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About 10% of all newborns require some assistance to begin breathing after birth, and ~1% require extensive resuscitation efforts. Newborn resuscitation cannot always be anticipated in time to transfer the mother before delivery to a facility with specialized neonatal support. Therefore, every hospital with a delivery suite should have an organized, skilled resuscitation team and appropriate equipment available (Table 3–1).

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  1. Normal physiologic events at birth. Normal transitional events at birth begin with initial lung expansion, generally requiring large negative intrathoracic pressures, followed by a cry (expiration against a partially closed glottis). Umbilical cord clamping is accompanied by a rise in systemic blood pressure and massive stimulation of the sympathetic nervous system. With onset of respiration and lung expansion, pulmonary vascular resistance decreases, followed by a gradual transition (over minutes to hours) from fetal to adult circulation, with closure of the foramen ovale and ductus arteriosus.

  2. Abnormal physiologic events at birth. The asphyxiated newborn undergoes an abnormal transition. Acutely with asphyxiation the fetus develops primary apnea, during which spontaneous respirations can be induced by appropriate sensory stimuli. If the asphyxial insult persists about another minute, the fetus develops deep gasping for 4–5 minutes, followed by a period of secondary apnea, during which spontaneous respirations cannot be induced by sensory stimulation. Death occurs if secondary apnea is not reversed by vigorous ventilatory support within several minutes. Because one can never be certain whether an apneic newborn has primary or secondary apnea, resuscitative efforts should proceed as though secondary apnea is present.

  3. Preparation for high-risk delivery. Preparation for a high-risk delivery is often the key to a successful outcome. Cooperation between the obstetric and pediatric staff is important. Knowledge of potential high-risk situations and appropriate interventions is essential (Table 3–2). It is useful to have an estimation of weight and gestational age (Table 3–3), so that drug dosages can be calculated and the appropriate endotracheal tube (see Table 28–1) and umbilical catheter size can be chosen. While waiting for the infant ...

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