Resuscitation of the Newborn
Seema Awatramani
Patrick Dolan
OVERVIEW
There are approximately 4 million infants born in the United States annually.1 The majority of these babies are born without complications at the time of birth; however, 10% require some assistance to breathe and 1% require extensive resuscitation.2 The incidence of emergency department deliveries is unknown but are rare events. Preparation and advanced planning aids the emergency provider in successfully managing these situations. Preparedness includes having the appropriate equipment, personnel, as well as familiarity with the American Heart Association (AHA) guidelines for neonatal resuscitation.3 Trained personnel are needed as births in the emergency department are high risk and may be associated with trauma, prematurity, or patients lacking in prenatal care. A focused history can rapidly assess the expected level of resuscitation. Current AHA guidelines recommend that ideally three skilled providers be present for any birth occurring in the emergency department.2
PREDELIVERY PREPARATION
History
Several maternal risk factors predispose the infant to requiring resuscitation (Table 31.1). A maternal history should be obtained including the gestational age, last menstrual period, parity, and previous history of fetal or neonatal demise. Antepartum complications such as gestational diabetes or preeclampsia increase the risk of delivery complications. The peripartum history should elicit if there was prolonged labor, prolonged rupture of membranes, meconium-stained fluids, prolapsed cord, maternal fever, or recent narcotic use.
The AHA guidelines for neonatal resuscitation recommend using the following questions to obtain a rapid history to help providers anticipate resuscitation needs of the infant:3
What is the gestational age?
Is the amniotic fluid clear?
How many babies are expected?
Are there additional risk factors?
Knowing the answers to these questions assists in the preparation of equipment and personnel for the forthcoming delivery.
TABLE 31.1 Perinatal Risk Factors for Delivery C omplication | ||||||
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Equipment
The essential supplies for neonatal resuscitation are listed in Table 31.2. An equipment check should be conducted periodically as well as before every birth.4
TABLE 31.2 Equipment Checklist for Neonatal Resuscitation | ||||||||||||||||
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Personnel
Current AHA guidelines recommend that at least two, but ideally three, skilled providers be present for emergency department deliveries as these deliveries are considered high risk. This is in contrast to the recommendation of at least one skilled provider in the labor and delivery room setting.3 Providers should be familiar with positive pressure ventilation (PPV). A qualified team with full resuscitation skills including endotracheal (ET) intubation and emergency vascular access should be identified and immediately available if required.
A precipitous delivery may not allow a team adequate time to prepare; however, time permitting, a team briefing helps the resuscitation run more smoothly. A team leader is identified and team member roles assigned such as assessment, stimulation, PPV (if needed), and documentation.
RAPID ASSESSMENT OF THE NEONATE
The rapid assessment of the neonate identifies resuscitation needs and the following three critical questions should be answered in the first 30 seconds of life:2
Does the baby appear to be full term?
Is there good muscle tone?
Is the infant breathing or crying?
If the answer is “yes” to all the above questions, the infant can remain with the mother to continue transition if there are no other concerns. If the answer is “no” to any of these questions, the infant should be moved to the radiant warmer for further assessment.
Gestational Age
Full gestation is defined as 37 weeks or more. Preterm infants are more apt to need support during the transition process as they are predisposed to difficulties with respiration, thermal regulation, and chest expansion. The gestational age of the neonate may not be known at the time of delivery. If the baby appears term, proceed with the rapid assessment; however, if the baby appears preterm, then proceed to the radiant warmer for continued support.
Appearance and Tone
The next step in the rapid assessment of the newborn is to determine activity and tone. Visually evaluate the patient to assess for tone. Is the patient active and moving? If the baby is in a normal full-term and flexed position, then the routine assessment can be continued. An infant that is flaccid, not moving, or with extended extremities should be moved to a radiant warmer for continued support.
Respiratory Effort/Crying
Newborns that are vigorously crying have an appropriate respiratory effort. If the baby is not crying, assess the respiratory effort by inspecting chest movement and effort. Infants that are gasping or not breathing well need to be moved to a radiant warmer for continued support. If the infant appears to be full term with good tone and good respiratory effort, the infant can be given to the mother for skin-to-skin contact where observation and care of the neonate will continue.5
NEWBORNS REQUIRING MINIMUM RESUSCITATIVE EFFORTS
The management of the newly born infant not requiring significant sustained resuscitative efforts should follow a systematic approach (Figure 31.1).
