Neonatal Resuscitation

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Neonatal Resuscitation
• Author: Robin L Bissinger, PhD, APRN, NNP-BC; Chief Editor: Ted
Rosenkrantz, D !ore"""

#$dated: No% &, '())
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• +%er%ie,
• Transition to E-trauterine Ph.sio/og.
• Pre$aration for Resus*itation
• Resus*itation of Neonates
• 0!!ediate Postresus*itation Period
• 1$e*ia/ Prob/e!s During Resus*itation
• Contro%ersies in Resus*itation
• 1ho, A//
u/ti!edia Librar.
Neonata/ resus*itation ski//s are essentia/ for a// hea/th *are $ro%iders ,ho are
in%o/%ed in the de/i%er. of ne,borns" The transition fro! fetus to ne,born
re2uires inter%ention b. a ski//ed indi%idua/ or tea! in a$$ro-i!ate/. )(3 of
a// de/i%eries"
This figure is *on*erning be*ause 4)3 of a// babies in the #nited 1tates are
born in nontea*hing, nonaffi/iated /e%e/ 0 or 00 hos$ita/s" 0n su*h hos$ita/s, the
%o/u!e of de/i%er. ser%i*e !a. not be $er*ei%ed as suffi*ient e*ono!i*
5ustifi*ation for the *ontinuous in-hos$ita/ $resen*e of $ersonne/ ,ith high-risk
de/i%er. roo! e-$erien*e, as re*o!!ended b. the A!eri*an A*ade!. of
Pediatri*s 6AAP7 and the A!eri*an Co//ege of +bstetri*ians and*o/ogists
Perinata/ as$h.-ia and e-tre!e $re!aturit. are the ' *o!$/i*ations of
$regnan*. that !ost fre2uent/. ne*essitate *o!$/e- resus*itation b. ski//ed
$ersonne/" ;o,e%er, on/. <(3 of as$h.-iated ne,borns *an be $redi*ted ante
$artu!" The re!aining ne,borns are not identified unti/ the ti!e of birth"
Additiona//., a$$ro-i!ate/. 4(3 of /o,-birth-,eight infants re2uire
resus*itation and stabi/ization at de/i%er."
Near/. one ha/f of ne,born deaths 6!an. of ,hi*h in%o/%e e-tre!e/.
$re!ature infants7 o**ur during the first '& hours after birth" an. of these
ear/. deaths a/so ha%e a *o!$onent of as$h.-ia or res$irator. de$ression as an
etio/og." =or the sur%i%ing infants, effe*ti%e !anage!ent of as$h.-ia in the
first fe, !inutes of /ife !a. inf/uen*e /ong-ter! out*o!e"
E%en though $renata/ *are *an identif. !an. $otentia/ feta/ diffi*u/ties ante
$artu!, a//o,ing !aterna/ transfer to the referra/ *enter for *are, !an. ,o!en
,ho e-$erien*e $reter! /abor are not identified $ros$e*ti%e/. and therefore are
not a$$ro$riate/. transferred to a tertiar. $erinata/ *enter" Conse2uent/., !an.
de/i%eries of e-tre!e/. $re!ature infants o**ur in s!a//er hos$ita/s"
=or this reason, a// $ersonne/ in%o/%ed in de/i%er. roo! *are of the ne,born
shou/d be trained ade2uate/. in a// as$e*ts of neonata/ resus*itation"
Additiona//., e2ui$!ent that is a$$ro$riate/. sized to resus*itate infants of a//
gestationa/ ages shou/d be a%ai/ab/e in a// de/i%ering institutions, e%en if the
institution does not *are for $reter! or intensi%e *are infants"
A/ong ,ith the ne*essar. ski//s, the $ra*titioner shou/d a$$roa*h an.
resus*itation ,ith a good *o!$rehension of transitiona/ $h.sio/og. and
ada$tation, as ,e// as an understanding of the infant>s res$onse to resus*itation"
Resus*itation in%o/%es !u*h !ore than $ossessing an ordered /ist of te*hni*a/
ski//s and ha%ing a resus*itation tea!; it re2uires e-*e//ent assess!ent ski//s
and a grounded understanding of $h.sio/og."
This arti*/e re%ie,s the ada$tation $ro*ess at de/i%er., out/ines the ste$s
ne*essar. to resus*itate neonates, ser%es as a re%ie, for $ra*titioners ,ho
a/read. resus*itate infants, and high/ights s$e*ia/ $rob/e!s and *ontro%ersies"
Ne, $ra*titioners !ust *o!$/ete the Neonata/ Resus*itation Progra! 6NRP7 or
so!e other $rogra! that introdu*es resus*itation !ateria/ and a//o,s ski//
assess!ent" After reading the !ateria/ and $ra*ti*ing the ski//s, the. shou/d
,ork ,ith e-$erien*ed $ersonne/ before $ro%iding resus*itation at de/i%eries"
=or $atient edu*ation resour*es, see the Pub/i* ;ea/th Center, as ,e//
as Cardio$u/!onar. Resus*itation 6CPR7"
Transition to Extrauterine Physiology
To de*rease neonata/ !orbidit. and !orta/it., the $ra*titioner !ust be ab/e to
ra$id/. identif. infants ,hose transition fro! an intrauterine to e-trauterine
$h.sio/og. is de/a.ed" Neonata/ transition re2uires s$ontaneous breathing and
su**essfu/ *ardio$u/!onar. *hanges, as ,e// as other *hanges to inde$endent
organ s.ste! fun*tions" A thorough understanding of nor!a/ transitiona/
$h.sio/og. /eads to a better understanding of the needs of the infant ,ho is
e-$erien*ing diffi*u/ties and thus shou/d resu/t in a !ore effe*ti%e resus*itati%e
Respiratory adaptation
After birth, the air,a.s and the a/%eo/i !ust be */eared of feta/ /ung f/uid so
that the /ungs *an o$erate as a fun*tiona/ res$irator. unit $ro%iding ade2uate
gas e-*hange" Pu/!onar. b/ood f/o, !ust in*rease, and s$ontaneous
res$irations !ust be estab/ished" 0n utero, !ost of the b/ood f/o, is shunted
a,a. fro! the /ungs and dire*ted to the $/a*enta ,here feto$/a*enta/ gas
e-*hange o**urs"
=eta/ $u/!onar. %as*u/ar resistan*e is high, and the feta/ s.ste!i* %as*u/ar
resistan*e is /o," ?ithin !inutes of de/i%er., the ne,born>s $u/!onar. %as*u/ar
resistan*e !a. de*rease 4- to )(-fo/d, *ausing a *orres$onding in*rease in
neonata/ $u/!onar. b/ood f/o," At birth, the /ungs !ust transition ra$id/. to
be*o!e the site for gas e-*hange, or e/se *.anosis and h.$o-ia ,i// ra$id/.
A**ording/., an understanding of the stru*ture and fun*tion of the feta/
$u/!onar. %as*u/ature and the subse2uent transition to neonata/ $h.sio/og. is
i!$ortant for fa*i/itating the ne*essar. ada$tations during resus*itation" 0n
utero, the /ungs de%e/o$ steadi/. fro! ear/. in gestation 6see Tab/e ) be/o,7"
@no,/edge of the stages of de%e/o$!ent */arifies ,h. neonates born before
about 'A-'& ,eeks> gestationa/ age often /a*k suffi*ient /ung de%e/o$!ent for
sur%i%a/ be*ause of the absen*e of a *a$i//ar. net,ork ad5a*ent to the i!!ature
%enti/ator. units"
Tab/e )" E!br.o/ogi* 1tages of Lung De%e/o$!ent 6+$en Tab/e in a ne,
Structure "evelop#ent
E!br.oni* B ,k Bron*hi de%e/o$, and air,a. bran*hing o**urs; $u/!onar.
%eins return to /eft atriu!
Pseudog/andu/ar B-)C ,k Lungs take on g/andu/ar a$$earan*e, and there is *ontinua/
bran*hing of tra*hea/ bron*hia/ tree 6ending at )4-)D ,k
gestation7; b/ood %esse/s and /.!$hati*s begin to for!,
and dia$hrag! de%e/o$s
Cana/i*u/ar )A-'B ,k Ri*h %as*u/ar su$$/. de%e/o$s, and *a$i//aries are brought
*/oser to air,a.s; $ri!iti%e res$irator. bron*hio/es begin
to for!
Ter!ina/ air sa* '&-&( ,k A/%eo/i a$$ear and begin in*reasing in nu!ber, and b/ood-
gas interfa*e de%e/o$s; t.$e 00 a/%eo/ar *e//s a$$ear
bet,een '( and 'B ,k and start $rodu*ing surfa*tant
bet,een '& and 'B ,k, though nor!a/ intra-air,a.
*on*entrations are not rea*hed unti/ EA& ,k
Postnata/ &( ,k to 4 . Thinning of a/%eo/ar sa* /inings and *ontinued a/%eo/ar
$ro/iferation o**ur
$etal pul#onary physiology
At ter!, the feta/ /ung is fi//ed ,ith a$$ro-i!ate/. '( !L of f/uid" =eta/
air,a.s, a/%eo/i, and ter!ina/ sa**u/es are o$en and stab/e at nor!a/ feta/ /ung
%o/u!es, distended b. /ung f/uid se*reted b. the $u/!onar. e$ithe/iu!" This
/ung f/uid !aintains /ung %o/u!e at about the fun*tiona/ residua/ *a$a*it.
6=RC7 and is a deter!inant of nor!a/ /ung gro,th" A *onstant f/o, of this f/uid
is se*reted into the a/%eo/ar s$a*es throughout de%e/o$!ent, ,hi*h *ontributes
to the feta/ a!nioti* f/uid"
Pu/!onar. and bron*hia/ *ir*u/ation a/so de%e/o$s as the a/%eo/i a$$ear"
Be*ause of the *o!$ressi%e effe*t of the feta/ /ung f/uid and the /o, a/%eo/ar
$artia/ $ressure of o-.gen 6P
7 in utero, the $u/!onar. *a$i//ar. bed and
$u/!onar. b/ood %esse/s re!ain *onstri*ted" ;igh %as*u/ar resistan*e and /o,
$u/!onar. b/ood f/o, resu/t"
The $/a*enta $ro%ides the res$irator. fun*tion for the fetus" The $/a*enta/
*ir*u/ation has ' !a5or *hara*teristi*s that enab/e the $/a*enta to !aintain
ade2uate o-.genation of the fetus" =irst, the $/a*enta has a !u/ti%i//ous
*ir*u/ation that $ro%ides the !a-i!u! surfa*e area for the e-*hange of o-.gen
and *arbon dio-ide bet,een the !other and fetus" 1e*ond, se%era/ fa*tors resu/t
in the /o,ering of !aterna/ $; and in*reasing of feta/ $;, ,hi*h resu/ts in
in*reased transfer of o-.gen fro! !aterna/ to feta/ he!og/obin or red b/ood
*e//s 6RBCs7"
aterna/ b/ood, * o-.gen on adu/t he!og/obin, re/eases o-.gen to the
feta/ *ir*u/ation and a**e$ts both *arbon dio-ide and %arious b.$rodu*ts of
!etabo/is! fro! the feta/ *ir*u/ation" These transfers de*rease !aterna/
$/a*enta/ b/ood $; and shift the !aterna/ o-.gen-disso*iation *ur%e to the
right, ,hi*h resu/ts in /o,er affinit. of the he!og/obin for o-.gen and the
re/ease of additiona/ o-.gen to the feta/ he!og/obin" The *orres$onding shift in
the feta/ o-.gen-disso*iation *ur%e to the /eft a//o,s the feta/ he!og/obin to
bind !ore o-.gen"
=eta/ FbreathingF 6ie, *hest ,a// and dia$hrag!ati* !o%e!ent7 begins at
a$$ro-i!ate/. )) ,eeks> gestation and in*reases in strength and fre2uen*.
throughout gestation" =eta/ breathing is *ontro//ed b. *he!ore*e$tors /o*ated in
the aorta and at the bifur*ation of the *o!!on *arotid arter." These areas sense
both $; and $artia/ $ressure of *arbon dio-ide 6PC+
A ref/e- res$onse to a/tered $; and PC+
is $resent at a$$ro-i!ate/. )4 ,eeks>
gestation; ho,e%er, the fetus is not ab/e to regu/ate this res$onse unti/
a$$ro-i!ate/. '& ,eeks> gestation" 1o!e studies ha%e indi*ated that this
res$onse *annot be e/i*ited in utero e%en ,hen the $; and PC+
are a/tered,
/eading resear*hers to be/ie%e that the res$onse is su$$ressed in utero and is not
a*ti%ated unti/ birth"
1tudies a/so suggest that the /o, P
in utero !a. be the !e*hanis! that
inhibits *ontinuous breathing, finding that ,hen P
is in*reased, *ontinuous
breathing is sti!u/ated"
Neonatal pul#onary physiology
As noted 6see abo%e7, the feta/ air,a.s and a/%eo/i are fi//ed ,ith /ung f/uid that
needs to be re!o%ed before res$iration" +n/. a s!a// $ortion of this feta/ /ung
f/uid is re!o%ed $*a//. during de/i%er." During the thora*i* s2ueeze, 'B-
AA3 of the f/uid 6so!eti!es !arked/. /ess7 !a. be e-$ressed fro! the
oro$har.n- and u$$er air,a.s" Thora*i* re*oi/ a//o,s $assi%e ins$iration of air
into the /arger bron*hio/es" Effe*ti%e transition re2uires that an. re!aining
/i2uid be 2ui*k/. absorbed to a//o, effe*ti%e gas e-*hange"
The de*rease in /ung f/uid begins during /abor" 1tudies using a feta/ /a!b !ode/
sho,ed that the $rodu*tion of /ung f/uid de*reases ,ith the onset of /abor" The
subse2uent redu*tion in /ung f/uid ,as asso*iated ,ith i!$ro%ed gas e-*hange
and a*id-base ba/an*e" Labor is a/so asso*iated ,ith in*reased *ate*ho/a!ine
/e%e/s, ,hi*h sti!u/ate /.!$hati* drainage of the /ung f/uid"
0n addition, ,ith the onset of /abor, the fetus $rodu*es adrena/ine and the
!other $rodu*es th.rotro$in-re/easing hor!one, ,hi*h sti!u/ates the
$u/!onar. e$ithe/ia/ *e//s to begin readsor$tion of f/uid" These findings *ou/d
a**ount for the in*reased in*iden*e of transient ta*h.$nea of the ne,born after
birth b. *esarean de/i%er. ,ithout /abor"
After birth, /ung f/uid is re!o%ed b. se%era/ !e*hanis!s, in*/uding
e%a$oration, a*ti%e ion trans$ort, $assi%e !o%e!ent fro! 1tar/ing for*es, and
/.!$hati* drainage" A*ti%e sodiu! trans$ort b. energ.-re2uiring sodiu!
