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Neonatal Resuscitation

By

Robert L. Stavis

, PhD, MD

Last full review/revision Jul 2019| Content last modified Jul 2019
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Extensive physiologic changes accompany the birth process, sometimes unmasking conditions that posed no problem during intrauterine life. For that reason, a person with neonatal resuscitation skills must attend each birth. Gestational age and growth parameters help identify the risk of neonatal pathology.

About 10% of neonates require some respiratory assistance at birth. Less than 1% need extensive resuscitation. There are numerous causes of depression requiring resuscitation at birth (see Table: Problems in the Neonate That May Require Resuscitation). The need for resuscitation rises significantly if birthweight is < 1500 g.

Table
icon

Problems in the Neonate That May Require Resuscitation

Problem

Possible Causes

Failure to breathe

Antepartum mechanism

Maternal toxemia

Recent intrapartum asphyxia

Cord compression

Fetal exsanguination

Maternal hypotension

Uterine tetany

Central nervous system depression

Drugs

Analgesics or hypnotics

Anesthetics

Magnesium sulfate

Failure to expand the lungs

Airway obstruction

Blood

Mucus

Malformations involving the respiratory tract

Agenesis

Hypoplasia

Stenosis or atresia

Apgar score

The Apgar score is used to describe a neonate's cardiorespiratory and neurologic condition at birth. The score is not a tool to guide resuscitation or subsequent treatment and does not determine the prognosis of an individual patient.

The Apgar score assigns 0 to 2 points for each of 5 measures of neonatal health (Appearance, Pulse, Grimace, Activity, Respiration—see Table: Apgar Score). Scores depend on physiologic maturity and birthweight, maternal perinatal therapy, and fetal cardiorespiratory and neurologic conditions. A score of 7 to 10 at 5 minutes is considered normal; 4 to 6, intermediate; and 0 to 3, low.

There are multiple possible causes of low (0 to 3) Apgar scores, including severe, chronic problems that have a poor prognosis and acute problems that can be quickly resolved and have a good prognosis. A low Apgar score is a clinical finding and not a diagnosis.

Table
icon

Apgar Score

Score*

Criteria

Mnemonic

0

1

2

Color

Appearance

All blue, pale

Pink body, blue extremities

All pink

Heart rate

Pulse

Absent

< 100 beats/minute

> 100 beats/minute

Reflex response to nasal catheter/tactile stimulation

Grimace

None

Grimace

Sneeze, cough

Muscle tone

Activity

Limp

Some flexion of extremities

Active

Respiration

Respiration

Absent

Irregular, slow

Good, crying

*A total score of 7–10 at 5 minute is considered normal; 4–6, intermediate; and 0–3, low.

Resuscitation

Neonatal resuscitation should follow the most recent recommendations of the American Academy of Pediatrics and the American Heart Association (1).

Preparation is essential. Identify perinatal risk factors, assign roles to team members, and prepare and check equipment: 

  • At least 1 person skilled in the initial steps of neonatal resuscitation, including giving positive pressure ventilation (PPV), should be in attendance at every birth, and additional personnel with the ability to do a complete resuscitation should be rapidly available even in the absence of specific risk factors. A team of 4 or more members may be required for a complex resuscitation, and depending on the risk factors, it may be appropriate for the entire resuscitation team to be present prior to the birth.

  • Before a preterm delivery, set room temperature to 23 to 25° C (74 to 77° F).

  • A thermal mattress, hat, and plastic bag or wrap should be used for premature infants < 32 weeks gestation. 

There are many perinatal risk factors that increase the likelihood of a need for resuscitation. In addition to those noted in table Problems in the Neonate That May Require Resuscitation, some other risk factors include

  • Lack of prenatal care

  • Gestational age < 36 weeks or ≥ 41 weeks

  • Multiple gestation

  • Need for forceps, vacuum assist or emergency cesarean delivery

  • Meconium-stained fluid

  • Shoulder dystocia, breech, or other abnormal presentation

  • Certain abnormal heart rate patterns in the fetus

Initial measures

Initial measures for all neonates include

  • Rapid assessment (within 60 seconds of birth) of breathing, heart rate, and color

  • Providing warmth to maintain a body temperature of 36.5 to 37.5° C

  • Drying

Suctioning, including the use of a bulb syringe, is indicated only for infants who have obvious airway obstruction or who require positive pressure ventilation.

