Neonatal Resuscitation

Vasili Chernishof, M.D.

Andrew Costandi, M.D., M.M.M
Children’s Hospital Los Angeles

Updated 1/2020
Disclosures

No relevant financial relationship

Learning Objectives:
• Recognize the signs and symptoms of neonates in
distress
• Describe the initial assessment steps post birth
• Recognize the important steps that make up the
“golden minute”
• Describe the indications and components of
neonatal resuscitation
Introduction
• Approximately 10% of newborns require some form
of assistance to begin breathing at birth
• Less than 1% require extensive resuscitation
measures, such as cardiac compressions and
medications1
Clinical Scenario
You are called to attend a cesarean section delivery of a 33-
week infant with an estimated weight of 1.9 kg.
The mother is a G3P2, 39-year-old woman with history of
pre-eclampsia. The mother has been in labor for the past 18
hours with failure to progress.
Fetal heart rate tracing shows frequent, intermittent late
decelerations.
Resuscitation Need
• Assessment of perinatal risk e.g., preterm infant,
IUGR, macrosomia, craniofacial abnormalities,
congenital defects and malformations, prolonged
labor, fetal distress
• A standardized checklist to ensure that all necessary
supplies and equipment are available and ready
• Standardization of behavioral skills for effective
teamwork and communication
Clinical Scenario
The patient is rapidly transported to the OR for
cesarean section delivery.

A 1.9 kg, 33-week-old male infant is delivered.

Initial Assessment
Initial assessment of a newly born infant should rapidly
answer the following three questions?

• Term gestation?
• Good tone?
• Breathing or crying?
Initial Assessment - YES
Initial assessment of a newly born infant should rapidly
answer the following three questions?

• Term gestation? Yes!

• Good tone? Yes!
• Breathing or crying? Yes!

“YES”  Infant may stay with the mother for routine

care.
Initial Assessment
Routine care includes:
 Making sure the infant is dried, and covered to
maintain normothermia
 Clearing secretions as needed
 Placing the infant skin to skin with the mother
 Continuing to evaluate breathing, activity, and color
Initial Assessment - NO
• Term gestation?
• Good tone?
• Breathing or crying?

• “NO”  Infant should be moved to a radiant warmer,

and resuscitation should being in a step-wise fashion
Clinical Scenario

Post-delivery, the infant is limp, pale, and not crying.

Based on your initial assessment, you decide that

resuscitation should begin promptly…
“Golden Minute”

Initial steps

Re-evaluation

Begin
Ventilation
Apgar score
• A method to quickly
summarize the health of the
newborn against infant
mortality.

• Generally done at 1 and 5

minutes after birth.

• Apgar score is not used to

determine if initial
resuscitation is needed, but
rather if resuscitation
efforts should be continued. https://en.wikipedia.org/wiki/Apgar_score
Apgar Score
Indicator 0 Points 1 Point 2 Points
A Activity
(Muscle tone)
Absent Flexed limbs Active

P Pulse Absent < 100 bpm > 100 bpm

Grimace
G (reflex
irritability)
Floppy
Minimal
response
Prompt
response
Pink body
A Appearance
(Skin Color)
Blue, Pale Blue
extremities
Pink

R Respiration Absent
Slow and
irregular
Vigorous cry

Total score: >7: Normal 4-6: fairly low <3: critical

Clinical Scenario

But wait, what about the umbilical cord?

Immediate or delayed umbilical cord clamping?

Umbilical Cord Management

Breathing or Crying ? Delayed Cord Clamping in

Preterm Infants is associated
with:
YES NO
• less intraventricular
hemorrhage (IVH)
Delayed
cord Clamp cord
• higher blood pressure
clamping • higher blood volume
• less need for transfusion
Resuscitate • less necrotizing
enterocolitis2
Umbilical Cord Management

Breathing or Crying ? Delayed Cord Clamping

in Preterm Infants is
YES NO associated with:
• Slightly increased level of
Delayed bilirubin
cord Clamp cord
clamping • Need for phototherapy

Resuscitate
Clinical Scenario
To Summarize up to this point:
• You are called to a cesarean section delivery of a 33 week
infant with an estimated weight of 1.9 kg.
• Post-delivery, the infant is limp, appears pale, and not crying.
• Umbilical cord is clamped so that resuscitation can begin
promptly.
• Next, you decide to commence the initial steps of
resuscitation…
Initial Steps
• Dry the infant
• Stimulate the infant to breathe

It is reasonable to place the newborn in a clean,

food-grade plastic bag up to the level of the neck and
swaddle them after drying.
Initial Steps:
Maintain Normal Temperature
• Maintain temperature (36.5°C - 37.5°C)
• Avoid Hypo and Hyperthermia
• Hypothermia is associated with:
– Increased risk of intraventricular
hemorrhage (IVH)
– Respiratory complications3,8,9,
– Hypoglycemia10-12
– Late-onset sepsis13,14
Initial Steps:
Temperature Interventions
• Radiant warmers
• Plastic wrap with a cap for preterm infants
• Increase room temperature
• Thermal mattresses
• Warmed humidified resuscitation gases
• The use of plastic wraps15,16 and skin-to-skin contact17-
21
reduces hypothermia
Initial Steps:
“Sniffing” Position

https://commons.wikimedia.org/wiki/Category:
Airway_management#/media/File:CPR_Infant_C
losed_vs_Open_Airway.png
Initial Steps:
Clear Secretions
• A bulb syringe or suction catheter may be used
• Suctioning immediately after birth may be
considered only if the airway appears obstructed or if
Positive Pressure Ventilation (PPV) is required
• Avoid unnecessary suctioning, which may induce
bradycardia
Clinical Scenario
You have undertaken the following steps of the initial
resuscitation:
1. Dried the infant
2. Maintained normothermia
3. Placed the infant in the “sniffing position”
4. Cleared secretions

You noticed thick, green, meconium secretions!

