13
Neonatal resuscitation and post-resuscitation care

Relatively few infants require resuscitation at birth. The aim of resuscitation is to optimize the airway, breathing and circulation as quickly as possible. Most infants respond to lung inflation. Very few require chest compressions or medications. As the need for resuscitation has become uncommon, there is increasing emphasis on simulation and teamwork training to ensure proficient resuscitation when it is required.

Preparation

The presence of antenatal or intrapartum risk factors often allows anticipation that resuscitation may be required. This enables those skilled in neonatal resuscitation to be present. However, the need for resuscitation cannot always be predicted. There should always be at least one health professional skilled in basic resuscitation readily available at every delivery. Staff skilled in advanced resuscitation should attend high risk deliveries and be readily available at all times (see video: Basic newborn resuscitation).

Before delivery

• Introduce yourself to parents and explain why you are present.
• Review maternal history and obstetric records.
• Turn on the radiant warmer.
• Wash hands and put on gloves.
• Check equipment is present and functional:
  • – several warm towels (and plastic wrap or bag for preterm infants)
  • – clock
  • – stethoscope
  • – suction equipment
  • – gas supply and pressure-limited T-piece circuit (e.g. Neopuff®) or self-inflating bag and mask
  • – oropharyngeal (Guedel) airway
  • – laryngoscope, tracheal tubes and introducers
  • – exhaled CO₂ detector
  • – pulse oximeter
  • – venous access equipment and drugs.

Specific questions to consider

• Will you need help? If so, call for it early.
• Is neonatal transport going to be needed?

Cord clamping

Delay in cord clamping of at least 1 minute from complete delivery of the infant is recommended for uncompromised infants. For the compromised infant, resuscitation is the priority and a plan of action should be agreed with the obstetric team. Resuscitation tables that can be placed directly adjacent to the mother to allow resuscitation with intact cord have been developed; studies are currently determining their impact on outcomes.

Temperature control

Thermoregulation is critical as hypothermia contributes to hypoglycemia, acidosis and even mortality, especially in extremely preterm infants (see video: Resuscitation of preterm).

Action

• Resuscitation area should be warm and draft free.
• Perform resuscitation under radiant warmer.
• Dry infant, remove wet towel, then wrap in dry towel.
• For preterm infants (<30 weeks), place wet infant directly in plastic wrap (bag) with only face exposed. Cover head with hat. An exothermic mattress may also be used.

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Key point

Thermoregulation is critical. The vigorous term infant can be dried then placed against the mother’s chest and covered with a warm towel.

If resuscitation is required – rapidly dry and place under radiant warmer. Preterm babies should be placed (wet) in plastic wrapping under a radiant heater with head covered. If neonatal admission temperature is >36.5 °C (97.8 °F), time on mechanical ventilation, length of stay and mortality are reduced.

After prolonged resuscitation in term infants, passive cooling should be started pending a decision about therapeutic hypothermia. Hyperthermia can worsen the outcome and should be avoided

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Initial assessment at birth

Start the clock or note the time.

Is the baby:

• term gestation?
• crying or breathing vigorously?
• good muscle tone?

If this is the case, the baby should dried, placed skin-to-skin with the mother if desired and covered with dry linen to maintain temperature.

If not, assess breathing (rate, depth and symmetry), heart rate (stethoscope on apex), color and tone and initiate resuscitation as required. Drying often produces enough stimulation to induce breathing.

A – Airway

If gasping or not breathing – open airway:

• Position – optimize head position, avoiding head overextension or flexion, using a towel beneath the shoulders if desired.
• Suction – only if obvious obstruction (e.g. blood, meconium) and unable to achieve chest rise. Suction should be under direct vision with a wide-bore suction device (bulb syringe or Yankauer). Tracheal suctioning of meconium-stained fluid is only indicated for depressed, hypotonic babies. Care is required as pharyngeal suctioning may cause laryngeal spasm and vagal bradycardia. Suctioning meconium from the oropharynx at the perineum, routinely practiced for many years, does not improve outcome.
• For congenital airway abnormalities – choanal atresia, severe micrognathia (small jaw) or macroglossia (large tongue) – consider using an oral airway or laryngeal mask airway.

B – Breathing

Assessment

• Look for chest movement – check if inadequate or absent or if heart rate is <100 beats/min.
• Attach oxygen saturation monitor to right hand if resuscitation is anticipated, if baby remains cyanotic or if positive-pressure ventilation or supplementary oxygen required. Oxygen saturation monitors provide continuous reading of heart rate and oxygen saturation but take time to apply and may not function if poor perfusion. In healthy term infants following vaginal birth, it takes about 10 minutes for preductal oxygen saturation to reach levels >90%.

Action

If inadequate respiratory effort, gasping or not breathing or heart rate is <100 beats/min, the priority is to inflate the lungs with mask ventilation (Fig. 13.1), using a T-piece pressure device or self-inflating bag (Fig. 13.2).

Fig. 13.1 Correct size and position of face mask. It should cover the mouth, nose and chin.

Fig. 13.2 Mask ventilation via a T-piece connected to air/oxygen blender from a pressure-limited circuit.