trans$orters, /o*ated at the basi/ar / of the $u/!onar. e$ithe/ia/ *e//s, dri%es
/i2uid fro! the /ung /u!en into the $u/!onar. interstitiu!, ,here it is
absorbed b. the $u/!onar. *ir*u/ation and /.!$hati*s"
E-$osure to an air interfa*e, a/ong ,ith high *on*entrations of g/u*o*orti*oids
and *.*/i* nu*/eotides, re%erses the dire*tion of ion and ,ater !o%e!ent in the
a/%eo/i and /eads to high/. se/e*ti%e sodiu! *hanne/s" These *hanges shift the
feta/ /ung e$ithe/ia/ *e//s fro! a $attern of *h/oride se*retion to one of sodiu!
reabsor$tion, ,hi*h a**e/erates reabsor$tion of feta/ /ung f/uid"
The first breath !ust o%er*o!e the %is*osit. of the /ung f/uid and the intra-
a/%eo/ar surfa*e tension" This first breath !ust a/so generate high
trans$u/!onar. $ressure, ,hi*h he/$s dri%e the a/%eo/ar f/uid a*ross the
a/%eo/ar e$ithe/iu!" ?ith subse2uent /ung aeration, the intra$aren*h.!a/
stru*tures stret*h, and gases enter the a/%eo/i, resu/ting in in*reased P
$;" The in*reased P
and $; resu/t in $u/!onar. %asodi/ation and
*onstri*tion of the du*tus arteriosus"
Lung e-$ansion and aeration is a/so a sti!u/us for surfa*tant re/ease, ,hi*h
resu/ts in the estab/ish!ent of an air-f/uid interfa*e and the de%e/o$!ent of
=RC" Nor!a//., 4(-D(3 of =RC is estab/ished ,ithin the first hour of birth in
ter! neonates ,ith s$ontaneous res$irations" Pre!ature and *riti*a//. i// infants
,ith surfa*tant defi*ien*. or d.sfun*tion !a. ha%e /i!ited abi/it. to */ear /ung
f/uid and estab/ish =RC"
The $u/!onar. %as*u/ature is sti!u/ated to di/ate b. *he!i*a/ !ediators, nitri*
o-ide 6N+7, and $rostag/andins" N+ is re/eased ,hen $u/!onar. b/ood f/o,
and o-.genation in*reases" The for!ation of *ertain $rostag/andins, su*h as
$rosta*.*/in, is indu*ed b. the $resen*e of in*reased o-.gen tension"
Prosta*.*/in a*ts on the $u/!onar. %as*u/ar s!ooth !us*/e bed to indu*e
$u/!onar. %asodi/ation" 0t has a short ha/f-/ife in the b/oodstrea! and therefore
does not affe*t the s.ste!i* *ir*u/ation"
1oon after birth, feta/ res$irator. a*ti%it. !ust transition to nor!a/ s$ontaneous
breathing" To o%er*o!e the %is*osit. of the /ung f/uid and the resistan*e
generated b. the f/uid-fi//ed /ungs and the re*oi/ and resistan*e of the *hest
,a//, /ungs, and air,a.s, the infant !ust generate a negati%e $ressure so that air
!o%es fro! an area of higher $ressure to one of /o,er $ressure" There are '
!a5or $h.sio/ogi* res$onses that go%ern the initia/ /ung inf/ation in the neonate"
The first res$onse is the so-*a//ed re5e*tion res$onse, in ,hi*h the neonate
res$onds to $ositi%e-$ressure /ung inf/ation b. generating a $ositi%e
intraeso$hagea/ $ressure to resist the inf/ation" That is, the infant a*ti%e/.
resists atte!$ts to inf/ate the /ungs b. $erfor!ing an a*ti%e e-ha/ation" This
res$onse not on/. a*ts to redu*e /ung inf/ation but a/so !a. *ause high
transient inf/ation $ressures"
The se*ond res$onse is ;ead>s $arado-i*a/ res$onse, in ,hi*h the neonate
res$onds to $ositi%e-$ressure /ung inf/ation ,ith an ins$irator. effort, ,hi*h
generates a negati%e intraeso$hagea/ $ressure" This ins$irator. effort and the
resu/tant negati%e $ressure $rodu*e a fa// in inf/ation $ressures but resu/t in a
transient in*rease in tida/ %o/u!e"
+f *ourse, the neonate !a. de!onstrate no res$onse to the inf/ation atte!$t
and !a. not generate an. *hange in intraeso$hagea/ $ressure during $ositi%e-
$ressure inf/ation, in ,hi*h *ase $assi%e inf/ation resu/ts" These $h.sio/ogi*
res$onses to $ositi%e-$ressure inf/ation in the de/i%er. roo! !a. *ause /arge
%ariabi/it. in tida/ %o/u!e and intra$u/!onar. $ressures, des$ite *onstant
de/i%er. of inf/ation $ressure"
1ti!u/i for the first breath !a. be !u/tifa*toria/" The en%iron!enta/ *hanges
that o**ur ,ith birth 6eg, ta*ti/e and ther!a/ *hanges and in*reased noise and
/ight7 a*ti%ate a nu!ber of sensor. re*e$tors that !a. he/$ initiate and !aintain
breathing" C/a!$ing of the *ord re!o%es the /o, resistan*e $/a*enta, *ausing
an in*rease in s.ste!i* %as*u/ar resistan*e and *onse2uent/. *ausing an
in*rease in both s.ste!i* b/ood $ressure and $u/!onar. b/ood f/o,"
Certain e%iden*e a/so suggests that the in*reased arteria/ $artia/ $ressure of
o-.gen 6P
7 after the initia/ breaths !a. be res$onsib/e for the de%e/o$!ent
of *ontinuous breathing %ia hor!ona/ or *he!i*a/ !ediators that are sti//
?hen the ne,born /ungs fi// ,ith air, the P
shou/d rise gradua//." 0n ter!
infants ,ith a $ersistent h.$o-ia, an initia/ in*rease in %enti/ation o**urs,
fo//o,ed b. a de*rease in %enti/ation o**urs" This effe*t is e%en !ore $rofound
in $re!ature infants ,hose *entra/ ner%ous s.ste! 6CN17 is not as !ature"
The *arotid bodies and $eri$hera/ *he!ore*e$tors /o*ated at the bifur*ation of
the *o!!on *arotid arter. are sti!u/ated during h.$o-ia to in*rease !inute
%enti/ation" 0n as$h.-iated infants ,ho *annot in*rease !inute %enti/ation 6eg,
be*ause of e-tre!e $re!aturit. or sedation7, $rofound brad.*ardia !a. resu/t"
%ardiovascular adaptation
Fetal circulation
To understand the *ardio%as*u/ar *hanges that o**ur in the neonate at birth, an
understanding of nor!a/ feta/ *ir*u/ation is ne*essar." The u!bi/i*a/ %ein
*arries the o-.genated b/ood fro! the $/a*enta to the fetus" B/ood f/o, in this
%ein di%ides at the $orta he$atis, ,ith B(-<(3 of the b/ood $assing dire*t/. to
the inferior %ena *a%a 60GC7 %ia the du*tus %enosus and the re!ainder $assing
into the $orta/ *ir*u/ation" This $orta/ b/ood f/o, $erfuses the /i%er and then
$asses into the 0GC"
=/o, studies ha%e re%ea/ed that re/ati%e/. /itt/e !i-ing of the b/ood fro! these
' sites o**urs in the 0GC" The !ore high/. o-.genated b/ood, ,hi*h has
b.$assed the /i%er, strea!s into the 0GC to $ass $referentia//. through the
$atent fora!en o%a/e into the /eft atriu!" The desaturated b/ood returning fro!
the /i%er and /o,er bod. strea!s into the 0GC to the right atriu!"
0n the right atriu!, the desaturated b/ood !i-es ,ith b/ood returning fro! the
*oronar. sinus and su$erior %ena *a%a 61GC7 and f/o,s into the right %entri*/e"
The !ore high/. o-.genated b/ood that *rosses the fora!en o%a/e !i-es ,ith
the s!a// a!ount of $u/!onar. %enous return and then *rosses the !itra/ %a/%e
into the /eft %entri*/e" The out$ut fro! the /eft %entri*/e $asses into the
as*ending aorta to the heart, brain, head, and u$$er torso" The /ess saturated
b/ood fro! the right %entri*/e $asses into the $u/!onar. arteries"
Be*ause the $u/!onar. %esse/s are *onstri*ted and high/. resistant to f/o,, on/.
about )'3 of this b/ood fro! the right %entri*/e enters the /ungs; the re!ainder
takes the $ath of /east resistan*e through the $atent du*tus arteriosus into the
des*ending aorta" A$$ro-i!ate/. one third of this b/ood is *arried to the trunk,
abdo!en, and /o,er e-tre!ities, ,ith the re!ainder entering the u!bi/i*a/
arter., ,here it is returned to the $/a*enta for reo-.genation"
Neonatal circulation
The aeration of the /ung resu/ts in an in*rease in arteria/ o-.genation and $;,
,ith a resu/ting di/ation of the $u/!onar. %esse/s" De*o!$ression of the
*a$i//ar. /ung bed further de*reases the $u/!onar. %as*u/ar resistan*e" A
*orres$onding de*rease in right %entri*u/ar and $u/!onar. arter. $ressures is
a/so noted" The de*rease in $u/!onar. %as*u/ar resistan*e /eads to an in*rease
in b/ood f/o, to the /ungs and in $u/!onar. %enous return"
C/a!$ing of the u!bi/i*a/ *ord re!o%es the /o,-resistan*e $/a*enta/ %as*u/ar
*ir*uit and thereb. raises tota/ s.ste!i* %as*u/ar resistan*e, ,ith a resu/tant
in*rease in /eft %entri*u/ar and aorti* $ressures" The in*reased s.ste!i*
%as*u/ar resistan*e, *o!bined ,ith the de*reased $u/!onar. %as*u/ar
resistan*e, re%erses the shunt through the du*tus arteriosus 6fro! right-to-/eft
shunting to /eft-to-right shunting7 unti/ the du*tus */oses *o!$/ete/."
A// of these e%ents resu/t in */osure of the other feta/ shunts" ?ith the de*rease
in right atria/ $ressure and the in*rease in /eft atria/ $ressure, the )-,a. Ff/a$-
%a/%eF fora!en o%a/e is $ushed */osed against the atria/ se$tu!" This fun*tiona/
*/osure at birth is fo//o,ed b. anato!i* */osure, ,hi*h usua//. o**urs at
se%era/ !onths of age"
The du*tus %enosus */oses be*ause of the */a!$ing of the u!bi/i*a/ *ord,
,hi*h ter!inates u!bi/i*a/ %enous return" =un*tiona/ !e*hani*a/ */osure of the
du*tus %enosus is a**o!$/ished b. the *o//a$se of the thin-,a//ed %esse/s"
Anato!i* */osure subse2uent/. o**urs at a$$ro-i!ate/. )-' ,eeks"
Per!anent */osure of the du*tus %enosus !a. be de/a.ed in $reter! infants or
infants ,ith $ersistent $u/!onar. h.$ertension" The *onstri*tion and */osure of
the du*tus arteriosus is a**o!$/ished b. *ontra*ti/e tissue ,ithin the ,a//s of
this b/ood %esse/" The *ontra*tion of this tissue is de$endent both on the
in*rease in arteria/ o-.gen re/ated to the onset of s$ontaneous res$irations and
on a fa// in *ir*u/ating $rostag/andin E
Be*ause the $/a*enta is a !a5or site of feta/ P8E
$rodu*tion, re!o%a/ of the
$/a*enta fro! the *ir*u/ation *auses *ir*u/ating P8E
*on*entration to de*rease
!arked/." =urther redu*tions in P8E
*on*entration o**ur be*ause of in*reased
b/ood f/o, to the /ungs 6the site of P8E
!etabo/is!7" =un*tiona/ */osure of the
du*tus genera//. o**urs ,ithin C' hours of /ife, ,ith anato!i* */osure b. age )-
' ,eeks"
0n su!!ar., fun*tiona/ $ostnata/ *ir*u/ation genera//. is estab/ished ,ithin <(
se*onds; ho,e%er, *o!$/etion of the transfor!ation *an take u$ to < ,eeks"
Response to asphyxia
A fetus or ne,born that is sub5e*ted to as$h.-ia 6see the i!age be/o,7 initiates
a Fdi%ingF ref/e- 6so ter!ed be*ause of *ertain si!i/arities to the $h.sio/og. of
di%ing sea/s7 in an atte!$t to !aintain $erfusion and o-.gen de/i%er. to %ita/
organs" ;.$o-ia and a*idosis /ead to $u/!onar. arterio/ar %aso*onstri*tion"
Pu/!onar. %as*u/ar resistan*e in*reases, /eading to de*reased $u/!onar. b/ood
f/o, and in*reased b/ood f/o, dire*t/. to the /eft atriu!"
=eta/ res$onse to as$h.-ia i//ustrating initia/ redistribution of b/ood f/o, to
%ita/ organs" ?ith $ro/onged as$h.-ia/ insu/t and fai/ure of *o!$ensator.
!e*hanis!s, *erebra/ b/ood f/o, fa//s, /eading to is*he!i* brain in5ur."
1.ste!i* *ardia* out$ut is redistributed, ,ith in*reased f/o, to the heart, brain,
and adrena/ g/ands and de*reased f/o, to the rest of the bod." Ear/. in the
*ourse of as$h.-ia, s.ste!i* b/ood $ressure in*reases" ?ith ongoing h.$o-ia
and a*idosis, ho,e%er, the !.o*ardiu! fai/s and brad.*ardia o**urs; this
*auses a de*rease in b/ood $ressure and tissue $erfusion, /eading to e%entua/
tissue is*he!ia and h.$o-ia"
0nfants ,ho are undergoing as$h.-ia e-hibit an a/tered res$irator. $attern"
0nitia//., the. ha%e ra$id res$irations" These res$irator. efforts e%entua//. *ease
,ith *ontinued as$h.-ia 6$ri!ar. a$nea7" During $ri!ar. a$nea, the infant
res$onds to sti!u/ation ,ith reinstitution of breathing" ;o,e%er, if the
as$h.-ia *ontinues, the infant then begins irregu/ar gas$ing efforts, ,hi*h
s/o,/. de*rease in fre2uen*. and e%entua//. *ease 6se*ondar. a$nea7"
0nfants ,ho e-$erien*e se*ondar. a$nea do not res$ond to ta*ti/e or no-ious
sti!u/ation and re2uire $ositi%e-$ressure %enti/ation 6PPG7 to restore
%enti/ation" Pri!ar. and se*ondar. a$nea *annot be */ini*a//. distinguished"
Therefore, if an infant does not readi/. res$ond to sti!u/ation, PPG shou/d be
instituted as out/ined in the Neonata/ Resus*itation Progra! 6NRP7 guide/ines"
0f an infant is e-$erien*ing $ri!ar. a$nea, the sti!u/ation of the %enti/ator.
efforts *auses the infant to resu!e breathing" 0f the infant is in se*ondar. a$nea,
PPG is re2uired for a /onger $eriod" The /onger the infant undergoes as$h.-ia,
the /onger the onset of s$ontaneous res$irations is de/a.ed after the initiation of
effe*ti%e %enti/ation through the use of PPG"
Preparation &or Resuscitation
Nu!erous sour*es of infor!ation are a%ai/ab/e on the training, ski//s, and
$ro*edures needed for de/i%er. roo! resus*itation of the ne,born" A!ong the
!ost high/. res$e*ted of these sour*es is the Neonata/ Resus*itation Progra!
