Chapter 3: Resuscitation of the Newborn

INTRODUCTION

Approximately 10% of all newborns need help with breathing at the time of birth, and 1 in 1000 newborns require resuscitation with chest compressions and cardiac medications. Given the high frequency of newborn resuscitation, it is vital that all neonatal healthcare workers are trained and competent to provide resuscitation to babies in need. 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 a skilled resuscitation team (see Chapter 4, “Neonatal Transport”) and appropriate equipment available (Table 3–1).

I. NORMAL PHYSIOLOGIC EVENTS AT BIRTH

Normal transition at birth begins with 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 stimulation of the sympathetic nervous system. With the 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 the closure of the foramen ovale and ductus arteriosus.

II. ABNORMAL PHYSIOLOGIC EVENTS AT BIRTH

The asphyxiated newborn undergoes an abnormal fetal to neonatal transition. With asphyxiation, the fetus develops primary apnea, during which spontaneous respirations can be induced by appropriate sensory stimuli such as drying. If the asphyxial insult persists, the fetus develops deep gasping, followed by a period of secondary apnea, during which spontaneous respirations cannot be induced by sensory stimuli. Death occurs if secondary apnea is not reversed by 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.

III. PREPARATION FOR HIGH-RISK DELIVERY

Preparation for a high-risk delivery is the key to a successful outcome. Cooperation between the obstetric, anesthesia, and pediatric staff is important. As noted in Figure 3–1, each resuscitation should begin with a team briefing and equipment check. 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) for calculating drug dosages and equipment size. The team briefing prior to delivery is used for assigning team member roles and reviewing expected resuscitation measures in order to establish a shared mental model within the resuscitation team. Antenatal counseling should be provided to the parents prior to the birth, especially when the fetus is at the limit of viability or when life-threatening anomalies are anticipated.

IV. ASSESSMENT OF THE NEED FOR RESUSCITATION

The Apgar score is assigned at 1, 5, and, occasionally, 10 to 20 minutes after delivery. It gives a fairly objective idea ...