While 90% of births occur without difficulty for neonates, 10% require some resuscitation, and 1% require substantial measures. Asphyxia at time of birth accounts for almost 1 million neonatal deaths yearly worldwide, representing over 20% of all neonatal deaths (WHO, 1995). For the majority of these, simple, effective treatment through neonatal resuscitation can be lifesaving.
There are a number of effective training programs teaching neonatal resuscitation. These include:
While these vary slightly, the foundations of what they teach are standard, and are presented here.
The video at right presents the 'Helping Babies Breathe' approach to resuscitation. Like other programs, and our materials here, it focuses on rapid assessment of the infant's status, simple initial management steps, and more involved treatment if initial steps are unsuccessful.
For health care providers involved in labour and delivery, it is critical to have an approach memorized, and to practice regularly. SiH uses a NeoNatalie simulator for this purpose.
Distress can occur before, during, or after labour.
Problems in utero are usually related to compromise of blood flow of the uterus or placenta, represented by deceleration of fetal heart rate. Other causes include sepsis, hypoglycemia, and medications (narcotics, anesthesia agents).
Problems after delivery are usually respiratory in nature, involving the baby's airways and/or lungs. Issues may include insufficient force of breathing, meconium occluding the airways, excessive blood loss, poor cardiac function/bradycardia from hypoxia, or poor dilation of pulmonary vasculature, from hypoxia or persistent pulmonary hypertension of the newborn (PPHN).
Evaluate breathing, heart rate, and color
A baby who is not oxygenating will initially decrease blood flow to the GI tract, kidneys, musculature, and skin. Further hypoxia will result in decreased cardiac function. Signs can include poor tone, cyanosis, tachypnea or decreased respiratory drive, low blood pressure, or bradycardia.
Begin with intial questions about the situation:
If yes, provide routine care.
If no, provide warmth, position and clear airway as necessary, dry, stimulate, and reposition.
If available, have a radiant warmer set, as well as warm, absorbent towels ready. Place baby on a towel. The baby should be positioned on his back or side, with head slightly extended in the 'sniffing' position. A pillow under the shoulders may help with this. If a second person is available, he or she can dry the baby as the first person manages the airway.
Clear the mouth and nose of secretions before stimulating. This is done by wiping the nose and mouth with a towel, or by suctioning with a bulb syringe. If there is a lot of secretions, turn the head to one side to allow pooling and removal.
Suctioning that is too vigorous can cause a vagal response, with apnea or bardycardia resulting. Gentle suctioning is normally all that is required.
Suction mouth before nose to avoid stimulating the baby before the oroparynx is clear.
If meconium is present, it is next important to assess whether the baby is vigorous (strong respiratory efforts, good tone, and HR >100bpm).
To suction mouth and trachea, use a laryngoscope and a 12F or 14F suction catheter to clean the oropharynx, if available.
If available, insert an endotracheal tube and attach to suction. Apply suction as tube is withdrawn. Repeat as necessary until meconium appears largely clear, or if HR <60bpm.
Once the airway is clear, stimulate baby to breathe. Attempt effective but brief stimulation. Use the towel to dry the fluid, if not already done. Other techniques include:
Do NOT shake, squeeze, or do other things to the infant, as it may cause damage.
Assess respirations by chest movement, rate, and depth of respiration. Gasping does not represent effective respiration. If the infant is not breathing after stimulation, immediately begin positive pressure ventilation (see below).
If baby is breathing, assess respirations, heart rate, and colour. To assess heart rate, feel for a pulse at the base of the umbilical cord. If it is not palpable, listen for the pulse with a stethoscope. Count the number of beats in 6 seconds and multiply by 10.
Consider attaching a pulse oximeter in the presence of persistent cyanosis with normal heart rate and normal respirations. To allow the quickest reading, attach the probe on the hand before it is connected to the oximeter. Once there is a reading and the detected pulse is accurate as compared by auscultation or feeling the base of the umbilical cord, the oxygen blender is adjusted so that saturation levels are within the target range for each minute of age, as seen in the following table:
Using an oxygen blender allows the practitioner to respond to the baby’s oxygen needs in an appropriate and timely manner.
At this time, a pulse oximeter should be placed on the infant’s right hand or wrist if available. See the table in “Drying, Stimulation and Reposition” for target ranges according to age of infant in minutes.
Resuscitation should never be started with 100% oxygen due to the risk of oxygen toxicity and long term consequences such as retinopathy. If an oxygen blender is unavailable, resuscitation should be started with room air and 100% oxygen initiated only when either adequate ventilation is established and there is persistent cyanosis or when chest compressions are initiated (Richmond, 2011).
If there is inadequate air entry, follow Mr. Sopa to help establish good ventilation:
M- mask adjustment
R- reposition airway
S- suction mouth and nose
O- open mouth
P- pressure increase
A- airway alternative (consider Laryngeal mask airway)
Positive pressure ventilation (PPV) is indicated for all infants in respiratory or cardiovascular distress immediately after birth. There are a number of ways of providing PPV.
The most important signs are improvement in colour and muscle tone, adequate chest movement, auscultation of breath sounds with the stethoscope, and rise in heart rate.