6NRP7, 5oint/. de%e/o$ed b. the A!eri*an A*ade!. of Pediatri*s 6AAP7 and
the A!eri*an ;eart Asso*iation 6A;A7" The fo//o,ing se*tions *ontain a
re%ie, of resus*itation $ro*edures in a for!at that is si!i/ar to the for!at used
b. the NRP"
Co!$/etion of the NRP shou/d be *onsidered b. a// hos$ita/ $ersonne/ ,ho
!a. be in%o/%ed in the stabi/ization and resus*itation of neonates in the
de/i%er. roo!" To de%e/o$ true e-$ertise, additiona/ su$er%ised e-$erien*e ,ith
ski//ed $ersonne/ is essentia/"
A/though the NRP is *onsidered high/. authoritati%e, it is i!$ortant that !ore
resear*h *ontinue to e%a/uate the effe*ti%eness of the te*hni2ues of neonata/
resus*itation" The NRP has a/read. e%o/%ed *onsiderab/. and ,i// *ontinue to
e%o/%e as ne, data fro! */ini*a/ studies and basi* $h.sio/ogi* resear*h be*o!e
Rapid assess#ent
Ne,born infants ,ho need e-tensi%e resus*itation shou/d be ra$id/. identified"
Ter! infants ,ith */ear a!nioti* f/uid, ade2uate res$irator. effort, and good
!us*/e tone shou/d re*ei%e routine *are, ,hi*h in*/udes $ro%ision of ,ar!th,
*/earing of the air,a. 6if needed7, of the infant, and assess!ent of the
infant>s *o/or" These infants shou/d re!ain ,ith their !others during and after
routine *are"
0nfants ,ho do not !eet the *riteria for routine *are need additiona/ ste$s in
their resus*itation" =or su*h infants, resus*itation !a. in*/ude not on/. initia/
stabi/ization 6$ro%iding ,ar!th, $ositioning, */earing the air,a.,,
sti!u/ating, and re$ositioning7 but a/so %enti/ation, *hest *o!$ressions, and
!nticipation o& potential pro'le#s
The goa/s of resus*itation are to assist ,ith the initiation and !aintenan*e of
ade2uate %enti/ation and o-.genation, ade2uate *ardia* out$ut and tissue
$erfusion, and nor!a/ *ore te!$erature and seru! g/u*ose" These goa/s !a. be
attained !ore readi/. ,hen risk fa*tors are identified ear/., neonata/ $rob/e!s
are anti*i$ated, e2ui$!ent is a%ai/ab/e, $ersonne/ are 2ua/ified and a%ai/ab/e,
and a *are $/an is for!u/ated"
A /arge nu!ber of ante$artu! and intra$artu! !aterna/ *onditions *arr. an
in*reased risk for intra$artu! as$h.-ia" an. e-*e//ent te-ts des*ribe the
e-tensi%e !edi*a/ and surgi*a/ $rob/e!s of the obstetri*a/ $atient; a detai/ed
re%ie, of these $rob/e!s is be.ond the s*o$e of this arti*/e to re%ie,"
Resuscitation e(uip#ent
The de/i%er. roo! shou/d be e2ui$$ed ,ith a// the too/s ne*essar. for
su**essfu/ resus*itation of a ne,born of an. size or gestationa/ age" The
e2ui$!ent shou/d in*/ude a radiant ,ar!er, ,ar!ed b/ankets, a sour*e of
o-.gen, instru!ents for %isua/izing and estab/ishing an air,a., a sour*e of
regu/ated su*tion, instru!ents and su$$/ies for estab/ishing intra%enous 60G7
a**ess, tra.s e2ui$$ed for e!ergen*. $ro*edures, and drugs that !a. be usefu/
in resus*itation"
Res$iration e2ui$!ent in*/udes the fo//o,ing:
• +-.gen su$$/.
• Assorted !asks
• Neonata/ bag and tubing to *onne*t to an o-.gen sour*e
• ano!eter
• Endotra*hea/ tubes 6size '"B-&7
• Ta$e and s*issors
• Lar.ngos*o$e 6,ith size ( and ) b/ades7
• E-tra bu/bs and batteries
• Carbon dio-ide dete*tors
• 1t./ettes for endotra*hea/ tubes 6o$tiona/7
• Lar.ngea/ !ask air,a. 6o$tiona/7
1u*tion e2ui$!ent in*/udes the fo//o,ing:
• Bu/b s.ringe
• Regu/ated !e*hani*a/ su*tion
• 1u*tion *atheters 6<, 4, and )( =ren*h7
• 1u*tion tubing
• 1u*tion *anister
• Re$/og/e or 1a/e! $u!$ 6)( =ren*h *atheter7
• =eeding tube 64 =ren*h *atheter7
• 1.ringe, *atheter-ti$$ed 6'( !L7
• e*oniu! as$irator
=/uid e2ui$!ent in*/udes the fo//o,ing:
• 0G *atheters 6'' g7
• Ta$e and steri/e dressing !ateria/
• De-trose )(3 in ,ater 6D)(?7
• 0sotoni* sa/ine so/ution
• T-*onne*tors
• 1.ringes, assorted 6)-'( !L7
Drugs used in*/ude e$ine$hrine 6):)(,(((7"
Pro*edura/ e2ui$!ent in*/udes the fo//o,ing:
• #!bi/i*a/ *atheters 6'"B and B =ren*h7
• Chest tube 6)( =ren*h *atheter7
• 1teri/e $ro*edure tra.s 6eg, s*a/$e/s, he!ostats, for*e$s7
Trained personnel
=or a// de/i%eries, at /east ) $erson shou/d be $resent ,ho is ski//ed in neonata/
resus*itation and is res$onsib/e on/. for the infant" This $erson !ust be ski//ed
in the initiation of resus*itation, the use of bag-!ask %enti/ation, and the
$erfor!an*e of *hest *o!$ressions"
Additiona/ $ersonne/ shou/d be i!!ediate/. a%ai/ab/e to assist in tasks that
!a. be re2uired as $art of resus*itation, in*/uding intubation, !edi*ation
ad!inistration, and e!ergen*. $ro*edures, if needed" 0f the de/i%er. is
identified as high-risk, ' or !ore ski//ed indi%idua/s shou/d be assigned to the
infant at de/i%er."
Re!e!ber that staff trained in neonata/ resus*itation !ust a$$renti*e ,ith
e-$erien*ed $ersonne/ for so!e ti!e before the. *an be inde$endent/.
res$onsib/e for an infant at a de/i%er." 1i!u/ation is /ike/. to be*o!e an
in*reasing/. i!$ortant *o!$onent of training in neonata/ resus*itation"
Resuscitation o& Neonates
Pre%enting heat /oss during resus*itation is essentia/" 0ntrauterine
ther!oregu/ation is $assi%e, ,ith no use of *a/ories or o-.gen b. the fetus" This
$assi%e ther!oregu/ation $ro*ess a//o,s the fetus to a*hie%e !a-i!a/
intrauterine gro,th ,ithout ha%ing to e-$end energ. on ther!a/ ho!eostasis"
Bro,n fat storage begins during the third tri!ester" Bro,n fat !a. be used for
heat $rodu*tion in the ne,born $eriod"
1e%era/ fa*tors /ead to in*reased heat /osses in the ne,born" Neonates ha%e a
high ratio of skin surfa*e area to bod. ,eight, ,hi*h in*reases heat /oss and
e%a$orati%e f/uid /oss" The f/uid /oss fro! the skin 6due not to s,eating but to
dire*t transder!a/ ,ater /oss7 resu/ts in !assi%e heat /oss" The thin feta/ skin,
,ith b/ood %esse/s that are near the surfa*e, $ro%ides $oor insu/ation, ,hi*h
/eads to further heat /oss"
Additiona//., the ne,born infant 6es$e*ia//. if $re!ature7 has a /i!ited
*a$a*it. to *hange bod. $osition for heat *onser%ation" Ani!a/s ordinari/.
atte!$t to de*rease heat /oss b. de*reasing their e-$osed surfa*e area 6eg, b.
*ur/ing u$7" This redu*tion in e-$osed surfa*e area is a**o!$/ished b.
assu!ing a f/e-ed $osition; ho,e%er, $re!ature, *riti*a//. i//, and de$ressed
infants are unab/e to a**o!$/ish f/e-ed $ositioning"
Neonates ha%e a %er. /i!ited *a$a*it. for !etabo/i* heat $rodu*tion" The
ne,born infant has /i!ited energ. stores, /arge/. be*ause of de*reased
sub*utaneous fat and bro,n fat stores, and this $au*it. of fat stores is !ore
$ronoun*ed in $re!ature and gro,th-retarded infants" oreo%er, infants are
not *a$ab/e of effe*ti%e shi%ering, ,hi*h is a !a5or sour*e of heat $rodu*tion in
the adu/t" The !ain sour*e of heat $rodu*tion in the ne,born is nonshi%ering
Ther!ore*e$tors in the fa*e are !arked/. sensiti%e to heat and *o/d" Co/d
sti!u/ation /eads to nore$ine$hrine $rodu*tion and th.roid hor!one re/ease,
*ausing bro,n fat to be !etabo/ized" Bro,n fat is high/. %as*u/arized and
stored in $o*kets around the neonate>s bod." ?hen it is !etabo/ized,
trig/.*erides are h.dro/.zed to fatt. a*ids and g/.*ero/" Additiona//., g/.*o/.sis
is initiated and g/.*ogen stores are used, both of ,hi*h resu/t in g/u*ose
$rodu*tion" ;eat is $rodu*ed as a b.$rodu*t of the in*reased !etabo/i* rate and
o-.gen *onsu!$tion"
0nfants ,ho e-$erien*e heat /oss ha%e an in*reased !etabo/i* rate and use !ore
o-.gen" 0n*reased o-.gen *onsu!$tion *an be dangerous in infants ,ho are
e-$erien*ing res$irator. *o!$ro!ise" The addition of *o/d stress in infants ,ho
are $oor/. o-.genated *an $otentia//. trigger a *hange fro! aerobi* to
anaerobi* !etabo/is!" This *hange in !etabo/is! !a. /ead to tissue h.$o-ia
and a*idosis be*ause of the bui/du$ of !etabo/i* b.$rodu*ts su*h as /a*tate"
Be*ause of the ineffi*ien*. of anaerobi* !etabo/is!, the infant uses u$ g/u*ose
and g/.*ogen reser%es ra$id/. ,hi/e sti// generating on/. a /i!ited a!ount of
energ. for heat $rodu*tion" Therefore, *o/d stress *an /ead to both !etabo/i*
a*idosis and h.$og/.*e!ia" 0nfants ,ith as$h.-ia ha%e ther!oregu/ator.
instabi/it., and h.$other!ia de/a.s re*o%er. fro! a*idosis"
;.$other!ia on ad!ission to the neonata/ unit has been sho,n to be asso*iated
,ith an in*reased !orta/it."
0n %ie, of this finding, it is */ear/. essentia/ to
$re%ent e-*essi%e heat /oss in the de/i%er. roo! and throughout stabi/ization
and trans$ort to the neonata/ unit" Nor!other!ia and h.$other!ia in infants
ha%e been defined b. the ?or/d ;ea/th +rganization 6?;+7 as out/ined in
Tab/e ' be/o,"
Tab/e '" A-i//ar. Te!$eratures in 0nfants ?eighing Less Than )B(( g 6+$en
Tab/e in a ne, ,indo,7
Ranges Te#perature !ction Needed
Nor!a/ A<"B-AC"B
C Continue
Potentia/ *o/d stress A<-A<"B
C Cause for *on*ern
oderate h.$other!ia A'-A<
C Danger; i!!ediate ,ar!ing of bab. needed
1e%ere h.$other!ia H A'
C +ut/ook gra%e; ski//ed *are urgent/. needed
The A!eri*an ;eart Asso*iation 6A;A7 and the A!eri*an A*ade!. of
Pediatri*s 6AAP7 ha%e stated that the goa/ 6of the first te!$erature7 shou/d be
an a-i//ar. te!$erature of A<"B
C" The ai! is to a*hie%e nor!other!ia and
a%oid h.$erther!ia, ,hi*h is asso*iated ,ith $rogressi%e *erebra/ in5ur."
The en%iron!enta/ te!$erature is a/so i!$ortant in *ontro//ing heat /oss in the
ne,born" =or a fetus, the ther!a/ en%iron!ent is $re*ise/. regu/ated b. the
!other>s *ore te!$erature, and heat /osses are none-istent" After de/i%er., e%en
,ith and the use of a radiant heat sour*e are used, infants *ontinue to
/ose /arge a!ounts of heat through *on%e*ti%e and e%a$orati%e !e*hanis!s"
?hen the en%iron!enta/ air is *oo/er than the neutra/ ther!a/ en%iron!ent for
the infant being resus*itated, further ther!a/ /osses ensue"
;eat /osses are re/ated both to the differen*e in ,ater *on*entration bet,een
the skin and the air and to the abso/ute te!$erature gradient" The $ri!ar. goa/
in neonata/ ther!oregu/ation is $re%ention of heat /oss, as o$$osed to /ater
*orre*tion of heat /oss through re,ar!ing" 0dea//., a s$e*ifi* area 6eg, a
stabi/ization roo!7 shou/d be !aintained se$arate fro! the o$erating roo!
