Pediatricians should be familiar with the management of newborn infants in the delivery room. The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) updated the prior 1992 recommendations established after the Fifth National Conference on CPR and ECC. The most important aspect of this management is the establishment of adequate ventilation.

At birth, the newborn must make the dramatic transition from placental gas exchange and fluid-filled lungs to pulmonary gas exchange with air-filled lungs. The lungs expand, pulmonary blood flow increases, and pulmonary vascular resistance decreases. Some antepartum factors associated with risk for the newborn’s transition to be difficult include maternal diabetes, pregnancy-induced hypertension, poly- or oligohydramnios, and premature rupture of membranes. Some intrapartum risk factors for the newborn to have a difficult transition are breech presentation, premature labor, chorioamnionitis, or meconium-stained amniotic fluid.

It is recommended that at least one person skilled in neonatal resuscitation attend every delivery, and that another person, able to perform a complete resuscitation, should be immediately available. About 1% to 10% of newborns require some form of assisted ventilation. The need for intervention is based on evaluation of the newborn’s respirations, heart rate, and color. Gasping and apnea indicate the need for assistance with ventilation. Heart rate, which is most easily assessed by feeling the pulsations at the base of the umbilical cord, should be greater than 100 beats per minute. The newborn should be pink, although acrocyanosis is a normal finding at birth. Neonatal resuscitation can be broken down into four categories of intervention: (a) basic steps, (b) ventilation, (c) chest compressions, and (d) administration of medications and fluids.

The basic steps of neonatal resuscitation include warming the infant, clearing the airway, stimulation, and oxygen administration. Heat loss increases the newborn’s need for oxygen consumption. To prevent heat loss, the newborn should be rapidly dried under a radiant warmer, with continued
removal of the wet linens. Airway clearance involves the appropriate positioning of the infant, with the newborn placed on its back or side with the head neutral or somewhat extended, and the removal of secretions, by wiping away from the nose and mouth. If suctioning is necessary, a bulb syringe is generally adequate, with the mouth being suctioned prior to the nose to minimize the risk of aspiration. If a suction catheter is required, care must be taken to avoid long or aggressive suctioning, as stimulation of the posterior pharynx can result in a vagal response and bradycardia. If the amniotic fluid is stained with meconium, the newborn’s mouth and nose are suctioned on delivery of the head. In depressed infants (e.g., poor respirations, muscle tone, or heart rate), drying and suctioning are delayed, and the newborn is immediately intubated for tracheal suctioning, a process that is repeated until the airway is cleared of meconium or until further resuscitation is required.