harmful in neonatal resuscitation [3,64,65]. Although theoretically sodium bicarbonate

should be beneficial to correct acidosis, there is also evidence that sodium bicarbonate could

adversely affect myocardial and cerebral function [66]. Given the uncertainty of benefit and the

potential for adverse effects, we do not routinely recommend the use of sodium bicarbonate. This

approach is consistent with the 2010 AHA/American Academy of Pediatrics(AAP)/ILCOR guidelines

for neonatal resuscitative care, which do not include the use of sodium bicarbonate as a

recommended or useful medication [1,13,14]. (See"Approach to the child with metabolic acidosis",

section on 'Bicarbonate therapy in neonates'.)

Ifsodium bicarbonateis used, it should be given only after adequate ventilation and circulation has

been established to prevent increased CO2retention. Sodium bicarbonate is a caustic and

hypertonic agent, and, if administered, it must be given through a large vein. Given the controversy

over its use in neonatal resuscitation, no dose for sodium bicarbonate use has been established. If

it is used, the usual dose is 1 or 2 mEq/kg, given at a rate no faster than 1 mEq/kg per minute.

(See"Primary drugs in pediatric resuscitation", section on 'Sodium bicarbonate'.)

FAILURE OF INITIAL RESUSCITATIONRarely, infants will not respond to the initial

resuscitative efforts. The clinical team needs to review that all the resuscitative steps were fully and

properly administered.

If the infant fails to respond despite properly executed resuscitation, the following clinical approachmay help ascertain the cause:

Failure to respond to positive pressure ventilation (PPV):

Mechanical blockage (eg, meconium, mucus, choanal atresia, pharyngeal airway

malformation [Robin sequence], or laryngeal web)
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Impaired lung function (pneumothorax, pleural effusions, congenital diaphragmatic

hernia, pulmonary hypoplasia, congenital pneumonia, or hyaline membrane disease)

Central cyanosisCongenital heart disease

Persistent bradycardiaHeart block

ApneaBrain injury (hypoxic ischemic encephalopathy), congenital neuromuscular

disorder, or respiratory depression from maternally administered opioids

WITHHOLDING RESUSCITATIONWith antenatal screening, it is now possible to identify

conditions associated with high neonatal mortality or poor outcome. In these settings, intensive

therapy including neonatal resuscitation may result in prolongation of dying with significant pain and

discomfort for the neonate or survival with unacceptable quality of life. Decisions regarding whether

intervention should be initiated and to what degree are difficult and are made together by parents

and care providers, guided by their understanding of the child's best interests.

Our approach in deciding whether resuscitation should be initiated or withheld is consistent with the

recommendations of the American Academy of Pediatrics (AAP) and includes the following [1,67].

The decision not to initiate intensive therapy is made together by the parents and the

healthcare team. Parents should be active participants in the decision-making process

concerning the treatment of their child. Discussion, if possible, should occur prior to the

birth of the infant.

Noninitiation of resuscitation may be considered if early death is very likely and survival

would be accompanied by unacceptably high morbidity. These clinical conditions include

infants with gestational age


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DISCONTINUING RESUSCITATIONResuscitation efforts may be discontinued if the neonate

has demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes)

after 10 minutes of resuscitation [1,3], because outcome is associated with high early mortality and

unacceptably high morbidity among the rare survivors [68-70].

As previously discussed, if additional data obtained after resuscitation is started demonstrates that

neonatal outcome is almost certain early death or unacceptably high morbidity, support can bediscontinued if agreed upon by the parents and healthcare team.

POSTRESUSCITATIONInfants who required resuscitation are at risk of developing

postresuscitative complications [71]. These include:

Hypo- or hyperthermia

Hypoglycemia (see"Neonatal hypoglycemia")

Central nervous system (CNS) complications: apnea, seizures, or hypoxic ischemic

encephalopathy (see"Clinical features, diagnosis, and treatment of neonatal

encephalopathy")

Pulmonary complications: Pulmonary hypertension, pneumonia, pulmonary air leaks, or

transient tachypnea of the newborn (see"Overview of neonatal respiratory distress:Disorders of transition")

Hypotension

Electrolyte abnormalities: Hyponatremia or hypocalcemia

Feeding difficulties: Ileus, gastrointestinal bleeding, or dysfunctional sucking or swallowing

The longer and the greater the extent of resuscitation, the more likely that there will be subsequent

and serious complications. Thus, infants who required resuscitation should be placed in a setting in

which close monitoring and ongoing appropriate care can be provided.

SUMMARY AND RECOMMENDATIONS

Most infants successfully transfer from intrauterine to extrauterine life without any special

assistance. However, about 10 percent of newborns will need some intervention, and 1

percent will require extensive resuscitative measures at birth.

Because the need for resuscitation is not anticipated in the majority of neonates, personnel

who are adequately trained should be readily available to perform neonatal resuscitation at

every birthing location, whether or not problems are anticipated. (See'Anticipation of

resuscitation need'above.)

Infants who are more likely to require resuscitation can be identified by maternal and

neonatal risk factors, and the presence of antepartum and delivery room complications.

Care providers skilled in neonatal resuscitation should be present and equipment should be

prepared prior to the birth of the high-risk infant. (See'High-risk delivery'above.)

Preterm infants are more likely to require resuscitation and develop complications fromresuscitation than term infants. If a preterm birth can be anticipated and time permits, it is

preferable to transfer the mother prior to delivery to a perinatal center. (See'Preterm

infants'above.)

Resuscitation stepsWe suggest the following practices described in the 2010 American Heart

Association, American Academy of Pediatrics, and International Liaison Committee on
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