Neonatal Resuscitation

Table of Contents

Aliases

None noted

Patient Care Goals

  1. Provide routine care to the newly born infant
  2. Perform a neonatal assessment
  3. Rapidly identify newly born infants requiring resuscitative efforts
  4. Provide appropriate interventions to minimize distress in the newly born infant
  5. Recognize the need for additional resources based on patient condition and/or environmental factors

Patient Presentation

Inclusion Criteria

Newly born infants

Exclusion Criteria

Documented gestational age less than 20 weeks (usually calculated by date of last menstrual period). If any doubt about accuracy of gestational age, initiate resuscitation.

Patient Management

Assessment

  1. History
    1. Date and time of birth
    2. Onset of symptoms
    3. Prenatal history (prenatal care, substance abuse, multiple gestation, maternal illness)
    4. Birth history (maternal fever, presence of meconium, prolapsed or nuchal cord, maternal bleeding)
    5. Estimated gestational age (may be based on last menstrual period)
  2. Exam
    1. Respiratory rate and effort (strong, weak, or absent; regular or irregular)
    2. Signs of respiratory distress (grunting, nasal flaring, retractions, gasping, apnea)
    3. Heart rate (fast, slow, or absent)
      1. Precordium, umbilical stump or brachial pulse may be used
      2. Auscultation of chest is preferred since palpation of umbilical stump is less accurate
    4. Muscle tone (poor or strong)
    5. Color/Appearance (central cyanosis, acrocyanosis, pallor, normal)
    6. APGAR score (appearance, pulse, grimace, activity, respiratory effort) – may be calculated for documentation, but not necessary to guide resuscitative efforts
    7. Estimated gestational age (term, late preterm, premature)
    8. Pulse oximetry should be considered if prolonged resuscitative efforts or if supplemental oxygen is administered – goal:
      1. oxygen saturation at 1 minute is 60-65%
      2. oxygen saturation at 2 minutes is 65-70%
      3. oxygen saturation at 3 minutes is 70-75%
      4. oxygen saturation at 4 minutes is 75-80%
      5. oxygen saturation at 5 minutes is 80-85%
      6. oxygen saturation at 10 minutes is 85-95%

Treatment and Interventions

  1. If immediate resuscitation is required and the newborn is still attached to the mother, clamp the cord in two places and cut between the clamps. If no resuscitation is required, warm/dry/stimulate the newborn and then cut/clamp the cord after 60 seconds or the cord stops pulsating
  2. Warm, dry, and stimulate
    1. Wrap infant in dry towel or thermal blanket to keep infant as warm as possible during resuscitation; keep head covered if possible
    2. If strong cry, regular respiratory effort, good tone, and term gestation, infant should be placed skin-to-skin with mother and covered with dry linen
  3. If weak cry, signs of respiratory distress, poor tone, or preterm gestation then position airway (sniffing position) and clear airway as needed – if thick meconium or secretions present and signs of respiratory distress, suction mouth then nose
  4. If heart rate greater than 100 beats per minute
    1. Monitor for central cyanosis – provide blow-by oxygen as needed
    2. Monitor for signs of respiratory distress. If apneic or in significant respiratory distress:
      1. Initiate bag-valve-mask ventilation with room air at 40-60 breaths per minute
      2. Consider extraglottic airway placement
  5. If heart rate less than 100 beats per minute
    1. Initiate bag-valve-mask ventilation with room air at 40-60 breaths per minute
      1. Primary indicator of effective ventilation is improvement in heart rate
      2. Rates and volumes of ventilation required can be variable, only use the minimum necessary rate and volume to achieve chest rise and a change in heart rate
    2. If no improvement after 90 seconds, use O2 until heart rate normalizes
    3. Consider extraglottic airway placement if bag-valve-mask ventilation is ineffective
  6. If heart rate less than 60 beats per minute
    1. Ensure effective ventilations with supplementary oxygen and adequate chest rise
    2. If no improvement after 30 seconds, initiate chest compressions – two-thumb-encircling-hands technique is preferred
    3. Coordinate chest compressions with positive pressure ventilation (3:1 ratio, 90 compressions and 30 breaths per minute)
    4. Consider endotracheal intubation per local guidelines
    5. Administer epinephrine (0.1mg/mL) 0.01 mg/kg IV/IO (preferable if access obtained) or 0.1 mg/kg via the ETT (if unable to obtain access)
      1. Use length-based tape or age-based card for weight approximation and dosage.
  7. Consider checking a blood glucose for ongoing resuscitation, maternal history of diabetes, ill appearing or unable to feed
  8. Administer 20 mL/kg normal saline IV/IO for signs of shock or post-resuscitative care

Notes – Neonatal Resuscitation