Vigorous Term Infants
Newborns that are born at term gestation, spontaneously breathing or crying, and with good tone require minimal resuscitative efforts. In these infants, drying and clearing secretions are the only required actions prior to handing the infant back to the mother (Figures 31.2 and 31.3). The initial steps can also be performed on the mother’s chest or abdomen. If needed, secretions in the mouth and nose can be gently cleared with a cloth. Gentle suctioning with a bulb syringe is reserved for babies that are having difficulty clearing their secretions or when the fluid is meconium stained.3 Care should be taken to continue observing the infant’s breathing, tone, color, activity, and temperature in the minutes after these steps are completed.
 Figure 31.1: Highlighted area of minimal resuscitation. CPAP, continuous positive airway pressure; HR, heart rate. (From Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543-S560.) |
 Figure 31.2: Picture of a vigorous term infant. (From Ricci S. Essentials of Maternity, Newborn, and Women’s Health Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016.) |
 Figure 31.3: Highlighted area of handing baby back to mother. (From Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543-S560.) |
Clamping of the Umbilical Cord
The ideal time for umbilical cord clamping is the subject of ongoing research,6 but evidence suggests that clamping be delayed at least 30 to 60 seconds after birth for most vigorous term and preterm newborns.3 Delayed clamping allows for continued placental blood to transfuse to the infant while placental gas exchange is ongoing before its separation from the uterus. Delayed clamping is associated with decreased infant mortality, less risk of brain hemorrhage and necrotizing enterocolitis, higher blood pressure and blood volume, and improved neurodevelopmental outcomes.3 Prior to cord clamping, the infant should remain warm. This can be accomplished by skin-to-skin contact with the mother, placing the newborn in a warm towel or blanket in an otherwise uncomplicated delivery, or in polyethylene plastic for a preterm infant per AHA guidelines. If the placental circulation is not intact, such as with placental abruption, placenta previa, vasa previa, or cord avulsion, cord clamping should occur immediately. In infants who are limp or not breathing, delay for cord clamping should not supersede immediate resuscitative efforts.
Nonvigorous and Preterm Newborns
Infants that are not term gestation, are not breathing well, or have poor tone should be brought to the radiant warmer for continued resuscitation and evaluation (Figure 31.4). The five initial steps
of newborn care should be initiated: provide warmth, position head and neck to open the airway, clear airway secretions if necessary, dry, and stimulate (Figure 31.5).
of newborn care should be initiated: provide warmth, position head and neck to open the airway, clear airway secretions if necessary, dry, and stimulate (Figure 31.5).
 Figure 31.4: Picture of a preterm infant with poor tone. (From MacDonald MG, Seshia MM. Avery’s Neonatology. 7th ed. Philadelphia, PA: Wolters Kluwer; 2015.) |
 Figure 31.5: Highlighted area of initial five steps. HR, heart rate. (From Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543-S560.) |
Provide Warmth
The newborn is placed under a radiant warmer to allow for continued resuscitation without endangering the infant due to heat loss (Figure 31.6). The baby is left uncovered to allow the heat to reach the baby and to enable unencumbered visualization of the infant. A cap can be placed on the infant’s head to further reduce heat loss. Ideally, the resuscitation room should be kept
at 74°F to 77°F and the newborn’s temperature should be kept between 36.5°C and 37.5°C.7 A servo-controlled temperature sensor can be applied to the skin to monitor the temperature. Additional support is needed to retain warmth in premature infants such as with a polyethylene plastic bag or wrap and thermal mattress.8
at 74°F to 77°F and the newborn’s temperature should be kept between 36.5°C and 37.5°C.7 A servo-controlled temperature sensor can be applied to the skin to monitor the temperature. Additional support is needed to retain warmth in premature infants such as with a polyethylene plastic bag or wrap and thermal mattress.8
 Figure 31.6: Picture of a radiant warmer in the emergency department. |
Positioning
The infant should be placed in the sniffing position to allow for unrestricted air entry (Figure 31.7). If the infant has a large occiput, a shoulder roll is used to facilitate proper positioning (Figure 31.8).