Clearing the Airway: Meconium
Respiratory effort?
Muscle tone?

Poor Good

Ineffective Initial steps of

breathing newborn care
Or

HR <100 bpm

Clear mouth
and nose
*Routine intubation for tracheal
suction is not recommended23-26
PPV
https://commons.wikimedia.org/wiki/File:Me
conium_aspiration_syndrome_(MAS).png
Clinical Scenario
You are about to provide positive pressure
ventilation (PPV). The nurse in the room asked
you about your device preference…
Positive Pressure Ventilation (PPV)
• Standard recommended
treatment for apneic
infants
• 5 cmH2O PEEP is suggested
• Delivered effectively with:
- A flow-inflating bag
- Self-inflating bag
- T-piece resuscitator27,28
PPV: Supraglottic Airways (SGAs)
• SGAs can facilitate effective
ventilation for newborns >
34 weeks
• Used when face-mask
ventilation, or tracheal
intubation is unsuccessful29
• Data for use is limited for
infants under 34 weeks
and/or under 2000 g
PPV: Endotracheal Tube
Indications:
• Ventilation is ineffective or prolonged
• Chest compressions are performed
• Special circumstances such as
congenital diaphragmatic hernia

The best indicator of successful

endotracheal intubation is a prompt
increase in heart rate
Clinical Scenario

Post completion of the initial resuscitation steps, you

decide to evaluate the effectiveness of the newborn’s
spontaneous respiratory effort.
How can you achieve this step?

Hint:
Clinical Scenario
Answer: Immediately after birth, assessment of the
newborn’s heart rate is used to evaluate the
effectiveness of spontaneous respiratory effort.

3-lead ECG is rapid, accurate, reliable, and easy to

apply.

Increase in the newborn’s heart rate is considered the

most sensitive indicator of successful response to
each intervention.
Assessment of Oxygen Need
Pulse Oximetry use is recommended in
the following settings:

• When resuscitation is anticipated

• PPV is administered
• Central cyanosis persists beyond the
first 5-10 minutes of life
• Supplemental oxygen is
administered
Administration of Oxygen
It is reasonable to initiate resuscitation with air
(21% Oxygen at sea level)

Resuscitation of preterm newborns of less than 35

weeks of gestation should be initiated with low
oxygen as well (21% to 30%)

Initiating resuscitation of preterm newborns with

high oxygen (65% or greater) is NOT recommended
Targeted Preductal SpO2 After Birth

1 min 60% - 65%

2 min 65% - 70%
3 min 70% - 75%
4 min 75% - 80%
5 min 80% - 85%
10 min 85% - 95%
The oxygen concentration should be titrated to achieve preductal oxygen
saturation approximating the interquartile range measured in healthy term
infants
Clinical Scenario

Post completion of the initial resuscitation steps, you

evaluate the effectiveness of the newborn’s
spontaneous respiratory efforts, and notice that the
HR remains under 100 bpm.
PPV is initiated using a flow-inflating bag.
Unfortunately, the HR continues to decline and is now
under 60 bpm. You decide to intubate.
What is the next step in resuscitation?
Chest Compressions
• Heart rate less than 60/min despite adequate
ventilation
• 3:1 ratio of compressions to ventilation
• Increase the oxygen concentration to 100%

https://commons.wikimedia.org/wiki/File:CPR_Infant_Chest_Compression.png
Clinical Scenario

Effective chest compressions are underway.

You are reminded to rule out other causes such as…

Pneumothorax, and hypovolemia.

Medications
• Rarely indicated.
• Bradycardia is usually due to hypoxemia.
• Establishing adequate ventilation is the most
important step.
• Indication: Heart rate less than 60/min despite
adequate ventilation with 100% oxygen, and
chest compressions.
Medications: Epinephrine
• Dose: 0.01 to 0.03mg/kg of 1:10000
epinephrine
• ETT dose: 0.05 to 0.1 mg/kg
Medications: Volume
• Isotonic crystalloid solution or blood
• Dose: 10 mL/kg
Medications: Glucose
Role of glucose in modulating neurologic outcome
after hypoxia-ischemia:
• Lower glucose levels were associated with an
increased risk for brain injury, while increased
glucose levels may be protective.
• A specific protective target [glucose] range
cannot be recommended at this time
Post Resuscitation Care

• Close monitoring and anticipatory care should be

provided for infants who have returned to
normal after resuscitation
Conclusions
• Initial step in stabilization is to warm and maintain
normal temperature. Position the patient in the
“sniffing” position, clear secretions only if copious.
Dry and stimulate
• Ventilate and oxygenate
• Initiate chest compressions if HR < 60 bpm
• Administer medications such as epinephrine and/or
fluids if the above interventions are not enough
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