Mask ventilation

Most infants will respond to lung inflation.

• Term infants – start with air. Titrate additional oxygen according to oxygen saturation level.
• Preterm infants – as above but use air/oxygen blender and pulse oximetry.

Use minimum oxygen required, according to preductal saturation targets in first 10 minutes of life. Avoid oxygen saturation above target range 91–95% as hyperoxemia can be damaging to eyes, lungs and brain.

Achieving lung inflation

The aim is good chest rise using the lowest pressure.

Assess regularly, observing for:

• Increasing heart rate to >100 beats/min.
• Improving color (or saturations).
• Spontaneous breathing.
• If lung inflation is not achieved and the heart rate is not responding, further airway maneuvers may be required. Recheck the airway position and consider suction (if obstruction seen), increased peak pressure and inspiratory time, airway adjuncts (Guedel airway or laryngeal mask airway) or endotracheal intubation.

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Key point

The Golden Minute:

Initial assessment, dry the baby, observe breathing, check heart rate and start positive-pressure ventilation if required – all should be done in first minute after birth.

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Endotracheal intubation (see Chapter 74)

Indications

• If effective mask ventilation is not sustaining adequate ventilation (but only when all the basic measures described above have been checked).
• Consider in all babies who require cardiac compressions to maintain the airway.
• If prolonged ventilation is needed.
• Congenital diaphragmatic hernia and some congenital upper airway abnormalities.
• If direct tracheal suction is needed for thick meconium or other obstruction in depressed, hypotonic infant.

However:

• Should only be attempted by those with advanced airway skills.
• Limit each attempt to <30 seconds.
• Confirm tube in trachea with symmetrical air entry and end-tidal CO₂ detector.
• Provide effective mask ventilation between attempts if necessary.If no response to intubation consider DOPE:
• Displaced tube:
  • – Is it in oesophagus? (no chest movement, air entry over stomach greater than chest, no CO₂ detected)
  • – Is it in one (usually right) main bronchus?- asymmetrical chest rise or air entry, CO₂ may still be detected.
• Obstructed tracheal tube (especially meconium) – aspirate or replace tube, or tube too small for baby
• Patient:
  • – Lung disorders i.e. lung immaturity, surfactant deficiency, pneumothorax, diaphragmatic hernia, lung hypoplasia, pleural effusion
  • – Shock from blood loss, anemia
  • – Neonatal encephalopathy – perinatal asphyxia, head trauma, CNS hemorrhage or abnormality
• Equipment failure-exhausted or disconnected gas supply.

C – Circulation

• Assess heart rate regularly with stethoscope or feel pulse at base of the umbilical cord (or observe heart rate on saturation monitor, if connected).
• Start chest compressions (Fig. 13.3) if heart rate <60 beats/min despite adequate ventilation.
• Call for help – if not already available.

Fig. 13.3 (a) Apply pressure to lower third of sternum, just below an imaginary line joining the nipples. Avoid the xiphoid. Depress to reduce anteroposterior diameter of the chest by one-third with no bounce. The thumb technique (b and c) is more effective than the two-finger technique and is recommended, but the two-finger technique (d) is easier if you are alone.

There should be a 3:1 ratio of compressions to breaths (approximately 90 compressions and 30 breaths/minute) to maximize ventilation at an achievable rate. Compressions and ventilations should be coordinated to avoid simultaneous delivery.

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Key points

• Before starting chest compressions, ensure the lungs are inflated, i.e. good chest movement. If not, chest compressions are unlikely to be effective.
• Call for help – giving chest compressions is easier with two people.

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Drugs (Table 13.1)

Table 13.1 Resuscitation drugs

Medication	Concentration	Dosage/route	Indications
Epinephrine (adrenaline)	1 in 10 000 (0.1 mg/mL)	IV: 0.1 to 0.3 ml/kg Endotracheal: 0.5–1 ml/kg	No response in spite of visible lung inflation and cardiac compressions
Volume expander	Normal saline Whole blood	10 mL/kg IV over 5–10 min	Suspected acute blood loss and/or signs of hypovolemia
Sodium bicarbonate	0.5 mEq/mL (0.5 mmol/mL)	1–2 mEq/kg (1–2 mmol/kg) (2–4 mL/kg of 4.2% solution)	Consider only after prolonged arrest in spite of effective ventilation
Glucose	10%	2–2.5 mL/kg (250 mg/kg) IV	For documented hypoglycemia

Drugs are rarely indicated; only use if no response in spite of:

• visible lung inflation
• cardiac compressions for at least 30 seconds.

Epinephrine (adrenaline) administered intravenously via umbilical venous catheter is recommended. Whilst intravenous access is obtained, administration in higher dose via endotracheal tube may be considered, but its efficacy has not been established.

Volume expansion with saline or blood may be indicated when blood loss is suspected e.g. pale infant, history of hemorrhage.

The role of sodium bicarbonate is controversial. It may be considered in prolonged resuscitation to correct metabolic acidosis, but may potentially be harmful as it may exacerbate intracellular acidosis if breathing is inadequate.