6+R7 or /abor roo! so that s$e*ia/ attention *an be $aid to the unusua/ ther!a/
and en%iron!enta/ needs of the ne,born high-risk infant"
This stabi/ization area shou/d be ke$t as ,ar! as $ossib/e, ,ith the
re2uire!ents of the high-risk infant ba/an*ed against the *o!fort of the adu/t
staff in that area" Lo, de/i%er. roo! te!$eratures *an $redis$ose to
h.$other!ia, and Neonata/ Resus*itation $rogra! 6NRP7 guide/ines
re*o!!end that if a $reter! de/i%er. is anti*i$ated, the de/i%er. roo!
te!$erature shou/d be in*reased" 0dea//., a dedi*ated roo! ,ou/d be a%ai/ab/e
in ,hi*h a!bient te!$erature *an be ,e// *ontro//ed"
1uggested de/i%er. roo! te!$eratures b. age and ,eight 6deter!ined on the
basis of *onsensus grou$sIsti// *onsidered an e%o/%ing */ini*a/ $ra*ti*e7 are as
• Esti!ated gestationa/ age 6E8A7 /ess than '< ,eeks, esti!ated birth
,eight 6EB?7 /ess than CB( g, or both - C<
= or higher, target C4-4(
• E8A 'C-'4 ,eeks, EB? /ess than )((( g, or both - C&
= or higher,
target C4-4(
• E8A 'D-A' ,eeks, EB? )(()-)B(( g, or both - C'
=, target CB
• E8A AA-A< ,eeks, EB? )B()-'B(( g, or both - C'
=, target CB
• E8A 'C-&' ,eeks, EB? greater than 'B(( g, or both - C(
=, target
Ne,borns shou/d be dried ,ith $re,ar!ed b/ankets or to,e/s and $/a*ed on a
$re,ar!ed heat sour*e" +$en bed ,ar!ers, ,hi*h use radiant heat, are used in
!ost de/i%er. roo!s" The. $ro%ide ,ar!th during resus*itation and for an.
subse2uent in%asi%e $ro*edures" 0t is i!$ortant for the $ra*titioner to kee$ in
!ind that this sour*e of heat does not $rote*t the infant fro! e%a$orati%e heat
/oss but, instead, en*ourages e%a$orati%e heat /osses"
Continuous !onitoring of te!$erature shou/d o**ur as soon as $ossib/e after
the de/i%er." Pre!ature infants 6H )B(( g7 shou/d be *o%ered in $/asti* ,ra$
6$o/.eth./ene7 to $re%ent e-*essi%e heat /oss" A fu// resus*itation, in*/uding /ine
$/a*e!ent, *an and shou/d be $erfor!ed ,ith the $/asti* ,ra$ in $/a*e" A
,oo/en head *a$ shou/d be used"
?eights shou/d be obtained on radiant ,ar!er bed s*a/es" Ade2uate/. ,ar!ing
the trans$ort in*ubator is essentia/" The infant>s te!$erature shou/d be
do*u!ented as soon as $ossib/e after birth and e%er. )(-)B !inutes thereafter
unti/ *ontinuous te!$erature !onitoring has been estab/ished"
Another *o!!on sour*e of heat /oss in the neonate undergoing resus*itation is
the use of unheated nonhu!idified o-.gen sour*es for the bag-%a/%e-!ask
de%i*e" The ins$ired gases sent to the /ungs are subse2uent/. heated and
hu!idified b. the infant; this resu/ts in !assi%e heat e-*hange fro!
e%a$orati%e heat /oss and insensib/e ,ater /oss" ?hene%er $ossib/e, ,ar!ed
and hu!idified gases shou/d be $ro%ided in the resus*itation area"
A/ternati%e/., the intubated and %enti/ated infant shou/d be $/a*ed on a heated
%enti/ator *ir*uit as soon as is feasib/e"
!irway #anage#ent
+n*e in a heated en%iron!ent, the infant shou/d be $ositioned so as to o$en the
air,a., and the !outh and nose shou/d be su*tioned" A bu/b s.ringe shou/d be
used for the initia/ su*tioning"
0nfants ha%e a %aga/ ref/e- res$onse to sensor. sti!u/ation of the /ar.n-, ,hi*h
!a. indu*e a$nea, brad.*ardia, h.$otension, and /ar.ngos$as!" Thus,
su*tioning the $osterior ora/ air,a. or the tra*hea ,ith a *atheter be*ause of
e-tre!e/. thi*k or !e*oniu!-stained f/uids !a. *ause $rofound *entra/ a$nea,
$otentia//. $rofound brad.*ardia, and /ar.ngos$as!" A**ording/., it shou/d be
/i!ited to infants ,ith thi*k !u*us that *annot be re!o%ed b. bu/b s.ringe or
used for the as$iration of sto!a*h *ontents 6,hen ne*essar.7"
0nsti//ation of sa/ine into the tra*hea a/so has been sho,n to sti!u/ate the
afferent sensor. neurons /eading to these se2ue/ae and *onse2uent/. has no
$/a*e in the i!!ediate resus*itation $eriod" Lung inf/ation has been sho,n to
re%erse the effe*ts of %aga/ sti!u/ation" Gigorous su*tioning of the nares ,ith a
*atheter *an /ead to ede!a of the nasa/ tissues ,ith resu/ting res$irator. distress
after the infant /ea%es the de/i%er. roo!" ?a// su*tion shou/d be set so that
$ressures do not e-*eed )(( !! ;g"
Sti#ulation and su*tioning often $ro%ide enough sti!u/ation to initiate breathing;
ho,e%er, if !ore %igorous sti!u/ation is ne*essar., s/a$$ing the so/es of the
feet or rubbing the ba*k !a. be effe*ti%e" The ba*k shou/d be %isua/ized brief/.
for an. ob%ious defe*t in the s$ine before beginning these !aneu%ers"
0f there is no res$onse to sti!u/ation, it !a. be assu!ed that the infant is in
se*ondar. a$nea, and $ositi%e-$ressure %enti/ation 6PPG7 shou/d be initiated"
At this $oint, the infant>s res$irator. rate, heart rate, and *o/or shou/d be
e%a/uated" ost infants do not re2uire further inter%ention" This is *onsidered
routine *are for !ost ter! infants ,ith */ear a!nioti* f/uid ,ho are a*ti%e/.
breathing and * and ha%e good !us*/e tone"
Supple#ental oxygen
0nfants ,ho do not !eet the *riteria for routine *are or ,ho ha%e diffi*u/ties
,ith res$irator. effort, tone, or *o/or need further inter%ention" =urther
resus*itati%e efforts shou/d be guided b. si!u/taneous assess!ent of
res$irations, heart rate, and *o/or"
ost infants need obser%ationa/ *are" Neonata/ transition o**urs o%er ti!e"
0nfants ,ho ha%e a sustained heart rate higher than )(( beatsJ!in and ade2uate
res$irator. effort but ,ho re!ain *.anoti* shou/d re*ei%e b/o,-b. o-.gen %ia
o-.gen tubing or a !ask" ;eated hu!idified o-.gen is arguab/. ad%antageous,
but it is rare/. a%ai/ab/e in the de/i%er. roo! en%iron!ent"
1u$$/e!enta/ o-.gen shou/d be initia//. $ro%ided ,ith a fra*tion of ins$ired
o-.gen 6=
7 of ) at a f/o, rate of 4-)( LJ!in" 0f su$$/e!enta/ o-.gen is to
be $ro%ided for a $ro/onged $eriod, heated hu!idified o-.gen shou/d be
su$$/ied %ia an o-.gen hood, ,ith the =
ad5usted to resu/t in $u/se-o-i!etr.
saturations of D'-D<3 in the ter! infant and 44-D'3 in the $reter! infant"
Ter! infants !a. a/so be resus*itated ,ith a =
of /ess than ), but this %a/ue
shou/d be in*reased if the infant does not i!$ro%e ,ithin D( se*onds" 0n
$re!ature infants, o-.gen shou/d be on a b/ender and b/ended u$ or do,n to
kee$ the saturation around D(3" 0f a b/ender is not a%ai/ab/e, an =
of )
shou/d be used; this has not been sho,n to be detri!enta/ to $re!ature infants
for a brief duration"
Positive)pressure ventilation
=or a nu!ber of reasons 6see Transition to E-trauterine Ph.sio/og.7, it *an be
diffi*u/t for the infant to */ear f/uid fro! the air,a.s and estab/ish air-fi//ed
/ungs" 0nitia/ res$irator. efforts !a. ha%e to be aug!ented b. the addition of
either *ontinuous $ositi%e air,a. $ressure 6CPAP7 or PPG"
Postresus*itati%e *are is the ter! used for the !anage!ent of infants ,ho
re2uire !ore e-tensi%e resus*itation" The addition of $ositi%e $ressure aids in
the de%e/o$!ent of fun*tiona/ residua/ *a$a*it. 6=RC7 and is needed !ore
*o!!on/. in $re!ature infants" e*hani*a/ /ung inf/ation is a/so i!$ortant to
re%erse $ersistent brad.*ardia in an a$nei* as$h.-iated infant" Ca// for
assistan*e ,hen beginning PPG if other tea! !e!bers are not a/read. in
0nfants ,ith ade2uate res$irations ,ho are e-$erien*ing res$irator. distress
6!anifested b. ta*h.$nea, grunting, f/aring, retra*ting, or $ersistent *entra/
*.anosis7 !a. benefit fro! $ositi%e end-e-$irator. $ressure 6PEEP7, CPAP, or
both" 0f the infant is a$nei*, is !aking inade2uate res$irator. efforts 6gas$ing7,
or has a heart rate /o,er than )(( beatsJ!in, PPG shou/d be initiated
i!!ediate/." 0nfants ,ho ha%e *ontinued *entra/ *.anosis des$ite su$$/e!enta/
o-.gen shou/d a/so re*ei%e PPG"
The idea/ bag is e2ui$$ed to de/i%er PEEP, and the a$$ro$riate/. sized !ask
shou/d be a$$/ied fir!/. to the fa*e" A T-$ie*e resus*itator de%i*e gi%es a
!easured $ressure through a !ask ,ith thu!b o**/usion and $ro%ides PEEP" 0t
has been sho,n to be 5ust as effe*ti%e as f/o,-inf/ating and se/f-inf/ating bags"
0t a//o,s !ore $re*ise de/i%er. of inf/ation $ressure and ins$irator. ti!es"
0n ter! infants, an =
of ) shou/d be used ,hen PPG is started" 0f an =
/ess than ) is used, this %a/ue shou/d be in*reased to ) if the infant does not
res$ond ,ithin D( se*onds" 0f su$$/e!enta/ o-.gen is not a%ai/ab/e, roo! air
shou/d be used to de/i%er PPG"
Pre!ature infants 6H A' ,k7 ,ho re2uire PPG shou/d begin ,ith o-.gen
*on*entrations bet,een roo! air and )((3 to !aintain an o-.he!og/obin
*on*entration of around D(3 as deter!ined b. $u/se o-i!etr." 0f the
o-.he!og/obin *on*entration rises to about DB3, o-.gen shou/d be ,eaned"
An. infant ,ho does not res$ond to PPG ,ith a heart rate of about )((
beatsJ!in shou/d be $/a*ed on an =
of ) and ha%e the !ask re$ositioned"
1o!e infants res$ond to brief !e*hani*a/ %enti/ation and subse2uent/. begin
inde$endent %enti/ation; others need *ontinued %enti/ator. su$$ort" 1uffi*ient,
but not e-*essi%e, initia/ $ressure !ust be used to ade2uate/. inf/ate the /ungs,
or e/se brad.*ardia and a$nea ,i// $ersist"
A $ressure !ano!eter shou/d a/,a.s be used ,ith a $ressure re/ease %a/%e,
/i!iting the $ositi%e $ressure to A(-&( *! ;
+ during the first breaths" This
!a. ha%e to be redu*ed to '(-'& *! ;
+ in $reter! infants ,ith an in*rease in
$ressures if the *hest does not rise or the heart rate does not ra$id/. in*rease"
To $ro%ide ade2uate distending $ressure, the infant !ust be $ro$er/.
$ositioned and the u$$er air,a. !ust be */eared of se*retions; the !ask !ust
be the *orre*t size and for! a tight sea/ on the fa*e"
?hen assisted breaths are being $ro%ided, the $ri!ar. !easure of ade2uate
initia/ %enti/ation is a ra$id in*rease in heart rate" A rise and fa// in the *hest
,a// !o%e!ent is not a/,a.s ade2uate/. assessed"
0f no *hest rise o**urs,
either the air,a. is b/o*ked or insuffi*ient $ressure is being generated b. the
s2ueezing of the bag"
Genti/ator. rates of &(-<( breathsJ!in shou/d be $ro%ided initia//., ,ith
$ro$ortiona//. fe,er assisted breaths $ro%ided if the infant>s s$ontaneous
res$irator. efforts in*rease" A/though this $ra*ti*e has not been e-tensi%e/.
studied, initia/ inf/ation of the ne,born>s /ungs ,ith either s/o,-rise or s2uare-
,a%e inf/ation to a $ressure of A(-&( *! ;
+ for a$$ro-i!ate/. B se*onds has
been re$orted to resu/t in !ore ra$id for!ation of =RC"
At the !o!ent of de/i%er. and first breath, the neonata/ /ung is *on%erting fro!
a feta/ nonaerated status to a neonata/ status" The neonata/ /ung has a
re2uire!ent for gas e-*hange, and this re2uires the de%e/o$!ent of =RC ,ith
the resor$tion of /ung f/uid and the reso/ution of !ost of the ate/e*tasis"
Therefore, initia/ s/o, %enti/ation ,ith !ore $ro/onged ins$irator. ti!es !a.
be usefu/ to assist in this task, ba/an*ed against the need to a%oid ina$$ro$riate
ins$irator. $ressures"
=/o,-*ontro//ed, $ressure-/i!ited !e*hani*a/ de%i*es are a**e$tab/e for
de/i%ering PPG" These !e*hani*a/ de%i*es *ontro/ f/o, and /i!it $ressure and
ha%e been sho,n to be !ore *onsistent than bags" 1e/f-inf/ating and f/o,-
inf/ating bags re!ain a standard of *are" Lar.ngea/ !ask air,a.s are effe*ti%e
for assisted %enti/ation ,hen bag-!ask %enti/ation and intubation are
Pre!ature infants are at high risk for /ung in5ur. fro! /arge-%o/u!e inf/ation"
onitoring the $ressure used in these $atients and $ro%iding *onsistent
inf/ations ,ithout high $ressures is essentia/" 0nitia/ inf/ation $ressures of '(-'B
*! ;
+ are usua//. ade2uate" ;igher $ressures !a. be needed if no
i!$ro%e!ent in heart rate or *hest !o%e!ent is noted" CPAP !a. be benefi*ia/
in $re!ature infants on*e the. are breathing s$ontaneous/."
The effe*ti%eness of assisted %enti/ation shou/d be e%a/uated b. obser%ing an
in*rease in heart rate" +ther signs that shou/d be !onitored in*/ude
i!$ro%e!ent in *o/or, s$ontaneous breathing, and i!$ro%e!ent in !us*/e tone"
A// of these signs shou/d be assessed ,ithin A( se*onds of PPG ad!inistration"
0nfants !a. re2uire tra*hea/ intubation if dire*t tra*hea/ su*tioning is re2uired,
effe*ti%e bag-!ask %enti/ation *annot be $ro%ided, *hest *o!$ressions are
$erfor!ed, endotra*hea/ 6ET7 ad!inistration of !edi*ations is desired,
*ongenita/ dia$hrag!ati* hernia is sus$e*ted, or a $ro/onged need for assisted
%enti/ation e-ists"
An a$$ro$riate b/ade 6i//er size ( or )7 shou/d be *hosen in a**ordan*e ,ith
the size of the infant" Pre!ature infants !a. be !ore easi/. intubated ,ith a
size ( b/ade, and ter! infants re2uire a size ) b/ade" An a$$ro$riate/. sized
endotra*hea/ tube shou/d be *hosen in a**ordan*e ,ith the ,eight of the infant
6see Tab/e A be/o,7"
Tab/e A" Endotra*hea/ Tube 1ize and easure!ent at Li$ A**ording to 0nfant
?eight 6+$en Tab/e in a ne, ,indo,7
*n&ant Weight Endotracheal Tu'e Si+e Endotracheal Tu'e ,easure#ent at -ip
H )((( g '"B C *!
)(((-'((( g '"B-A 4 *!
'(((-A((( g A-A"B D *!
K A((( g A"B-& )( *!
