Part 15: Neonatal Resuscitation

T he following guidelines are an interpretation of the evidence presented in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1 ).They apply primarily to newly born infants undergoing transition from intrauterine to extrauterine life, but the recommendations are also applicable to neonates who have completed perinatal transition and require resuscitation during the first few weeks to months following birth.Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should consider following these guidelines.For the purposes of these guidelines, the terms newborn and neonate are intended to apply to any infant during the initial hospitalization.The term newly born is intended to apply specifically to an infant at the time of birth.Approximately 10% of newborns require some assistance to begin breathing at birth.Less than 1% require extensive resuscitative measures.2,3 Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation.Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics:• Term gestation?• Crying or breathing?• Good muscle tone?If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother.The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature.Observation of breathing, activity, and color should be ongoing.If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence:A. Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate) B. Ventilation C. Chest compressions D. Administration of epinephrine and/or volume expansionApproximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps, reevaluating, and beginning ventilation if required (see Figure ).The decision to progress beyond the initial steps is determined by simultaneous assessment of 2 vital characteristics: respirations (apnea, gasping, or labored or unlabored breathing) and heart rate (whether greater than or less than 100 beats per minute).Assessment of heart rate should be done by intermittently auscultating the precordial pulse.When a pulse is detectable, palpation of the umbilical pulse can also provide a rapid estimate of the pulse and is more accurate than palpation at other sites.4,5 A pulse oximeter can provide a continuous assessment of the pulse without interruption of other resuscitation measures, but the device takes 1 to 2 minutes to apply, and it may not function during states of very poor cardiac output or perfusion.Once positive pressure ventilation or supplementary oxygen administration is begun, assessment should consist of simultaneous evaluation of 3 vital characteristics: heart rate, respirations, and the state of oxygenation, the latter optimally determined by a pulse oximeter as discussed under “Assessment of Oxygen Need and Administration of Oxygen” below.The most sensitive indicator of a successful response to each step is an increase in heart rate. Anticipation of Resuscitation NeedAnticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation.At every delivery there should be at least 1 person whose primary responsibility is the newly born.This person must be capable of initiating resuscitation, including administra-