Prevention of hypoglycemia should be considered following prolonged resuscitation.

Drugs should be flushed with a bolus of saline.

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Key point

In neonates, drugs are not indicated unless there is no response to effective ventilation (visible lung inflation) and optimally performed cardiac compressions.

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Key point

The principles of neonatal resuscitation are agreed internationally and regularly updated [see ILCOR (International Liaison Committee on Resuscitation)]. As details differ between countries, the UK/European and US algorithms are shown.

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Withholding and discontinuing resuscitation

Difficult decisions arise at the margins of viability and for infants with conditions that have unacceptably high morbidity or almost certain early mortality. Attitudes and practices vary widely between practitioners, institutions and countries. Whenever possible, decisions should be made with parental agreement.

Discontinuation of resuscitation should be considered if the heart rate is undetectable at birth and remains so for 10 minutes despite full resuscitation. If there is doubt, rather than hasty decisions in the delivery room, it is often best to transfer to the neonatal unit for detailed assessment.

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Question

What are the guidelines used in the UK and Europe?

The UK/European Resuscitation guidelines are shown in Fig. 13.4.

Fig. 13.4 Algorithm for newborn life support.

(Source: Resuscitation Council UK, 2010.)

Particular features are:

• Airway – neutral position (Fig. 13.5).

  Suction airway only if obvious airway obstruction not corrected by appropriate airway positioning, and only under direct vision.

• Breathing – if not breathing or heart rate is not established, give five inflation breaths, preferably using air (pressure of 30 cmH₂O for 2–3 s for term babies, 20–25 cmH₂O for preterm).

  If heart rate increases but baby not breathing, provide regular ventilation breaths at 30–40 breaths/min.

  If heart rate does not increase, check that chest is moving effectively. If not, check that baby’s head is in neutral position, consider the need for jaw thrust, longer inflation time, a second person’s help with the airway (Fig. 13.6), obstruction in the oropharynx or trachea, need for oropharyngeal (Guedel) airway.

  If the heart rate remains at <60 breaths/min despite effective chest movement, start cardiac compression.

• Cardiac compression – ratio of 3 compressions to 1 inflation, rate of 90 compressions and 30 inflation breaths per minute.
• Drugs – rarely needed (<1 in 1000 births) if there is effective lung inflation and chest compression.

  If epinephrine required, intravenous route is recommended. Tracheal route only if intravenous delivery not possible.

  If blood loss suspected, give blood or 0.9% sodium chloride.

  Consider sodium bicarbonate and dextrose.

• Meconium-stained liquor – aspirating meconium from the nose and mouth before complete delivery is not recommended. If breathing is compromised and infant is hypotonic, inspect oral pharynx rapidly and aspirate obstructions to airway. Tracheal intubation may be helpful, if expertise is available (see video: Resuscitation after meconium).

Fig. 13.5 Head position, the key to airway management. (a) Head in the correct neutral position. (b) Head overextended – incorrect. (c) Head flexed – incorrect.

Fig. 13.6 Two-person airway control – consider if mask inflation ineffective. One person holds the head in the correct position, applies jaw thrust and holds the mask in place, the assistant operates the T-piece to provide lung inflation.

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Question

What are the neonatal resuscitation guidelines used in the US?

The algorithm used is shown in Fig. 13.7.

Particular features are:

• Airway – place head in slightly extended ‘sniffing position’ to open airway. Clear airway if necessary with bulb syringe or suction catheter only if obvious obstruction to breathing or require positive pressure ventilation.
• Breathing – positive-pressure ventilation is started if the infants remains apneic or gasping or if heart rate remains at <100 beats/min.

  Initial inflation pressure of 20 cmH₂O may be effective, but 30–40 cmH₂O may be required in some term babies. Ventilation should be delivered at 40–60 breaths/min to achieve promptly a heart rate >100 beats/min.

  Endotracheal intubation may be indicated at any stage if there is inadequate response to mask ventilation.

• Chest compression – indicated for heart rate <60 beats/min despite adequate ventilation with supplementary oxygen for 30 s.
• Drugs –if heart rate remains at <60 beats/min despite adequate ventilation, usually with endotracheal intubation, with 100% oxygen and chest compressions.

  Epinephrine (adrenaline) should be administered intravenously; endotracheal administration may be considered while access is obtained.

  Volume expansion should be considered when blood loss is known or suspected.

  Intravenous glucose should be considered as soon as practical after resuscitation in order to avoid hypoglycemia.

• Meconium-stained liquor – Endotracheal suctioning of meconium-stained amniotic fluid for non-vigorous babies. Monitor for subsequent respiratory distress and persistent pulmonary hypertension.

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Fig. 13.7 Neonatal resuscitation algorithm.

(Source: Kattwinkel J. et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010; 126; e1400–e1413.

© American Heart Association, 2010; http://pediatrics.aappublications.org/content/126/5/e1400.full.html.)

Post-resuscitation care in the delivery room

Following resuscitation, stabilizing the extremely preterm or sick newborn infant starts in the delivery room before transfer to the neonatal unit (Fig. 13.8).

Fig. 13.8 Post-resuscitation care in the delivery room.