+n*e inserted, the ET tube shou/d be ad%an*ed unti/ the %o*a/ *ord guide !ark
near its dista/ ti$ is obser%ed to be s/ight/. $ast the %o*a/ *ords" This guide
!ark is $ositioned a %ariab/e distan*e fro! the dista/ ti$ 6de$ending on the tube
size7 and is designed to resu/t in the $/a*e!ent of the tube ti$ bet,een the %o*a/
*ords and the *arina at the bifur*ation of the right and /eft !ainste! bron*hi"
+n*e *orre*t/. $ositioned, the ET tube shou/d be se*ured and *ut to an
a$$ro$riate /ength to !ini!ize dead s$a*e and f/o, resistan*e"
Another ,a. of esti!ating *orre*t $/a*e!ent of the ET tube is to take the
,eight of the infant in ki/ogra!s and add < to .ie/d at the nu!ber of
*enti!eters at ,hi*h the tube shou/d be se*ured at the /i$" Before the tube is
se*ured, the infant shou/d be assessed for e2ua/ bi/atera/ breath sounds ,ith
!aintenan*e of o-.genation" An in*rease in the heart rate ,ithin B-)B se*onds
is an e-*e//ent indi*ator of ade2uate %enti/ation and a$$ro$riate ET tube
easure!ent of e-ha/ed *arbon dio-ide $ro%ides se*ondar. *onfir!ation"
Carbon dio-ide dete*tors use a *o/ori!etri* *hange to indi*ate e-ha/ation of the
gas" The use of su*h dete*tors is the on/. te*hni2ue that has been e%a/uated for
*onfir!ation of ET tube $/a*e!ent in infants and is therefore re*o!!ended"
?hen *arbon dio-ide dete*tors are used in infants ,ith $oor $u/!onar. b/ood
f/o, that *annot de/i%er suffi*ient *arbon dio-ide to the /ungs, a fa/se negati%e
resu/t !a. o**ur, /eading to unne*essar. e-tubation"
#/ti!ate/., ET tube $osition is *onfir!ed ,ith *hest radiogra$h." =ree-f/o,
o-.gen shou/d be $ro%ided throughout the $ro*edure, and effe*ti%e %enti/ation
shou/d be $ro%ided %ia the bag or %enti/ator after the infant is intubated"
%ardiovascular support and chest co#pressions
ost infants ,ho $resent at de/i%er. ,ith a heart rate /o,er than )(( beatsJ!in
res$ond to effe*ti%e %enti/ator. assistan*e b. ra$id/. in*reasing their heart rate
to nor!a/ /e%e/s" 0n *ontrast, if an effe*ti%e air,a. and effe*ti%e %enti/ation are
not estab/ished, further su$$ort is not effe*ti%e" Chest *o!$ressions shou/d be
initiated after on/. A( se*onds of effe*ti%e PPG if the heart rate re!ains be/o,
<( beatsJ!in"
An assess!ent of the heart rate *an be obtained through $a/$ation of the
u!bi/i*a/ stu!$ at the /e%e/ of insertion of the infant>s abdo!en or through
dire*t aus*u/tation of the $re*ordiu!" Chest *o!$ressions shou/d be
dis*ontinued as soon as the heart rate is higher than <( beatsJ!in"
Chest *o!$ressions !a. be $erfor!ed either b. *ir*/ing the *hest ,ith both
hands and using a thu!b to *o!$ress the sternu! or b. su$$orting the infant>s
ba*k ,ith one hand and using the ti$s of the !idd/e and inde- finger to
*o!$ress the sternu!" The thu!b te*hni2ue is $referred be*ause it a//o,s
better de$th *ontro/ during *o!$ressions" This te*hni2ue !a. a/so generate
higher $eak s.sto/i* and *oronar. $erfusion" The '-finger te*hni2ue !a. be
used ,hen a**ess to the u!bi/i*us is re2uired"
Pressure shou/d be a$$/ied to the /o,er $ortion of the sternu!, de$ressing it to
a de$th of about one third of the anterior-$osterior dia!eter" The *hest shou/d
fu//. ree-$and during re/a-ation, but the res*uer>s thu!bs shou/d not re!ain in
$/a*e" +ne %enti/ation shou/d be inter$osed after e%er. A *hest *o!$ressions"
An o%era// rate of )'( *o!$ressionJ%enti/ation e%ents $er !inute is
re*o!!ended; ,ith the A:) *o!$ression-to-%enti/ation ratio, this e2uates to D(
*o!$ressions and A( breaths ea*h !inute"
E%a/uate heart rate and *o/or e%er. A( se*onds" 0nfants ,ho fai/ to res$ond !a.
not be re*ei%ing effe*ti%e %enti/ator. su$$ort; thus, *onstant/. e%a/uating
%enti/ation is i!$erati%e" Chest *o!$ressions shou/d be dis*ontinued ,hen the
heart rate is <( beatsJ!in or higher"
Neonata/ resus*itation drugs shou/d be sto*ked in an. area ,here neonates are
resus*itated, in*/uding ea*h de/i%er. and stabi/ization area, as ,e// as the
e!ergen*. de$art!ent 6ED7" Personne/ shou/d be fa!i/iar ,ith neonata/
!edi*ations, *on*entrations, dosages, and routes of ad!inistration" Drugs
*urrent/. re*o!!ended in*/ude e$ine$hrine 6):)(,(((7 and isotoni* sodiu!
*h/oride so/ution 6("D37 as an intra%as*u/ar %o/u!e e-$ansion agent"
E$ine$hrine shou/d be *onsidered on/. ,hen the heart rate is be/o, <(
beatsJ!in and %enti/ation has been estab/ished and $ro%ided for at /east A(
se*onds" The on/. e-*e$tion to this ru/e !a. be in infants born ,ithout a
dete*tab/e $u/se or heart rate" The re*o!!ended dose is ("()-("(A !gJkg 6(")-
("A !L of the ):)(,((( so/ution7, $referab/. ad!inistered intra%enous/. 60G7"
;igher 0G doses are not re*o!!ended, and the $ostresus*itation h.$ertension
*ou/d $ut $re!ature infants at risk for intra%entri*u/ar he!orrhage"
0f %as*u/ar a**ess *annot be obtained, e$ine$hrine !a. be gi%en %ia the ET
tube, but in su*h *ases, the dose shou/d be in*reased to A ti!es the 0G dose"
Ensure that the s!a// %o/u!e is not de$osited on the ET tube *onne*tor or in
the /u!en of the tube" Ad!inistration of e$ine$hrine !a. be fo//o,ed ,ith
infusion of ("B-) !L of sa/ine to ensure that the drug is de/i%ered to the /ung,
,here it is absorbed and de/i%ered to the heart"
0f an u!bi/i*a/ %enous *atheter is used for !edi*ation ad!inistration, the
*atheter shou/d be inserted on/. as far as the $oint ,here b/ood f/o, is obtained
6usua//. A-B *!7" Be*ause the dosing re*o!!endations for e$ine$hrine in*/ude
ET ad!inistration, the need for e!ergent $/a*e!ent of u!bi/i*a/ %enous
*atheters has been redu*ed !arked/. in the de/i%er. roo!"
0n an editor>s note *o!!enting on an arti*/e addressing *ardio$u/!onar.
resus*itation in the de/i%er. roo!,
Catherine DeAnge/is ,rote, F9C:he*k the
air,a. 6o$ti!ize res$irator. su$$ort7 one !ore ti!e before *o!$ressing the
*hest" ore often than not, .ou and the infant *an then take dee$ breaths, and
.ou *an beat .our o,n *hest instead of the infant>s"F
0n the stud. des*ribed in this arti*/e, a$$ro-i!ate/. one third of the infants ,ith
neonata/ de$ression at birth had asso*iated feta/ a*ide!ia"
;o,e%er, in the
re!aining infants ,ithout feta/ a*ide!ia, *hest *o!$ressions ,ere initiated as a
*onse2uen*e of i!$ro$er or inade2uate %enti/ator. su$$ort at birth"
0n the $o$u/ation of infants ,ithout initia/ a*ide!ia, *hest *o!$ression or
e$ine$hrine thera$. ,as ineffe*ti%e"
The heart rate on/. i!$ro%ed after
effe*ti%e tra*hea/ intubation estab/ished a $atent air,a. or after in*re!enta/
in*reases in PPG e-*eeded the o$ening $ressure of the /ungs, estab/ishing
This stud. and others *ontinue to reinfor*e the $ri!ar. i!$ortan*e of the
estab/ish!ent of effe*ti%e %enti/ation" ?ithout %enti/ation, other thera$ies,
in*/uding !edi*ations, ,i// not be effe*ti%e in estab/ishing ade2uate heart rate
and $erfusion"
1odiu! bi*arbonate had $re%ious/. been re*o!!ended in the de/i%er. roo! to
re%erse the effe*ts of !etabo/i* a*idosis re/ated to h.$o-ia and as$h.-ia"
;o,e%er, studies sho, that ("D3 sa/ine $ro%ides better *ardia* and b/ood
$ressure su$$ort to *orre*t both the !etabo/i* a*idosis itse/f and the under/.ing
*ause of the a*idosis" #se of sodiu! bi*arbonate in the de/i%er. roo! has been
asso*iated ,ith an in*reased in*iden*e of intra%entri*u/ar he!orrhage in %er.
/o, birth ,eight infants"
The data are insuffi*ient to su$$ort re*o!!ending routine use of bi*arbonate in
neonata/ resus*itation" ;o,e%er, sodiu! bi*arbonate !a. be usefu/ in *ases of
$ro/onged arrest after ade2uate %enti/ation is estab/ished" A dose of ' !E2Jkg
!a. be ad!inistered 0G" 0f sodiu! bi*arbonate is used in the fa*e of a
$ersistent res$irator. a*idosis and e/e%ated $artia/ $ressure of *arbon dio-ide
7, the a*idosis is not *orre*ted"
Go/u!e e-$ansion !a. be used in neonates ,ith e%iden*e of a*ute b/ood /oss
or ,ith e%iden*e of sho*k of an. etio/og." 0n genera/, the neonata/ heart
res$onds ,e// to the in*rease in $re/oad at the atria/ /e%e/ *aused b. the %o/u!e
e-$ansion" ;.$o%o/e!ia !a. be !asked in a ne,born infant be*ause of the
signifi*ant $eri$hera/ %aso*onstri*tion *aused b. the e/e%ation in *ate*ho/a!ine
/e%e/s after de/i%er." 1.sto/i* b/ood $ressure a/so !a. be e/e%ated fa/se/. ,ith
The *urrent re*o!!endations for %o/u!e e-$ansion during resus*itation
in*/ude isotoni* sodiu! *h/oride so/ution or /a*tated Ringer so/ution, B3
a/bu!in, $/as!a $rotein fra*tion 6eg, P/as!anate7, or +-negati%e b/ood that has
been *ross-!at*hed ,ith the !other" ;o,e%er, be*ause of the ad%antages of
/ong she/f /ife, /o, *ost, and read. a%ai/abi/it., *ou$/ed ,ith the /a*k of
e%iden*e for the su$eriorit. of an. other agents, isotoni* sodiu! *h/oride
so/ution is the !ost fre2uent/. used agent for %o/u!e e-$ansion"
The *urrent/. re*o!!ended dosage of isotoni* sodiu! *h/oride so/ution for
%o/u!e e-$ansion is )( !LJkg 0G o%er B-)( !inutes; the so/ution !a. be
infused !ore *autious/. in e-tre!e/. $reter! infants" ?hen b/ood /oss is
kno,n, *onsider use of +-negati%e $a*ked red b/ood *e//s 6RBCs7" Restoring
the *riti*a/ o-.gen-* *a$a*it. is essentia/"
*##ediate Postresuscitation Period
,aintenance o& airway and ventilation
The goa/ of de/i%er. roo! !anage!ent is to stabi/ize the air,a. and ensure
effe*ti%e o-.genation and %enti/ation"
+n*e initia/ /ung re*ruit!ent is obtained, a%oiding o%erdistention is essentia/"
Breaths de/i%ered b. bag-!ask %enti/ation !a. be diffi*u/t to *ontro/ and !a.
resu/t in o%erdistention and *onse2uent $neu!othora- or $neu!o!ediastinu!"
Additiona//., the unheated nonhu!idified o-.gen *an 2ui*k/. *oo/ the infant
%ia the /arge surfa*e area of the /ungs, resu/ting in h.$other!ia" Therefore,
!e*hani*a/ %enti/ation shou/d be initiated as soon as $ossib/e on*e the infant is
A/though the idea/ !ode of assisted %enti/ation is *ontro%ersia/, $ro%iding
ade2uate $ositi%e end-e-$irator. $ressure 6PEEP7 to $re%ent ate/e*tasis, ,hi/e
at the sa!e ti!e $re%enting o%erinf/ation, is indi*ated" +n*e the a$$ro$riate
fun*tiona/ residua/ *a$a*it. 6=RC7 is obtained, it is essentia/ to use the /o,est
$ossib/e /e%e/ of su$$ort that sti// a//o,s ade2uate o-.genation and %enti/ation"
+-.gen saturation shou/d be !onitored *ontinua//. and arteria/ b/ood gas
ana/.sis $erfor!ed as needed during the initia/ stabi/ization $eriod" 1aturations
shou/d be !aintained in the D(-D<3 range for the ter! infant and in the 44-
D'3 range for the $reter! infant after the initia/ stabi/ization"
$luid and electrolyte #anage#ent
0n utero, nutrients are $ro%ided in their basi* for!" 8/u*ose is the !a5or energ.
substrate of the fetus" =eta/ g/u*ose u$take $ara//e/s !aterna/ b/ood g/u*ose
*on*entration" The /i%er, heart, and brain re*ei%e the greatest *ardia* out$ut and
*onse2uent/. the /argest a!ount of g/u*ose" The fetus uses g/u*ose, /a*tate, and
a!ino a*ids to store fue/s that are used during transition"
Neonates !ust de%e/o$ a ho!eostati* ba/an*e bet,een energ. re2uire!ents
and the su$$/. of substrate as the. !o%e fro! the *onstant g/u*ose su$$/. of
feta/ /ife to the nor!a/ inter!ittent su$$/. of g/u*ose and other fue/s that is
*hara*teristi* of e-trauterine /ife" ?ith the */a!$ing of the *ord, the !aterna/
g/u*ose su$$/. is *ut off" A fa// in b/ood g/u*ose during the first '-< hours of
/ife o**urs in hea/th. ne,borns" The b/ood g/u*ose usua//. rea*hes a nadir and
stabi/izes at B(-<( !gJdL"
The i!!ediate goa/s of f/uid and e/e*tro/.te su$$ort after resus*itation are to
!aintain an a$$ro$riate intra%as*u/ar %o/u!e and to a*hie%e g/u*ose
ho!eostasis and e/e*tro/.te ba/an*e" The neonata/ *ardio%as*u/ar s.ste! is
%er. sensiti%e to $re/oad, re2uiring ade2uate intra%as*u/ar %o/u!e to !aintain
ade2uate *ardia* out$ut" Therefore, e-$ansion of intra%as*u/ar %o/u!e ,ith
a$$ro$riate so/utions 6eg, isotoni* sodiu! *h/oride so/ution7 often is *onsidered
in the neonate ,ith inade2uate b/ood $ressure or $erfusion"
Additiona//., h.$og/.*e!ia !a. o**ur ra$id/. in *riti*a//. i// or $re!ature
infants" B/ood g/u*ose deter!inations shou/d be $erfor!ed as soon as $ossib/e,
and a *ontinuous infusion of g/u*ose shou/d be started at &-< !gJkgJ!in for
infants ,ho are unab/e to to/erate entera/ feedings"
De-trose bo/uses shou/d be /i!ited to s.!$to!ati* infants be*ause the. !a.
