Part 7: Neonatal Resuscitation

Abstract

The transition from intrauterine to extrauterine life that occurs at the time of birth requires timely anatomic and physiologic adjustments to achieve the conversion from placental gas exchange to pulmonary respiration. This transition is brought about by initiation of air breathing and cessation of the placental circulation. Air breathing initiates marked relaxation of pulmonary vascular resistance, with considerable increase in pulmonary blood flow and increased return of now-welloxygenated blood to the left atrium and left ventricle, as well as increased left ventricular output. Removal of the lowresistance placental circuit will increase systemic vascular resistance and blood pressure and reduce right-to-left shunting across the ductus arteriosus. The systemic organs must equally and quickly adjust to the dramatic increase in blood pressure and oxygen exposure. Similarly, intrauterine thermostability must be replaced by neonatal thermoregulation with its inherent increase in oxygen consumption.Approximately 85% of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of birth, an additional 10% will respond during drying and stimulation, approximately 3% will initiate respirations after positive-pressure ventilation (PPV), 2% will be intubated to support respiratory function, and 0.1% will require chest compressions and/or epinephrine to achieve this transition. [1][2][3] Although the vast majority of newborn infants do not require intervention to make these transitional changes, the large number of births worldwide means that many infants require some assistance to achieve cardiorespiratory stability each year.Newly born infants who are breathing or crying and have good tone immediately after birth must be dried and kept warm so as to avoid hypothermia. These actions can be provided with the baby lying on the mother's chest and should not require separation of mother and baby. This does not preclude the need for clinical assessment of the baby. For the approximately 5% of newly born infants who do not initiate respiratory effort after stimulation by drying, and providing warmth to avoid hypothermia, 1 or more of the following actions should be undertaken: providing effective ventilation with a face mask or endotracheal intubation, and administration of chest compressions with or without intravenous medications or volume expansion for those with a persistent heart rate less than 60/min or asystole, despite strategies to achieve effective ventilation (Figure 1).The 2 vital signs that are used to identify the need for an intervention as well as to assess the response to interventions are heart rate and respirations. Progression down the algorithm should proceed only after successful completion of each step, the most critical being effective ventilation. A period of only approximately 60 seconds after birth is allotted to complete each of the first 2 steps, ie, determination of heart rate and institution of effective ventilation. Subsequent progression to the next step will depend o...

Normal Newborn Heart Rate in the First Five Minutes of Life Assessed by Dry-Electrode Electrocardiography

“…ILCOR 2015 guidelines suggest the use of electrocardiography (ECG) for rapid and accurate measurement of the HR during resuscitation [1]. Knowledge of a normal HR in the first minutes of life is therefore important, but few studies have been conducted on this subject [2,3,4]…”

Evidence on Adrenaline Use in Resuscitation and Its Relevance to Newborn Infants: A Non-Systematic Review

“…The 2015 International Liaison Committee on Resuscitation (ILCOR) treatment recommendations did not review the use of adrenaline during neonatal resuscitation [10]. However, in 2010 the ILCOR recommended a dose of 10-30 μg/kg IV, and advised against higher IV doses as they might be potentially harmful [50].…”

“…Bradycardia immediately after birth is usually the result of inadequate lung aeration [3], profound hypoxemia [9], or (more rarely) hypovolemia from blood loss. Establishing adequate ventilation is therefore the cornerstone intervention in DR resuscitation of bradycardic infants [10]. International resuscitation guidelines recommend CC only if the heart rate remains <60/min despite adequate ventilation [10].…”

“…Establishing adequate ventilation is therefore the cornerstone intervention in DR resuscitation of bradycardic infants [10]. International resuscitation guidelines recommend CC only if the heart rate remains <60/min despite adequate ventilation [10]. If the heart rate does not increase despite effective ventilation and CC administration, adrenaline administration should be considered [10].…”

“…International resuscitation guidelines recommend CC only if the heart rate remains <60/min despite adequate ventilation [10]. If the heart rate does not increase despite effective ventilation and CC administration, adrenaline administration should be considered [10]. However, the use of adrenaline during neonatal resuscitation is largely based on evidence from adult literature [11] and animal studies [12].…”