It is widely accepted that 10% of all newborns require some assistance to begin and maintain normal breathing and that 1% require aggressive resuscitation. Thus, using the national birth rate data, annually 400,000 newborns need some help during the perinatal period, 40,000 per year require expert assistance to reverse profound cardiorespiratory depression.¹ Of these, approximately 1200 per year will have severe hypoxic ischemic encephalopathy (HIE). According to the World Health Organization, more than 722,000 children died from birth asphyxia and birth trauma worldwide in 2004. An estimated 50% to 75% of infants with severe HIE will die, with 55% of these deaths occurring in the first month.

You need only to relate these statistics to your own practice to appreciate the frequency with which you may encounter an infant in need of neonatal resuscitation and at risk for long-term neurodevelopmental sequelae. Unfortunately, despite best efforts by care providers, this goal is often challenged by the expected, or, even more challenging, unexpected delivery of a neonate who requires urgent medical attention for a disorder(s) threatening his/her life. Obstetrical providers are, by training and experience, more skilled in adult than neonatal emergency care. Consequently, without standards in place that direct personnel, training, and equipment, an obstetrical practitioner may find himself/herself ill prepared to effectively respond to a neonatal emergency. The objective of this chapter is to offer an overview of the pathophysiology, organization, and provision of emergency medical care to the newly born patient for the obstetrical primary care provider.

This chapter is not meant to replace the information found in references such as the Textbook of Neonatal Resuscitation. Instead, the reader will be guided through an approach of creating an environment conducive to facilitating optimal neonatal emergency care. This will include a brief discussion of the organization of neonatal resuscitation teams and equipment, and a review of resuscitation guidelines. Readers interested in more detail will find additional resources in the selected list of suggested readings. All obstetrical clinicians will find completing Neonatal Resuscitation Program (NRP) certification useful and are encouraged to do so.

Identification of Peripartum Risk Factors

Anticipating the specific clinical circumstances leading to the need for neonatal resuscitation in the delivery room or postnatal Neonatal intensive care unit (NICU) care is very helpful. Not enough can be said for the value of time to prepare for a sick newborn. In addition, while the basics of resuscitation do not vary from one patient to the next, certain clinical situations will require the resuscitation team to be prepared to provide specific medical care beyond the usual. For example, the needs of an uncomplicated 28-week premature infant delivered for worsening maternal preeclampsia will be quite different from a term infant with chronic opioid exposure, or a 36-week-old child with nonimmune hydrops fetalis. Table 24-1 shows many of the more common ante- and intrapartum conditions likely to result in the initiation of neonatal resuscitation. Some of the additional requirements of children presenting under these circumstances are shown in Tables 24-2 and 24-3. An unusual example of this is the EXIT procedure (ex utero intrapartum treatment). This operating room procedure is used when a prenatal diagnosis is made of a fetus with airway anatomy likely to make endotracheal tube intubation difficult. The delivered infant’s umbilical cord blood flow is not interrupted until airway access is secured. This allows the intubation to proceed without immediate concern for asphyxia. In addition, if a tracheotomy is anticipated, the provision of anesthetic to the maternal circulation can provide the fetus with pain relief adequate for the procedure to be performed. Thus, advance preparation will optimize even the most complex and dire delivery room events.

Much attention is paid to risk factors that influence immediate care needs in the delivery room; however, there is increased awareness of conditions that may be relatively stable in the immediate postnatal period however may need increased surveillance as they pose a higher risk for later NICU admission. One such example that has gained significant attention in the last decade is neonatal abstinence syndrome (NAS). NAS refers to a constellation of typical signs and symptoms of withdrawal that occurs in infants that have been exposed to, and have developed dependence to certain illicit drugs or prescription medications during fetal life. The category of medications that is most frequently associated with need for neonatal pharmacotherapy and NICU admission is the opioid class. Opioid exposure during pregnancy has increased dramatically since the early 2000s. With this, the rate of NICU admission for NAS has increased from 4.7 cases/1000 admissions in 2004 to 27 cases/1000 admissions in 2013. The result of this has led to an increase in percentage of total NICU days attributed to NAS from 0.6% to 4%.²

Appropriate pharmacologic management of the pregnant woman is outside the scope of this chapter; however, there should be adequate counseling and consultation with the NICU care team to discuss postnatal symptomatology and treatment of NAS.

Team Identification

In order to function properly, each member of the resuscitation team (and back up members in the event of simultaneous resuscitations, eg, multiple gestation) should be identified for each shift. All team members should respond to high-risk deliveries and to urgent calls from the delivery room. In addition, it is standard of care for the team to attend all cesarean deliveries. A recommended team composition and delineation of responsibilities are listed in Table 24-4. Note the considerable overlap of duties. The nature of a neonatal delivery room emergency requires that all team members are capable of performing multiple tasks, as the circumstance requires. Indeed, a child who needs a thoracentesis for a spontaneous pneumothorax or large pleural effusion will need the most skilled practitioner to perform this procedure. Usually, this clinician is the one managing the airway. He/she will have to relinquish that responsibility to another to be free to emergently evacuate the chest of air or fluid. Team flexibility is a requirement rather than a luxury.