A 30-second delay in clamping the umbilical cord is recommended for preterm and term infants who do not need resuscitation. There is insufficient evidence to recommend delayed cord clamping in infants who do require resuscitation.

For the 90% of neonates who are vigorous and do not need resuscitation, establish skin-to-skin contact with the mother as soon as feasible.

The need for resuscitation is based primarily on the baby’s respiratory effort and heart rate. A 3-lead cardiac monitor is the preferred way to assess heart rate. In addition to clinical evaluation of respiration, monitor oxygen saturation using pulse oximetry with a preductal probe (ie, on the right wrist, hand, or finger), taking into account the expected slow rise in oxygen saturation over the first 10 minutes of life (see table Neonatal Oxygen Saturation Targets).

Table
icon

Neonatal Oxygen Saturation Targets

Time After Delivery

Preductal* SpO2

1 minute

60–65%

2 minutes

65–70%

3 minutes

70–75%

4 minutes

75–80%

5 minutes

80–85%

≥ 10 minutes

85–95%

* The right upper extremity receives preductal blood.

SpO2 = oxygen saturation.

Ventilation and oxygenation

If the neonate’s respiratory effort is depressed, stimulation by flicking the soles of the feet and/or rubbing the back may be effective. Suctioning, unless indicated for airway obstruction, is not an effective method of stimulation and may cause a vagal response with apnea and bradycardia.

For infants with a heart rate of ≥ 100 beats/minute who have respiratory distress, labored breathing, and/or persistent cyanosis, supplemental oxygen and/or continuous positive airway pressure (CPAP) is indicated.

For infants with a heart rate of 60 to < 100 beats/minute who have apnea, gasping, or ineffective respirations, positive pressure ventilation (PPV) using a mask is indicated. Before giving PPV, the airway should be cleared by gently suctioning the mouth and nose with a bulb syringe. The infant’s head and neck are supported in the neutral (sniffing) position, and the mouth is slightly opened with the jaw brought forward. Initial ventilator settings are peak inspiratory pressure (PIP) of 20 to 25 cm H2O, positive end-expiratory pressure (PEEP) of 5 cm H2O, and an assist control (AC) or intermittent mandatory ventilation (IMV) rate of 40 to 60 breaths/minute. There are insufficient data to recommend a specific inspiratory time, but inflations of > 5 seconds are not recommended. 

If the heart rate is < 60 beats/minute, neonates require endotracheal intubation.

The effectiveness of ventilation is judged mainly by rapid improvement in the heart rate. If the heart rate does not increase within 15 seconds, adjust the mask to ensure a good seal, check the position of the head, mouth, and chin to ensure the airway is open, suction the mouth and airway using a bulb syringe and/or a size 10 to 12 F catheter, and assess chest wall rise. Increase the airway pressure to ensure the chest wall rises adequately. Although the peak inspiratory pressure (PIP) should be set at the minimum level to which the infant responds, an initial PIP of 30 to 40 cm H2O or higher may be required to produce adequate ventilation. Because even brief periods of excessive tidal volume can easily damage neonatal lungs, particularly in premature infants, it is important to frequently assess and adjust PIP during resuscitation. Devices that measure and control tidal volume during resuscitation have been described and may be helpful, but their role currently is not established.

Supplemental oxygen should be provided with a blender to allow the oxygen concentration to be varied in accord with the infant’s clinical condition. Positive pressure ventilation should be initiated with 21% O2 (room air) for term infants or 21 to 30% O2 for preterm infants ≤ 35 weeks and titrated as indicated by pulse oximetry. Hyperoxia (O2 saturation > 95%) should be avoided. Infants who have otherwise responded well to resuscitation but who are persistently cyanotic may have congenital heart disease, and continued exposure to a high concentration of oxygen may be detrimental.