Ensure the mask is appropriately sized and seals to the baby's face. Be sure the airway is clear and the head is properly positioned.
Give 40-60 breaths per minute.
A pocket mask can be used to provide positive pressure if no other equipment is available. As it delivers exhaled air (16% oxygen), it is less effective than room air (21% oxygen).
A self-inflating fills spontaneously after being squeezed, providing air or oxygen. Flow rate (peak inspiratory pressure) is controlled by force with which the bag is squeezed. CPAP cannot reliably be provided.
Self-inflating bags are common, easy to use, and less likely to overinflate due to the presence of a pop-off valve. However, it is less reliable in terms of ensuring a good seal.
A flow-inflating bag fills only when gas is flowing into it, and therefore requires compressed gas and a tight patient seal. Gas flows to the path of least resistance, which is either into the bag or out the patient outlet.
Peak inspiratory pressure is controlled by flow of gas, the flow control valve, and the force with which the bag is squeezed.
A flow-inflating bag takes practice to use to avoid overinflation.
A T-piece recuscitator functions only when gas flows into it. It is similar to the flow-inflating bag, but also has the ability to limit airway pressure. It is also easier to use and does not lead to fatigue.
Peak inspiratory pressure is controlled by the device.
Reassess colour, tone, respirations and heart rate after 30 seconds. If heart rate is above 60, continue PPV as necessary until it rises to above 100. If it is below 60, begin chest compressions.
Chest compressions should be used if the heart rate is less than 60 bpm after 30 seconds of effective positive-ressure ventilation. This scenario suggests the blood oxygen levels are decreased, resulting in acidosis and poor contractility of the heart. Assistance with chest compressions are therefore required to help provide oxygen to the heart and other tissues.
If a pulse oximeter is available and has not already been attached to the infant’s right hand or wrist, attach now. If oximeter and blender are unavailable, turn oxygen to 100% at 5-10 L/min.
During chest compressions, the heart is squeezed between the sternum and the spine, and blood is circulated.
Compressions are best performed with a team of two people, the first at the head providing positive pressure ventilation.
3 compressions: 1 respiration
Remember, compressions must be accompanied by oxygenation, and these need to be coordinated with three compressions for every breath. It can be helpful to speak out loud, saying one-and-two-and-three-and-breathe-and-one-and-two-and-three-and-breathe-and...
The person doing the compressions may choose one of two techniques. In the two thumb technique, the hands are wrapped around the chest, and the thumbs are used to compress the sternum. In the two finger technique, the infant is on a hard surface or on one hand, and two fingers from the other hand are used to compress the sternum. Either technique can be used. The two thumb technique is less tiring and allows more control, while the two finger technique is easier for people with small hands and allows access to the umbilicus for medication administration.
In either technique, pressure should be provided at the lower third of the sternum, between the xyphoid and the nipple line. Do not push directly on the xyphoid due to a risk of fracture and lung perforation. Press to a depth of approx 1/3 the chest height. Allow the chest to fully expand between compressions, but do not remove your hand from the chest.
After 30 seconds, stop and reassess. Check the pulse at the base of the umbilical cord, or listen to the chest if necessary. If the heart rate is above 60, stop compressions, but continue PPV. If the heart rate remains below 60, ensure oxygen is being given, consider orogastric tube placement and endotracheal intubation, and ensure that compressions and ventilations are at high quality. Prepare for umbilical catheterization and administration of epinephrine.
Endotracheal intubation is an procedure that is discussed in detail in the topic advanced airways. It may be considered at various points during resuscitation, including:
IV access is usually obtained through the umbilical vein. Clean the cord and tie a string loosely around it. Pre-load an umbilical catheter with normal saline. Using a scalpel, cut perpindicularly across the cord 1-2 cm above the abdomen. The larger vein should be seen alongside the two smaller arteries. Insert the catheter into the vein, aiming upwards, towards the heart. Insert 2-4 cm and gently aspirate, ensuring you draw back blood.
If oxygen, PPV, and chest compressions fail to raise the heart rate above 60, and recuscitation is of good quality, the infant may benefit from epinephrine. This may be given through an umbilical catheter or through an endotracheal tube. The recommended dose is 0.01-0.03mg/kg, or 0.1-0.3 ml/kg of a 1:10,000 solution. A higher dose is required for endotracheal administration, or 0.03-0.1 mg/kg. If given intravenously, ensure you flush with 0.5-1 ml of saline.
Continue compressions, and assess the heart rate after 30 seconds. Consider repeat doses every 3-5 minutes.
If hypovolemia is suspected, due clincial picture (maternal bleeding, abruption, previa, or twin-twin transfusion), with poor response or poor colour (ie shock), fluids should be given. Options include:
The initial dose is 10 ml/kg, given over 5-10 minutes, with another bolus dose to be given if there is continued poor response.
If, after compressions, epinephrine, and correction of potential hypovolemia, the infant remains unresponsive, consider other potential conditions, including:
If quality recuscitation care has been provided for 10 minutes, and there is no sign of improvement, it may be appropriate to consider discontinuing care.
Equipment required includes:
Helping Babies Breathe (American Association of Pediatrics)
Neonatal Rescuscitation Program (American Association of Pediatrics)
Newborn Life Support (Resuscitation Council, UK)