Clearing Secretions
Secretions are carefully cleared from the airway with either a bulb suction or a suction catheter in infants with poor tone, that are gasping or not breathing, are suspected of having secretions, or are with meconium-stained fluids. If there are significant oral secretions noted, the newborn’s head is turned to allow secretions to pool in the cheek. The mouth should always be suctioned before the nose to prevent aspiration of oral secretions caused by sudden inhalation from stimulation. One way to remember this is to recall that “M comes before N” in the alphabet.3 The mouth and oropharynx should not be suctioned too vigorously or deeply, as it can lead to apnea and bradycardia.3 If using a suction catheter, the pressure should be set between 80 and 100 mm Hg.3
 Figure 31.7: Picture of an infant in the sniffing position. |
 Figure 31.8: Picture of an infant with a shoulder roll. |
Dry
Wet skin promotes rapid heat loss; therefore, newborns should be dried quickly. Wet towels need to be replaced with dry towels or blankets. The drying step can be skipped in infants less than 32 weeks, who should instead be immediately covered with polyethylene plastic.
Stimulate
In most cases, the prior steps of positioning, clearing secretions, and drying will provide adequate stimulation to initiate breathing. Occasionally, brief additional tactile stimulation such as rubbing the back, trunk, or extremities can be used if there has been a short period of impaired gas exchange. If the time of impairment has been longer, further efforts such as PPV will typically be required to stimulate breathing and should not be delayed.
Response to Initial Resuscitation
Both respirations and heart rate are checked to confirm that the newborn is responding to the initial steps of resuscitation. This evaluation should take no more than 30 seconds.3 Ventilation is the most important and effective action during resuscitation of the neonate. Therefore, if the newborn does not show improvement after the initial resuscitation or is apneic or has gasping respirations, then PPV should be initiated immediately.
If the newborn is breathing effectively, confirm the heart rate is above 100 beats per minute (BPM). The most reliable way to record the heart rate is auscultation of the chest with a stethoscope.9 Palpating pulsations of the umbilical cord base is less reliable. Checking the heart rate by pulse oximetry may be inaccurate if there is poor perfusion and checking by an ECG monitor might also provide incorrect data if pulseless electrical activity is present. If the infant has failed to improve with the initial steps of resuscitation, the neonatal resuscitation pathway should continue.
In cases where the respiratory effort of the infant improves and the heart rate is above 100 BPM but there is labored breathing or cyanosis is present, then supplemental oxygen or continuous positive airway pressure (CPAP) can be administered (Figure 31.9). PPV is started immediately in the event of continued poor respiratory effort or heart rate is less than 100 BPM.
Cyanosis
The provider needs to distinguish between acrocyanosis and central cyanosis. Acrocyanosis refers to cyanosis that is limited to the hands and feet, a common finding in newborns that does not indicate poor oxygenation. Central cyanosis occurs when blood oxygenation is low and manifests
with blue lips, tongue, and torso. At the time of birth, healthy infants transition from an intrauterine state of 60% blood oxygenation to more than 90%.10 This transition can take several minutes (Figure 31.10). If persistent cyanosis is suspected, a pulse oximeter should be used to monitor the newborn’s oxygenation.
with blue lips, tongue, and torso. At the time of birth, healthy infants transition from an intrauterine state of 60% blood oxygenation to more than 90%.10 This transition can take several minutes (Figure 31.10). If persistent cyanosis is suspected, a pulse oximeter should be used to monitor the newborn’s oxygenation.
 Figure 31.9: Highlighted area of supplemental oxygen. CPAP, continuous positive airway pressure. (From Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: neonatal resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S543-S560.) |
 Figure 31.10: Preductal SpO2 changes after birth. (From Dawson JA, C. Kamlin OF, Vento M, et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics. 2010; 125(6): e1340-e1347.) |
Pulse Oximetry
The pulse oximeter probe is placed on the right hand or wrist of the newborn infant (Figure 31.11).2 The right arm, in most instances, has a blood supply prior to being mixed with less oxygenated blood flowing from the ductus arteriosus. The left arm and both legs receive blood mixed with less oxygenated blood from the ductus arteriosus and have lower oxygen saturation. The heart and brain are also supplied by a preductal blood supply. A low heart rate or poor perfusion will prevent accurate pulse oximetry.
 Figure 31.11: Picture of an infant with pulse oximeter on right upper extremity.
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