resu/t in transient h.$eros!o/arit. and rebound h.$og/.*e!ia" E/e*tro/.tes 6eg,
sodiu!, $otassiu!, and *h/oride7 shou/d not be added initia//., be*ause the
f/uid shifts fro! other bod. *o!$art!ents a//o, ade2uate e/e*tro/.te su$$/.
unti/ ade2uate rena/ fun*tion is do*u!ented"
The $ra*titioner shou/d !onitor the ,eight, */ini*a/ h.dration status, urine
out$ut, and seru! sodiu! *on*entrations */ose/. be*ause ina$$ro$riate f/uid
o%er/oad or restri*tion *an /ead to in*reased !orta/it. and !orbidit." The
infant>s en%iron!ent !ust be taken into a**ount in the *a/*u/ation of f/uid
re2uire!ents" =/uid !a. be started at a rate of <(-4( !LJkgJda. for the infant
in a hu!idified in*ubator, ,hereas it !a. ha%e to be gi%en at a !u*h higher
rate for the infant in a dr. radiant-,ar!er en%iron!ent"
Preparation &or transport
Pre$aration of the infant for transfer to a re!ote nurser. for *are after
resus*itation in%o/%es the fo//o,ing ke. *onsiderations 6see Trans$ort of the
Criti*a//. 0// Ne,born7:
• Co!$/ete a// the routine *are that is re2uired of ne,born infants; these
basi*s of *are !a. be neg/e*ted in the rush to $re$are the infant for
trans$ort, ,ith $otentia//. disastrous resu/ts
• 1e*ure a// /ines, tubes, *atheters, and /eads for trans$ort; !onitoring in
the trans$ort en%iron!ent is $ossib/e on/. ,ith fun*tioning /eads in
$/a*e, ,hi*h is fre2uent/. diffi*u/t to a**o!$/ish
• Pro%ide ra$id and *o!$/ete do*u!entation of the resus*itation and
subse2uent thera$ies for the use of future *aretakers
Special Pro'le#s "uring Resuscitation
A nu!ber of *ongenita/ and other neonata/ *onditions !a. $resent in the
de/i%er. roo! and !a. ha%e an effe*t on the *ourse of resus*itation" The !ost
i!$ortant of these are brief/. re%ie,ed be/o,"
Extre#e pre#aturity
Pre!ature infants ha%e s$e*ia/ needs that !ust be *onsidered during the *riti*a/
$eriod i!!ediate/. after de/i%er. if !orta/it. and !orbidit. are to be de*reased
in this grou$" This $o$u/ation is at in*reased risk for res$irator. fai/ure,
insensib/e ,ater /osses, h.$og/.*e!ia, and intra%entri*u/ar he!orrhage" A fu//
dis*ussion of the !an. diffi*u/ties of e-tre!e $re!aturit. is be.ond the s*o$e
of this arti*/e, but additiona/ infor!ation !a. be found e/se,here
6see Pre!aturit.7"
0nsensib/e ,ater /oss in the $re!ature infant is in*reased se*ondar. to the
infant>s $oor/. *ornified e$ider!is and i!!ature stratu! *orneu!, ,hi*h
$resents on/. an insignifi*ant barrier to e%a$orati%e heat /oss" The stratu!
*orneu! is not fun*tiona//. !ature unti/ A'-A& ,eeks> gestation" Differen*es in
skin !aturit., $renata/ nutritiona/ status, %enti/ation re2uire!ents, and
en%iron!enta/ *onditions a// !a. inf/uen*e the !agnitude of insensib/e ,ater
/oss that o**urs after birth"
The skin is the !ost i!$ortant route for ,ater de$/etion after de/i%er. of the
e-tre!e/. i!!ature infant" Transe$ider!a/ ,ater /oss 6TE?L7 is highest at
birth in infants ,ho are born before '4 ,eeks> gestation and de*reases s/o,/.
,ith ad%an*ing gestationa/ age" Des$ite de*/ines in TE?L ,ith ad%an*ing age,
infants born before '4 ,eeks> gestation *ontinue to ha%e in*reased TE?L for
&-B ,eeks after birth, *o!$ared ,ith infants born at ter!"
Be*ause of high e%a$orati%e /oss ,ith the a**o!$ heat /oss, the abi/it.
to a*hie%e and !aintain ther!oregu/ation is *o!$ro!ised further" The skin
barrier d.sfun*tion in*reases the risk of infe*tion, es$e*ia//. ,ith organis!s
that *o/onize the skin surfa*e 6eg, sta$h./o*o**a/ s$e*ies7" This thin skin barrier
a/so $/a*es the e-tre!e/. i!!ature infant at risk for to-i* rea*tions to to$i*a//.
a$$/ied substan*es" Additiona//., skin integrit. is easi/. disru$ted b. the use of
adhesi%es, ,hi*h shou/d be /i!ited in $re!ature infants"
Pre!ature infants need in*reased f/uid ad!inistration rates initia//. if the. are
on radiant ,ar!ers for a $ro/onged $eriod" ?ith in*reased $arentera/ f/uid
ad!inistration using de-trose-*ontaining f/uids, the de-trose !ust be
!onitored */ose/. to ensure eug/.*e!ia" P/a*ing infants in a hu!idified
en%iron!ent de*reases TE?L, i!$ro%es !aintenan*e of bod. te!$erature, and
does not de/a. skin !aturation"
easures to de*rease insensib/e ,ater /oss shou/d be initiated at de/i%er."
Be*ause radiant ,ar!ers are used routine/. at de/i%eries out of a need for
!a-i!a/ $atient a**ess, infants ,eighing /ess than )((( g shou/d be ,ra$$ed
in a $/asti* b/anket or other barrier to de*rease e%a$orati%e ,ater /oss unti/ the.
*an be $/a*ed in a hu!idified en%iron!ent" ;o,e%er, *are shou/d be taken to
ensure that the barrier does not b/o*k the trans!ission of heat fro! the radiant
Pre!ature infants are at risk for intra%entri*u/ar he!orrhage and $eri%entri*u/ar
/euko!a/a*ia 6PGL7 se*ondar. to their i!!ature *erebra/ %as*u/ar regu/ation
and the $ersisten*e of the ger!ina/ !atri-" These disorders often /ead to serious
$er!anent neurode%e/o$!enta/ disabi/ities"
Pre%ention of these *onditions or redu*tion of their se%erit. !a. begin in the
de/i%er. roo!" e*hani*a/ %enti/ation and f/uid ad!inistration !ust be
!anaged *autious/. in this grou$ of infants" Go/u!e e-$ansion shou/d be
ad!inistered on/. in the fa*e of true h.$otension" @no,/edge of nor!a/ b/ood
$ressure %a/ues for infants of %arious gestationa/ ages is essentia/" Go/u!e
e-$ansion in the fa*e of nor!a/ b/ood $ressure in*reases the risk of
intra%entri*u/ar he!orrhage"
Additiona//., it is i!$ortant to ad!inister an. h.$eros!o/ar !edi*ations 6eg,
sodiu! bi*arbonate7 s/o,/." e*hani*a/ %enti/ation !a. /ead to har!fu/
f/u*tuations in *erebra/ b/ood f/o,, es$e*ia//. ,hen the $artia/ $ressure of
*arbon dio-ide 6PC+
7 and $; are ra$id/. a/tered" Ra$id a/terations in
and $; resu/t in a*ute f/u*tuations in the *erebra/ b/ood f/o, of the
$re!ature infant ,ith i!!ature *erebra/ %as*u/ar autoregu/ation"
Pre!ature infants are a/so at high risk for %o/utrau!a *aused b. $oor /ung
*o!$/ian*e and o%er%enti/ation after the ad!inistration of e-ogenous
surfa*tants if *hanges in /ung *o!$/ian*e are not !onitored *arefu//."
+%er%enti/ation ,ith e-*essi%e tida/ %o/u!es and h.$o*arbia is asso*iated ,ith
*hroni* /ung disease"
1tabi/ization of the infant using the /o,est $eak ins$irator. $ressure 6P0P7 that
,i// sti// .ie/d ade2uate o-.genation and %enti/ation is essentia/" ;and
%enti/ation of an intubated infant, es$e*ia//. ,hen done b. ine-$erien*ed
$ersonne/, often /eads to in*onsistent tida/ %o/u!es and $ressures" #se of a
!e*hani*a/ %enti/ator designed for infants offers the ad%antages of !ore
*onsistent tida/ %o/u!es and a redu*tion of the heat /osses asso*iated ,ith the
use of unheated nonhu!idified air in hand %enti/ation"
A/though artifi*ia/ surfa*tant ad!inistration is asso*iated ,ith a redu*tion of
ad%erse se2ue/ae in infants, it !a. /ead to h.$er%enti/ation and o%erdistention
if not *arried out b. e-$erien*ed and attenti%e $ersonne/" After the insti//ation
of artifi*ia/ surfa*tant, $ersonne/ !ust re!ain a/ert so that the. *an rea*t
ra$id/. to *hanges in $u/!onar. *o!$/ian*e to $re%ent the onset of h.$o*arbia
and a/ka/osis"
After the institution of !e*hani*a/ %enti/ation, *are shou/d be taken ,ith air,a.
su*tioning be*ause %igorous or fre2uent air,a. su*tioning is asso*iated ,ith
h.$o-ia, intra%entri*u/ar he!orrhage, and $eri%entri*u/ar /euko!a/a*ia"
Pre!aturit. ,ith res$irator. distress s.ndro!e 6RD17 is not asso*iated ,ith
!u*us $rodu*tion in the first '& hours of /ife; thus, su*tioning $roto*o/s shou/d
be a/tered to $ro%ide !ini!a/ su*tioning during this ti!e"
!irway pro'le#s
Choanal atresia
Choana/ atresia is *aused b. a fai/ure of e!br.o/ogi* regression of nasa/ air,a.
tissue, ,hi*h resu/ts in $artia/ or *o!$/ete o**/usion of the nasa/ air,a." These
*hoana/ defe*ts !a. be bon. or !e!branous, ,ith !ost ha%ing a bon.
*o!$onent" Co!$/ete bi/atera/ stenosis usua//. resu/ts in a neonata/ res$irator.
e!ergen*. at birth be*ause infants genera//. are ob/igate nasa/ breathers during
the first <-4 ,eeks of /ife" At rest, these infants usua//. !anifest se%ere a$nea,
retra*tions, and res$irator. distress that !a. be re/ie%ed ,ith *"
?heezing or stridor !a. be audib/e ,ith ins$iration, and *o//a$se of the s!a//
air,a.s ,ith %igorous ins$irator. effort *an o**ur" The infant in res$irator.
distress shou/d be sti!u/ated to *r., and an artifi*ia/ ora/ air,a. !a. be used to
a%oid intubation" The */ini*a/ diagnosis is based on the inabi/it. to $ass a s!a//-
*a/iber *atheter through the nasa/ $assages" ;o,e%er, the a*t of $assing
*atheters, es$e*ia//. if re$eated, !a. *ause nasa/ $assage s,e//ing in an.
infant, and the subse2uent iatrogeni* o**/usion *an !i!i* the *ongenita/
An a/ternati%e nonin%asi%e !ethod of e-*/uding the diagnosis of *o!$/ete
atresia is to $/a*e a g/ass s/ide under the nasa/ orifi*es and /ook for fogging
,ith e-$iration" 1u$$/e!enta/ o-.gen shou/d be ad!inistered to infants ,ith
*hoana/ atresia, and an ora/ air,a. !a. be of assistan*e" 0f the infant re!ains
in signifi*ant res$irator. distress, intubation is ne*essar." 0ntubation re/ie%es
the obstru*tion so that /itt/e if an. %enti/ation ,i// be re2uired"
Pierre Robin syndrome
Pierre Robin s.ndro!e $resents ,ith !i*rognathia and resu/tant dis$/a*e!ent
of the tongue into the $osterior $har.n-, ,hi*h !a. o**/ude the u$$er air,a."
A *entra/ */eft of the soft $a/ate is usua//. $resent" Res$irator. distress and
*.anosis are *aused b. the obstru*tion of the u$$er air,a."
0n the de/i%er. roo!, the infant shou/d be gi%en su$$/e!enta/ o-.gen and
$/a*ed in a $rone $osition in an atte!$t to indu*e the tongue to !o%e for,ard
in a de$endent fashion fro! the $osterior $har.n- and thereb. re/ie%e the
air,a. obstru*tion" 0f the infant *ontinues to ha%e $ersistent res$irator.
distress, an ora/ air,a. !a. be $/a*ed"
A/ternati%e/., an a$$ro$riate/. sized endotra*hea/ 6ET7 tube !a. be $assed
through the nose into the h.$o$har.n-" Tra*heoto!ies are genera//. not
ne*essar. and shou/d be a%oided" 0ntubation of these infants often is not eas.,
be*ause %isua/ization of the /ar.n- is diffi*u/t"
Tracheal webbing
The $athogenesis of tra*hea/ ,ebbing originates in the )(th ,eek of gestation,
,hen an arrest in the de%e/o$!ent of the /ar.n- near the %o*a/ *ords resu/ts in a
residua/ ,eb of tissue $ersisting in the air,a." A$$ro-i!ate/. CB3 of tra*hea/
,ebs o**ur at the /e%e/ of the %o*a/ *ords" These /esions are *riti*a/ if !ore
than B(3 of the air,a. dia!eter is o**/uded, but this degree of o**/usion is
rare" Tra*hea/ ,ebs !a. be re/ati%e/. as.!$to!ati* at birth, ,ith the
de%e/o$!ent of distress /ater ,hen a*ti%it. in*reases and the need for air,a.
f/o, in*reases"
During atte!$ted intubation, an obstru*ti%e *o%ering !a. be obser%ed o%er the
/ar.n- and !a. o**/ude the air,a. *o!$/ete/." 0f this !e!brane is thin, the ET
tube !a. be $ushed be.ond the obstru*tion" 0f the !e!brane is thi*k, the infant
re2uires an e!ergen*. tra*heoto!." 0f the infant is in se%ere distress, a /arge-
bore need/e or *atheter !a. be $/a*ed in the tra*hea to a//o, gas e-*hange
,hi/e e!ergen*. treat!ent is being arranged for" 0ne-$erien*ed $ersonne/ !a.
