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BIRTH AND NEONATAL RESUSCITATION: NEONATAL RESUSCITATION

Epidemiology

  • Each year in the United States, approximately 4 million infants are born.

  • Approximately 10% of infants will require some form of resuscitation at birth.

  • Less than 1% of infants require advanced resuscitation at birth (intubation, chest compressions, cardiac medications).

Pathophysiology

  • In newborns, the need for resuscitation is most commonly caused by inadequate ventilation.

  • Failure to breathe at birth is most commonly caused by a period of hypoxia related to birth asphyxia, maternal drug use, or maternal anesthesia.

  • Primary apnea is the absence of respiratory effort in the perinatal period that responds to stimulation. This is often the result of a short period of mild hypoxia immediately prior to birth.

  • Secondary apnea is the absence of respiratory effort in the perinatal period that does not respond to stimulation and requires positive pressure ventilation to resolve. This is more indicative of a longer period of in utero hypoxia.

  • Newborns with primary and secondary apnea will present similarly at birth with apnea. Assessing response to stimulation is the only way to distinguish between the two.

Management

The Neonatal Resuscitation Program (NRP) periodically updates the algorithm used for clinical decision-making at deliveries, the most recent recommendations are explained below.

  • Preparation for Birth

  • ✓ Personnel: Every delivery should have at least one person trained in neonatal resuscitation present. Additional personnel should be available if the need for advanced resuscitation is expected. Team roles should be assigned prior to birth.

  • ✓ Equipment: Necessary equipment should be present and checked to be sure that it is functioning. Equipment available should include a warmer bed, blankets, hat, stethoscope, bulb and wall suction, bag and mask device, oxygen with blender, pulse oximeter, laryngoscope with blade, and endotracheal tubes.

  • Initial Routine Evaluation and Care

  • ✓ Following delivery, the term infant should be warmed, dried, and stimulated.

  • ✓ If secretions are blocking the airway, they should be suctioned.

  • ✓ Simultaneously one should assess the infant’s muscle tone and respiratory effort.

  • ✓ In a term infant who does not appear to need resuscitation, the above steps can occur while the neonate is lying on the mother’s abdomen.

Need for Resuscitation

  • For infants who are still apneic or gasping despite above steps, or in whom the heart rate is <100 beats/minute, positive pressure ventilation should be given by 1 minute of life with an appropriately sized mask covering both the infant’s nose and mouth, ensuring an adequate seal.

  • Positive pressure ventilation should be initiated at peak inspiratory pressures of 20 cm H2O, at a rate of 40–60 breaths per minute, and at 21% FiO2 for term infants.

  • Concurrently, a pulse oximeter should be placed on the infant’s right hand (preductal saturation) and application of ...

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