Stabilization, Delivery Room Care, and Initial Treatment of the VLBW Infant

Stabilization in the Delivery Room


General Principles

  • Approximately 4 million infants are born in the United States each year, with up to 10% requiring some resuscitation.
  • Transition from fetal to neonatal physiology entails:

    • Expansion of the lungs with spontaneous breathing
    • Clearance of fetal lung fluid
    • Rise in PaO2 from ∼25 mm Hg (fetus) to >50 mm Hg (neonate), facilitating a decrease in pulmonary vascular resistance and closure of the ductus arteriosus
    • Increased left atrial venous return, facilitating closure of the patent foramen ovale

  • Alterations in this transition will cause varying degrees of hypoxia in the infant.

    • Initial response to hypoxia is apnea → This primary apnea can be reversed with tactile stimulation.
    • If hypoxia persists, the infant will begin irregular gasping respirations, which is followed by secondary apnea → This apnea cannot be reversed with tactile stimulation, and ventilatory assistance must be provided.

  • Please see Chapter 40 for definitions regarding asphyxiated infants, as there are definitive guidelines set jointly by the AAP and American College of Obstetricians and Gynecologists (ACOG) on when an infant can be termed “asphyxiated.”
  • Please refer to the NRP guidelines for a full discussion on resuscitation in the delivery room.

Anticipation of High-Risk Delivery

  • Situations in which resuscitation may be expected:

    • Preterm delivery
    • Narcotics in labor
    • Maternal infection
    • Postterm delivery
    • Fetal malformation
    • Uterine tetany
    • Thick meconium
    • Hydrops fetalis
    • Maternal diabetes
    • Multiple gestation
    • Fetal arrhythmia
    • Evidence of fetal distress
    • Acute fetal/placental hemorrhage
    • Poly/oligohydramnios
    • Preeclampsia
    • Intrauterine growth restriction
    • Emergent cesarean delivery

  • The key to successful resuscitation is clear communication between the neonatal team and the obstetric team.
  • If there is a known high-risk delivery and time permits, resuscitation plans should be discussed with the parents; this also serves to ascertain their wishes, which is especially important for infants born at the limits of viability or infants with life-threatening anomalies.
  • Equipment should be prepared in advance of known high-risk deliveries.

    • Radiant warmer: Should be turned on and pre-warmed to prevent rapid heat loss in VLBW or EBLW infants
    • Flow inflating bag and appropriately sized facemasks for the anticipated delivery: Be sure PEEP is set correctly and the bag is connected to an oxygen source. A flow meter, adequate tubing length, and oxygen blender may be necessary, as well as a pulse oximeter to monitor oxygen saturation. This is particularly important in the resuscitation of ELBW/VLBW infants and infants with known congenital cardiac disease (both scenarios in which excessive oxygen administration may need to be avoided).
    • Materials for endotracheal intubation (laryngoscope with Miller 00, 0, and 1 blades; appropriate sizes of endotracheal tubes [with 2.5-, 3.0-, and 3.5-mm internal diameters], stethoscope, suction catheters with suction source, CO2 detector to confirm endotracheal intubation).
    • Bulb suction.
    • Transport incubator with transport monitors.

eFigure 30-1

Algorithm for resuscitation of the newborn. (Reprinted with permission from DeCherney AH, Nathan L: Current Diagnosis & Treatment: Obstetrics & Gynecology, 10th ed. New York: McGraw-Hill. Available at Copyright © The McGraw-Hill Companies. All rights reserved.)

  • Caveats:

    • When providing positive-pressure ventilation (PPV) with a bag or mask, you must ensure an adequate seal is formed around the infant’s mouth to ensure the pressure being delivered is transmitted to the airway.
    • Use extreme caution when providing PPV to avoid overinflating the lungs; you should provide enough pressure to achieve adequate chest rise → Remember that volutrauma and barotrauma can cause significant lung injury.
    • An emergent umbilical venous catheter can be placed as indicated to provide immediate venous access → The catheter should be placed only as far as necessary to obtain free flow of blood.
    • Epinephrine can be administered via endotracheal tube if venous access is not readily available.

Medications Commonly Used during Neonatal Resuscitation


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Epinephrine (1:10,000 dilution), 0.1 mg/mL

0.1–0.3 mL/kg IV or via ETT*

  • Give rapidly
  • Repeat q3–5 min as needed

Volume expanders (normal saline, blood)

10 mL/kg IV or IO

  • Give over 5–10 min, slower for premature infants
  • Continue to reassess after each bolus

Sodium bicarbonate (0.5 mEq/mL)

2 mEq/kg IV or IO

  • Give slow push over at least 2 min
  • Must ensure adequate ventilation prior to dosing
  • Can repeat q5–10 min as needed

Naloxone (0.4 mg/mL)

0.25–0.5 mL/kg IV, IM, IO, SQ, or via ETT

  • Give rapidly
  • Repeat q3–5 min as needed

10% dextrose

2 mL/kg IV, IO

  • Check bedside glucose

* IV route is the preferred route and should be repeated as soon as IV access is established if the first dose was via ETT.

Commonly Used Inotropes in the NICU


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Infusion rate




2.5 – 20

  • 1st line for hypotension in neonates
  • Has been shown to increase cerebral blood flow in neonates
  • Cochrane review showed dopamine to be superior to dobutamine, with no increased efficacy with combining the two drugs


0.1 – 1

  • Added if maximal dopamine is not adequate
  • Some centers will use hydrocortisone at 1 mg/kg q8h for 3–5 d for refractory hypotension


0.125 – 0.750

  • Very limited data exist on the use of milrinone in the premature infant
  • Has been used as an adjunct therapy in older infants with pulmonary hypertension as a pulmonary vasodilator

Endotracheal Tube Sizes


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Laryngoscope Blade

ETT size (internal diameter in mm; all uncuffed tubes)

Depth of insertion (cm; as measured at the lips)

<1000 g




1000–2000 g




2000–4000 g




>4000 g




Placement of Umbilical Catheters

Umbilical Arterial Catheter

  • Sizes are 3.5 Fr (for <1500 g) and 5.0 Fr (>1500 g); both are single-lumen catheters.
  • Ideal position when verifying by X-ray is between T7 and T10 (above origin of celiac trunk).
  • Depth of insertion (in centimeters) is estimated as follows:

    • (weight (kg) × 3) + 9

Umbilical Venous Catheter

  • Sizes are 3.5 Fr (double lumen, for <1500 g) and 5 Fr (triple lumen, for >1500 g).
  • Ideal position is at the junction of the inferior vena cava and the right atrium.

    • If unable to advance UVC to this position, pull back so that the tip is proximal to the liver.
    • If UVC must be used in this “low lying” position, alternative vascular access must be established as soon as possible and this line removed.

  • Depth of insertion (in centimeters) is estimated as follows:

    • (Depth of UAC insertion ÷ 2) + 1

Assigning Apgar Scores


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Heart rate




Respiratory effort


Slow (irregular)

Good crying

Muscle tone


Some flexion of extremities

Active motion

Reflex irritability

No response


Cough or sneeze


Blue, pale

Pink body, blue extremities

All pink


  • Will be institution specific, so check with your hospital’s guidelines.

Jan 9, 2019 | Posted by in PEDIATRICS | Comments Off on Stabilization, Delivery Room Care, and Initial Treatment of the VLBW Infant
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