*onfuse this rare disorder ,ith si!$/e inabi/it. to %isua/ize the %o*a/ *ords"
Esophageal atresia with or without tracheoesophageal fistula
Eso$hagea/ atresia is rare/. *onsidered a /ife-threatening e!ergen*.; ho,e%er,
ear/. diagnosis is essentia/ to $re%ent further *o!$/i*ation" 0t !a. be di%ided
into B t.$es as fo//o,s:
• T.$e 0 6eso$hagea/ atresia ,ith a dista/ fistu/a7 - This is the !ost
*o!!on t.$e 64B37; air is $resent in the sto!a*h; a b/ind u$$er
eso$hagea/ seg!ent is $resent, ,ith the dista/ seg!ent of the eso$hagus
*onne*ted to the tra*hea %ia a fistu/a
• T.$e 00 6eso$hagea/ atresia on/.7 - A b/ind u$$er and /o,er eso$hagea/
seg!ent is $resent; air is absent fro! the /o,er gastrointestina/ 6807
tra*t, but an air-fi//ed b/ind u$$er $ou*h !a. be obser%ed
• T.$e 000 6;-t.$e eso$hagea/ atresia7 - An iso/ated fistu/a *onne*ts the
eso$hagus and tra*hea, usua//. o**urring at the u$$er $ortion of the
tra*hea and eso$hagus
• T.$e 0G 6eso$hagea/ atresia ,ith a $ro-i!a/ fistu/a7 - This t.$e is rare;
an u$$er eso$hagea/ seg!ent is $resent ,ith a fistu/a to the tra*hea and a
b/ind /o,er eso$hagea/ seg!ent; air is absent fro! the /o,er 80 tra*t
• T.$e G 6eso$hagea/ atresia ,ith a doub/e fistu/a7 - This t.$e is rare; an
u$$er eso$hagea/ seg!ent is $resent ,ith a fistu/a to the tra*hea, and a
se*ond fistu/a *onne*ts the dista/ eso$hagus and tra*hea; air is $resent in
the sto!a*h
The !ost *o!!on */ini*a/ s.!$to!s of eso$hagea/ atresia ,ith or ,ithout a
tra*heoeso$hagea/ fistu/a in*/ude *oughing, *hoking, and *.anosis" 0nfants ,ith
iso/ated eso$hagea/ atresia usua//. do not de!onstrate res$irator. distress
i!!ediate/. in the de/i%er. roo! but !a. ha%e e-*ess se*retions" The atreti*
air-fi//ed eso$hagea/ $ou*h o**asiona//. !a. be obser%ed on a *hest
radiogra$h, !anifested b. a !idthora*i* rounded /u*en*." This $ou*h is
%isua/ized !ore readi/. b. the $assage of a radio$a2ue *atheter into the
eso$hagus before the *hest radiogra$h"
Be*ause se*retions or ora/ feedings *annot $ass into the sto!a*h, the *ontents
of the eso$hagea/ $ou*h readi/. ref/u-, $/a*ing these infants at high risk for
as$iration" A Re$/og/e su*tion *atheter shou/d be inserted to rea*h the
eso$hagea/ $ou*h and $/a*ed on /o, *ontinuous su*tion as soon as $ossib/e"
0nfants ,ith an asso*iated dista/ fistu/a to the tra*hea are a/so at high risk for
as$iration of gastri* *ontents into the /ungs %ia the gastrobron*hia/ fistu/a,
,hi*h !ost often e!$ties into the air,a. near the *arina"
0f at a// $ossib/e, $ositi%e-$ressure %enti/ation 6PPG7 shou/d be a%oided in these
infants" An. $ositi%e $ressure a$$/ied to the air,a. resu/ts in inf/ation of the
fistu/a, sto!a*h, and bo,e/, ,hi*h then resu/ts in abdo!ina/ distention" This
distending $ressure *annot be re/ie%ed b. eso$hagea/ ref/u- through the atreti*
eso$hagus" Re/ief of the distending $ressure o**urs ,ith ref/u- of gastri*
*ontents into the /ungs %ia the fistu/a" The *ontinued a$$/i*ation of PPG a/so
!a. /ead to !assi%e gastri* distention and $ossib/e ru$ture"
0n rare e!ergen*. situations, $er*utaneous gastroto!. !a. be re2uired to
de*o!$ress the sto!a*h; ho,e%er, *ontro//ed surgi*a/ $/a*e!ent of a
gastrosto!. tube is $referab/e"
Cystic adenomatoid malformation
C.sti* adeno!atoid !a/for!ations of the /ung are !asses that !a. *ause a
s$e*tru! of s.!$to!s, fro! !assi%e !ediastina/ shifts in the fetus 6resu/ting
in $u/!onar. h.$o$/asia7 to iso/ated subseg!enta/ /obar !asses in the ne,born
6or adu/t7 ,ith !ini!a/ asso*iated s.!$to!s" 1e%ere /esions a/so !a. *ause
feta/ *ardia* *o!$ro!ise and resu/t in h.dro$s"
0f the infant re2uires PPG, e-tre!e *aution !ust be used, be*ause the
distending $ressure !a. inf/ate the *.sti* !a/for!ation" An inf/ated *.sti*
!a/for!ation is *a$ab/e of !assi%e e-$ansion, *ausing res$irator.
e!barrass!ent be*ause of the $re%ention of %enti/ation of other nor!a/ /ung
Cystic hygromas
C.sti* h.gro!a is the resu/t of a *ongenita/ defor!it. of the /.!$hati*
*hanne/s" L.!$h a**u!u/ates and !a. *o!$ress the air,a., de$ending on the
size and /o*ation of the /.!$h a**u!u/ation" A$$ro-i!ate/. 4(3 of these
/.!$hati* *.sti* a**u!u/ations o**ur in the ne*k and !a. *o!$ress the
These infants !a. $resent ,ith signifi*ant res$irator. distress and !a. re2uire
i!!ediate intubation ,ith dee$ $ositioning of the ET tube to re/ie%e the
obstru*tion b. stenting o$en the air,a." ;o,e%er, !ost of these /esions e-$and
out,ard fro! the ne*k and do not *ause signifi*ant air,a. *o!$ro!ise in the
de/i%er. roo!"
Pul#onary co#pression
Congenital diaphragmatic hernia
The $athogenesis of *ongenita/ dia$hrag!ati* hernia in%o/%es the in*o!$/ete
for!ation of the dia$hrag! in the fetus, resu/ting in a !igration of the
abdo!ina/ %is*era into the *hest during de%e/o$!ent" 0f the defe*t is /arge and
the abdo!ina/ %is*era ha%e *aused /ong-standing *o!$ression of the
de%e/o$ing /ungs, $u/!onar. h.$o$/asia !a. de%e/o$"
The diagnosis of dia$hrag!ati* hernia is fre2uent/. estab/ished b. !eans of
$renata/ u/trasonogra$h., ,hi*h a//o,s !anage!ent to be transferred to a
$erinata/ referra/ *enter ,here $ediatri* surger. and a$$ro$riate !edi*a/
su$$ort, in*/uding e-tra*or$orea/ b.$ass, are a%ai/ab/e" 0n the de/i%er. roo!,
the infant often $resents ,ith res$irator. distress"*a/ signs !a. in*/ude a
s*a$hoid abdo!en and a shift in heart sounds to the right he!ithora-"
Res$irator. distress in the de/i%er. roo! !a. be *aused b. $u/!onar.
h.$o$/asia or !a. be se*ondar. to e-$ansion of the bo,e/ *aused b.
s,a//o,ed air" The e-$ansion of the bo,e/ resu/ts in *o!$ression of the /ung"
De/i%er. roo! !anage!ent in*/udes i!!ediate intubation and $assage of a
/arge *atheter for gastri* de*o!$ression" 0ntubation $re%ents distention of the
sto!a*h and bo,e/ *ontents be*ause of * or bag-%a/%e-!ask %enti/ation"
The gastri* de*o!$ression shou/d be a*hie%ed ,ith a Re$/og/e or 1a/e! $u!$
su*tion *atheter *onne*ted to a /o, *ontinuous drain" Constant !aintenan*e of
gastri* su*tion during the $reo$erati%e and i!!ediate $osto$erati%e $eriods is
Ne, !odes of %enti/ation, su*h as high-fre2uen*. os*i//ator. %enti/ation
6;=+G7, ha%e de*reased the use of e-tra*or$orea/ !e!brane o-.genation
6EC+7 in this $o$u/ation" ;o,e%er, the sur%i%a/ rate for infants ,ith this
ano!a/. has not *hanged o%er the $ast de*ade"
Pneumothorax and pneumomediastinum
Air /eak s.ndro!es are disorders $rodu*ed ,hen a ru$ture of $u/!onar. tissue
o**urs, /eading to the es*a$e of air into s$a*es ,here air ,ou/d not nor!a//. be
$resent" The in*iden*e of $neu!othora- %aries ,ith gestationa/ age, se%erit. of
$u/!onar. disease, need for assisted %enti/ation, !ode of %enti/ation, and
e-$ertise of de/i%er. roo! $ersonne/"
After the initia/ ru$ture of a s!a// air,a. or an a/%eo/us, air !a. enter the
$eri%as*u/ar and $eribron*hia/ s$a*es and tra*k a/ong the /.!$hati* *hanne/s"
Air that disse*ts into the hi/u! resu/ts in a $neu!o!ediastinu!; air that tra*ks
into the $/eura/ s$a*e !anifests as a $neu!othora-" 1$ontaneous ru$ture of the
/ung dire*t/. into the $/eura/ s$a*e is thought to o**ur rare/. but !a. be *aused
iatrogeni*a//. b. the $er*utaneous insertion of a *hest tube" Caution is re2uired"
Pneu!o!ediastinu! fre2uent/. is an iso/ated disorder that o**urs
s$ontaneous/. in infants ,ith !ini!a/ $u/!onar. disease" These infants
usua//. are as.!$to!ati* or !ini!a//. s.!$to!ati* be*ause the air in the
!ediastinu! *an es*a$e to the tissues of the ne*k" 0ntrathora*i* tension is
re/ie%ed, and *ir*u/ation is not *o!$ro!ised" 0nfants ,ith a
$neu!o!ediastinu! shou/d be obser%ed" 0nter%ention usua//. is unne*essar."
Pneu!othora- !a. o**ur i!!ediate/. in the de/i%er. roo! or /ater, ,hen
signifi*ant $u/!onar. disease has de%e/o$ed" Pneu!othora- often is asso*iated
,ith PPG, but it a/so !a. o**ur in infants ,ho are not re*ei%ing assisted
%enti/ation" After the initia/ air /eak, the subse2uent e-$ansion of intrathora*i*
s$a*es often resu/ts in a ra$id in*rease of intrathora*i* $ressure to the $oint
,here the /ungs *annot be %enti/ated and %enous b/ood *annot be returned to
the heart" This *ondition is ter!ed a tension $neu!othora-"
The ra$id */ini*a/ deterioration of infants ,ith this *ondition is *aused b.
*ir*u/ator. *o//a$se and inabi/it. to %enti/ate" An. infant ,ho has a sudden
$re*i$itous *hange in %enti/ator. status asso*iated ,ith an abru$t fa// in b/ood
$ressure shou/d i!!ediate/. be e%a/uated for a $neu!othora-"
Transi//u!ination of the *hest !a. be used for the ra$id diagnosis of se%ere
tension $neu!othora-" ?hen the */ini*a/ situation a//o,s it, radiogra$h.
shou/d be $erfor!ed to estab/ish or *onfir! the diagnosis"
0nfants in a*ute distress shou/d undergo need/e as$iration to e%a*uate the
e-tra$u/!onar. air ,hi/e $re$arations are !ade to $/a*e a *hest tube"
1.!$to!ati* $neu!othora- is !anaged ,ith the insertion of a *hest tube unti/
the $u/!onar. /eak is reso/%ed" A *hest tube !a. not be re2uired if the
$neu!othora- is s!a// and the infant is not re*ei%ing PPG" 1u$$/e!enta/
o-.gen 6fra*tion of ins$ired o-.gen 6=
7 of )7 often is ad!inistered for <-)'
hours to hasten reabsor$tion of the tra$$ed intra$/eura/ air"
,iscellaneous conditions
Multiple gestation
The de/i%er. and subse2uent resus*itation of !u/ti$/e infants $resents a
*onsiderab/e *ha//enge to the /abor and de/i%er. tea!" The first *onsideration to
be addressed ,ith the initia/ $renata/ diagnosis of!u/ti$/e births is to ensure
that *are is being $ro%ided at an institution *a$ab/e of ade2uate/. su$$orting
both the !other and !u/ti$/e infants at de/i%er."
A !ini!u! of ' e-$erien*ed staff !e!bers shou/d be a%ai/ab/e for ea*h infant"
u/ti$/e-gestation infants are often born $re!ature/. 6es$e*ia//. ,ith higher-
order gestation7, and !ore $ersonne/ !a. be re2uired for ea*h infant"
Therefore, for higher-order gestation in%o/%ing tri$/ets or !ore, $re$aration to
ensure the $resen*e of a$$ro$riate $ersonne/ and e2ui$!ent !ust be $/anned
,e// in ad%an*e of the de/i%er."
The tea! shou/d be /ed and organized b. a designated e-$erien*ed /eader, and
the $/anning $hase shou/d in%o/%e hea/th*are $ro%iders fro! a nu!ber of
dis*i$/ines, in*/uding neonato/ogists, $erinato/ogists, nurse $ra*titioners,
$ediatri*ians, nurser. and obstetri*s nurses, res$irator. thera$ists, and
$har!a*ists" The de/i%er. tea! shou/d *onsist of indi%idua/s ,ho are $re$ared
to !ake *o!$/e- de*isions, $erfor! te*hni*a/ ski//s, and res$ond 2ui*k/. to
*hanging *ir*u!stan*es"
+rganization and tea!,ork are essentia/, ,ith ade2uate $ersonne/
$ros$e*ti%e/. identified as designated res$onders to ea*h infant" 1u*h
$re$arations are be*o!ing !ore *o!!on$/a*e, no, that assisted *on*e$tion is
gi%ing rise to an in*reasing nu!ber of !u/ti$/e-birth $regnan*ies"
?hen $re$aring for the resus*itation of an infant ,ith h.dro$s feta/is, suffi*ient
ski//ed $ersonne/ !ust be in the de/i%er. roo! to ensure that the !u/ti$/e needs
of this signifi*ant/. *o!$ro!ised neonate *an be !et" E2ui$!ent shou/d be
$re$ared before the de/i%er., and a// $ersonne/ in the roo! shou/d be assigned
s$e*ifi* $ro*edures, su*h as $ara*entesis or thora*entesis 6if re2uired7" These
$ro*edures !a. ha%e to be $erfor!ed i!!ediate/. if the f/uid a**u!u/ation is
*ausing diffi*u/ties in %enti/ation"
0f the h.dro$s is *aused b. ane!ia, b/ood for transfusion shou/d be a%ai/ab/e in
the de/i%er. roo!" Be*ause of the e-*ess f/uid in the /ungs, it is often ne*essar.
to use high $ressures and o-.gen initia//." Artifi*ia/ surfa*tant ad!inistration
a/so has been e!$/o.ed in the de/i%er. roo! to treat an. surfa*tant defi*ien*.
in an atte!$t to i!$ro%e $u/!onar. fun*tion" #!bi/i*a/ %enous and arteria/
/ines shou/d be $/a*ed and *entra/ %enous $ressures !onitored"
mphalocele and gastroschisis
8astros*hisis is an abdo!ina/ ,a// defe*t /atera/ to the u!bi/i*us that does not
ha%e a sa* or !e!brane *o%ering the bo,e/" 0n *ontrast, an o!$ha/o*e/e
in%o/%es herniation of the bo,e/ through the u!bi/i*a/ o$ening, ,ith the bo,e/
*o%ered b. a thin !e!brane, un/ess the !e!brane has been ru$tured during
=or both o!$ha/o*e/e and gastros*hisis, !aintain ade2uate intra%as*u/ar f/uid
%o/u!e, !aintain ther!oregu/ation, and $re%ent bo,e/ is*he!ia"
Preo$erati%e/., infants ,ith these *onditions ha%e in*reased f/uid re2uire!ents
un/ess the bo,e/ is a$$ro$riate/. ,ra$$ed ,ith an airtight !ateria/"
The bo,e/ !a. be first ,ra$$ed ,ith ,ar!ed sa/ine-soaked gauze" Care
shou/d be taken to su$$ort the bo,e/ and not *o!$ro!ise b/ood f/o," +bser%e
the bo,e/ */ose/. to ensure that no areas are *o!$ro!ised as a resu/t of the
bo,e/ t,isting" A )( =ren*h Re$/og/e or 1a/e! $u!$ su*tion *atheter shou/d
be $/a*ed on /o, *ontinuous su*tion to de*o!$ress the bo,e/ and $re%ent
further is*he!i* in5ur."
0f the infant is diagnosed ,ith an o!$ha/o*e/e, the b/ood g/u*ose /e%e/ shou/d
be assessed be*ause this defe*t !a. be asso*iated ,ith Be*k,ith-?iede!ann
s.ndro!e" Triso!. )4 is asso*iated ,ith this ano!a/." Therefore, if the
*ondition is re*ognized $renata//., a!nio*entesis for *hro!oso!a/ ana/.sis
shou/d be offered to the fa!i/." 0f *hro!oso!a/ infor!ation is not a%ai/ab/e at
the ti!e of de/i%er. and there are other ano!a/ies *onsistent ,ith triso!. )4,
surger. shou/d be de/a.ed unti/ a *o!$/ete geneti* e%a/uation is *o!$/ete"
Congenital anomalies
1e%ere !a/for!ations obser%ed in the de/i%er. roo! shou/d not a/ter
resus*itati%e !anage!ent un/ess ski//ed and e-$erien*ed *are $ro%iders are
ab/e to deter!ine that the *ondition is in*o!$atib/e ,ith /ife" The fa!i/. shou/d
be in%o/%ed in an. de*ision in%o/%ing the ,ithho/ding of resus*itation" 0nfants
,ith se%ere !a/for!ations shou/d be resus*itated and stabi/ized unti/ an
a**urate diagnosis *an be !ade"
%ontroversies in Resuscitation
The de%e/o$!ent of a *ertifi*ation $rogra! has /ed to the standardization of
neonata/ resus*itation" E%a/uation of the *urrent standards is an ongoing
$ro*ess" As ne, resear*h is $ub/ished, it is essentia/ to assess the 2ua/it. of the
studies and to deter!ine ,hether the e%iden*e is suffi*ient to !andate *hanges
in $ra*ti*e" E%en ,ith the *urrent standardization, there re!ain so!e i!$ortant
*ontro%ersies and *on*erns in resus*itation"
Roo# air versus .//0 oxygen
+-.gen is a drug ,ith $otentia//. serious ad%erse effe*ts that !ust be
*onsidered" +-.gen free radi*a/s are *a$ab/e of tissue in5ur. and ha%e been
i!$/i*ated in se%era/ disease states in the neonate" The use of /o,er o-.gen
*on*entrations in neonata/ resus*itation !a. de*rease the nu!ber of o-.gen
free radi*a/s and their da!aging ad%erse effe*ts"
0n one stud., resus*itation ,ith roo! air ,as sho,n to be as effe*ti%e as )((3
o-.gen at /o,ering $u/!onar. %as*u/ar resistan*e" +ther in%estigations ha%e
sho,n that there is no benefit to raising the $artia/ $ressure of o-.gen 6P+
abo%e B( !! ;g" A '()) !eta-ana/.sis *on*/uded that the /iterature ,as
insuffi*ient to su$$ort an. state!ent regarding the su$eriorit. of o-.gen or
roo! air as the initia/ gas !i-ture for neonata/ resus*itation"
A/though /arge *ontro//ed !u/ti*enter tria/s indi*ate that roo! air 6fra*tion of
ins$ired o-.gen 9=
7 L ("')7 is 5ust as effe*ti%e as )((3 o-.gen in
resus*itating ter! infants, /ong-ter! out*o!es are $ending" The on/. fo//o,-u$
stud. /ooking at these infants at )4-'& !onths sho,ed no signifi*ant differen*e
in so!ati* gro,th or neuro/ogi* handi*a$s bet,een infants resus*itated in roo!
air and infants re*ei%ing )((3 o-.gen"
The *urrent *onsensus is that su$$/e!enta/ o-.gen shou/d be $ro%ided
,hene%er $ositi%e-$ressure %enti/ation 6PPG7 is re2uired during resus*itation"
=ree-f/o,ing o-.gen shou/d a/so be used in infants ,ith *entra/ *.anosis"
C/ini*ians !a. begin resus*itation ,ith an o-.gen *on*entration of /ess than
)((3 and !a. e%en *onsider starting ,ith roo! air as ne, resear*h data
be*o!e a%ai/ab/e"
Resear*h studies indi*ate that the i!!ediate out*o!es of these ' a$$roa*hes
are si!i/ar in ter! infants ,ithout under/.ing /ung disease" 0n genera/, the data
suggest that in situations ,here )((3 o-.gen is not a%ai/ab/e, resus*itation
shou/d $ro*eed ,ith the use of roo! air and a se/f-inf/ating bag"
Ti#ing o& arti&icial sur&actant ad#inistration
1urfa*tant defi*ien*., the $ri!ar. fa*tor in the de%e/o$!ent of res$irator.
distress s.ndro!e 6RD17, is the !ost *o!!on *ause of $ersistent and
$rogressi%e res$irator. distress in $re!ature infants"
Contro//ed, rando!ized */ini*a/ studies ha%e sho,n that $ro$h./a*ti*
ad!inistration of e-ogenous surfa*tant to $re!ature infants effe*ti%e/. redu*es
death se*ondar. to RD1" 1tudies ha%e a/so sho,n that treat!ent of on/. infants
,ho de%e/o$ RD1 s.!$to!s .ie/ds a signifi*ant redu*tion in death se*ondar.
to RD1" Pro$h./a*ti* dosing of artifi*ia/ surfa*tant is $erfor!ed in the de/i%er.
roo! before the first breath or ,ithin )B !inutes after birth"
Contro%ersies re/ated to $ro$h./a*ti* artifi*ia/ surfa*tant use are re/ated to the
interru$tion of the standard resus*itation $aradig! for the ad!inistration,
treat!ent, and attendant risk !anage!ent of a $o$u/ation of infants ,ho ,ou/d
not de%e/o$ RD1, as ,e// as the additiona/ *osts re/ated to this dosing s*he!e"
The argu!ent for $ro$h./a*ti* surfa*tant dosing is that treated infants ,ho
re2uire surfa*tant re$/a*e!ent ha%e !ore unifor! and effe*ti%e drug
distribution ,hen the /ungs are f/uid-fi//ed and do not ha%e air-f/uid interfa*es"
+b%ious/., treat!ent of on/. infants ,ith a *onfir!ed diagnosis of RD1 resu/ts
in a s!a//er nu!ber of infants being treated" The $ro$ortion of infants gi%en
$ro$h./a*ti* artifi*ia/ surfa*tant thera$. ,ho ,ou/d not de%e/o$ RD1 de$ends
on the entr. *riteria for $ro$h./a*ti* treat!ent and on $o$u/ation
1tudies ha%e de!onstrated that ear/. $ro$h./a*ti* dosing of surfa*tant is
effi*a*ious and is asso*iated ,ith better out*o!es in e-tre!e/. $re!ature
infants" Resear*hers ha%e re*o!!ended that ,hene%er $ossib/e, infants ,ith
surfa*tant defi*ien*. shou/d be identified before de/i%er. b. using the /e*ithin-
s$hingo!.e/in ratio or testing for the $resen*e of $hos$hatid./g/.*ero/"
Resear*hers a/so suggest that a// infants de/i%ered ear/ier than A( ,eeks>
gestation shou/d re*ei%e their first dose of surfa*tant in the de/i%er. roo!
,ithin the first fe, !inutes of /ife, after *ardio$u/!onar. stabi/ization" 0nfants
born /ater than A( ,eeks> gestation shou/d re*ei%e res*ue thera$. as soon as
the. sho, */ini*a/ signs of RD1" 0nfants born at A(-A< ,eeks> gestation !a.
benefit fro! surfa*tant ,ith ra$id e-tubation to *ontinuous $ositi%e air,a.
$ressure 6CPAP7"
9)), )', )A, )&:
*ntu'ation and suctioning &or #econiu# aspiration
e*oniu!-stained a!nioti* f/uid 61A=7 is $resent in )(-)B3 of a// de/i%eries
but is rare/. seen before A& ,eeks> gestation" +f ne,borns born through 1A=,
<(3 re2uire stabi/ization or resus*itation" +f these <(3, A-&3 are diagnosed
,ith !e*oniu! as$iration s.ndro!e 6A17" e*oniu! as$iration in a
ne,born *an /ead to ate/e*tasis, o%erdistention of the a/%eo/i, $neu!othora-,
$neu!onitis, surfa*tant defi*ien*., and $ersistent $u/!onar. h.$ertension"
orta/it. is as high as B-)(3 in these infants"
Trained $ersonne/ shou/d be in attendan*e at a// !e*oniu!-stained de/i%eries"
1u*tioning of the oro$har.n- and nasa/ $har.n- on*e the head is de/i%ered is
no /onger re*o!!ended" A /arge, !u/ti*enter, rando!ized tria/ ,ith 'B)&
infants sho,ed that intra$artu! su*tioning did not de*rease the risk of A1"
The *urrent Neonata/ Resus*itation $rogra! 6NRP7 guide/ines and
re*o!!endations no /onger ad%ise routine intra$artu! oro$har.ngea/ and
naso$har.ngea/ su*tioning for infants born to !others ,ith 1A="
A !u/ti*enter, $ros$e*ti%e, rando!ized, *ontro//ed tria/ *on*/uded that
regard/ess of the t.$e of !e*oniu!, %igorous infants 6defined as those ,ith a
strong res$irator. effort, good !us*/e tone, and a heart rate higher than )((
beatsJ!in7 are not at in*reased risk for A1 if the. are not intubated and
The stud. a/so indi*ated that de$ressed infants, regard/ess of the
t.$e of !e*oniu!, do benefit fro! intubation and su*tioning before the
initiation of PPG"
De$ressed infants shou/d be $/a*ed on a radiant heat sour*e, and no or
sti!u/ation shou/d be $ro%ided unti/ the. are intubated and dire*t tra*hea/
su*tioning is $erfor!ed" A !e*oniu! as$irator shou/d be a$$/ied dire*t/. to the
endotra*hea/ 6ET7 tube, and a *ontinuous $ressure of )'(-)B( !! ;g shou/d
be a$$/ied as the tube is re!o%ed" 0f !e*oniu! is obtained, the heart rate !ust
be e%a/uated before a se*ond intubation is $erfor!ed" ?ith the se*ond
intubation, $ro%ision of PPG through the ET tube !a. be *onsidered after
+n*e an infant has been stabi/ized, intubation and su*tioning *an be $erfor!ed
again" Resear*hers ha%e stated that !e*oniu! *an be su*tioned fro! the
tra*hea u$ to an hour or e%en /onger after birth" Note that infants ,ho are
%igorous at de/i%er. and then !anifest res$irator. distress or be*o!e de$ressed
shou/d a/so undergo intubation and su*tioning before initiation of PPG, if
!e*oniu! ,as $resent"
Pre/i!inar. studies sho, $otentia/ benefits fro! using di/ute surfa*tant /a%age
in infants ,ith A1" 1urfa*tant is ina*ti%ated b. !e*oniu!, and surfa*tant
/a%age !a. ,ash out the residua/ !e*oniu!, i!$ro%e !u*o*i/iar. re!o%a/,
and !itigate the residua/ effe*ts on e-ogenous surfa*tant"
Resear*h has sho,n that infants ,ho re*ei%e surfa*tant re$/a*e!ent thera$.
,ithin < hours of de/i%er. ha%e i!$ro%ed o-.genation and a redu*ed in*iden*e
of air /eaks, $u/!onar. !orbidit., and /ength of sta.; ho,e%er, further studies
are sti// ne*essar. before this a$$roa*h *an be re*o!!ended as standard *are"
Current data are insuffi*ient to su$$ort re*o!!endation of s.ste!i* or head
*oo/ing for infants ,ith sus$e*ted as$h.-ia" 1tud. resu/ts are *onf/i*ting" +ne
!u/ti*enter tria/ did not sho, a differen*e in the nu!ber of sur%i%ors ,ith
se%ere disabi/ities ,hen head *oo/ing ,as used" Another /arge !u/ti*enter tria/
that e%a/uated s.ste!i* h.$other!ia found a signifi*ant de*rease in death or
!oderate disabi/it. at age )' !onths and )4 !onths, as did a s!a//er tria/"
;.$other!ia *arries risks of!ias, b/eeding, thro!bosis, and se$sis;
ho,e%er, *urrent studies of !odest h.$other!ia ha%e not re$orted these
*o!$/i*ations" =uture */ini*a/ tria/s are needed to deter!ine the benefits of
h.$other!ia and to *o!$are !ethods of *oo/ing" A%oiding h.$erther!ia in
infants ,ho ha%e suffered a h.$o-i*-is*he!i* e%ent at birth is essentia/" 1tudies
ha%e sho,n that h.$erther!ia of '-AM *an ,orsen out*o!e"
Withholding and discontinuing resuscitation
Neonata/ !orbidit. and !orta/it. %ar. throughout the #nited 1tates" The
obstetri* and neonata/ tea!, in *on5un*tion ,ith the $arents, shou/d de*ide
,hether and ,hen to ,ithho/d or dis*ontinue resus*itati%e efforts" 0nfants
,hose gestationa/ age, birth ,eight, and *ongenita/ ano!a/ies are asso*iated
,ith *ertain death shou/d not be resus*itated" These !a. in*/ude infants ,ith
e-tre!e $re!aturit. 6H 'A ,eeks> gestation7, e-tre!e/. /o, birth ,eight 6H &((
g7 or *hro!oso!a/ ano!a/ies in*onsistent ,ith /ife 6eg, triso!. )A7"
0n other situations ,here the $rognosis is un*ertain but the asso*iated !orbidit.
is high, $arenta/ desires shou/d be *onsidered" Dis*ontinuing resus*itation !a.
be 5ustified in infants ,ho ha%e not res$onded to *ontinuous and a$$ro$riate
resus*itation for a fu// )( !inutes and ,ho ha%e no heart rate or res$irator.
effort 6ie, no signs of /ife7"

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