Intubation and chest compression

If the infant fails to respond to positive pressure ventilation delivered by mask or the heart rate is < 60 beats/minute, the infant should undergo endotracheal intubation. Endotracheal intubation is also indicated if PPV is required for an infant with a prenatally diagnosed or clinically suspected diaphragmatic hernia.

The size of the tube and depth of intubation are selected according to the infant's weight and gestational age.

For endotracheal tube diameter:

  • 2.5 mm for infants < 1000 g or < 28 weeks gestation

  • 3 mm for infants 1000 to 2000 g or 28 to 34 weeks gestation

  • 3.5 mm for infants > 2000 g or > 34 weeks gestation

For insertion depth, the marker at the lip should typically be at

  • 5.5 to 6.5 cm for infants who weigh < 1 kg

  • 7 cm for infants who weigh 1 kg

  • 8 cm for infants who weigh 2 kg

  • 9 cm for infants who weigh 3 kg

Many endotracheal tubes have insertion markings to be positioned at the level of the vocal cords to guide the initial placement.

Immediately after intubation, clinicians should listen for bilaterally equal breath sounds. Selective intubation of the right mainstem bronchus with decreased breath sounds on the left is common if the tube is inserted too deeply.

Tracheal intubation should be confirmed by testing for exhaled CO2 using a colorimetric detector. A positive test, in which the colorimetric indicator turns from purple/blue to yellow, confirms tracheal intubation. A negative test is most commonly due to esophageal intubation but may occur when ventilation is insufficient or there is very poor cardiac output. A fixed yellow color can be due to direct contamination by epinephrine or may indicate the device is defective.

Proper endotracheal tube depth should result in the tip of the tube being about halfway between the clavicles and the carina on chest x-ray, coinciding roughly with vertebral level T1-T2.

For infants ≥ 34 weeks (or ≥ 2000 g), a laryngeal mask airway may be used if there is difficulty intubating the infant.

After intubation, if the heart rate does not improve and there is insufficient chest rise with adequate peak inspiratory pressure, the airway may be obstructed and suctioning should be done. Thinner-diameter catheters (5 to 8 F) may clear an endotracheal tube of thin secretions but are ineffective for thick secretions, blood, or meconium. In such cases, the endotracheal tube can be removed while applying continuous suction with a meconium aspirator and sometimes the trachea can be directly suctioned with a larger (10 to 12 F) catheter. After suctioning the trachea, the infant is reintubated.

If the infant is adequately ventilated and the heart rate remains < 60 beats/minute, chest compressions should be given using the 2-thumb/chest encircling technique in a coordinated ratio of 3 compressions to 1 ventilation with 90 compressions and 30 ventilations per minute. The 2-finger technique of chest compression is no longer recommended. Intubation is always indicated before initiating chest compression, and the oxygen concentration should be increased to 100%. The heart rate should be reassessed after 60 seconds of chest compressions. 

If severe bradycardia persists while the infant is adequately ventilated and chest compressions have been given for 1 minute, catheterize the umbilical vein or place an intraosseous needle to give intravascular epinephrine as soon as possible. While access is being established, a dose of epinephrine may be given via the endotracheal tube, but the efficacy of this route is unknown. The dose of epinephrine is 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of the 0.1 mg/mL solution, previously known as 1:10,000 solution), repeated as needed every 3 to 5 minutes. Higher doses of epinephrine have been considered in the past but are no longer recommended.

Failure to respond to resuscitation

If the infant fails to respond to resuscitation and has pallor and/or poor perfusion, volume expansion with 10 mL/kg of 0.9% saline IV over 5 to 10 minutes is recommended. Uncross-matched, O-negative packed red blood cells also may be used for volume expansion, especially if there has been acute, severe blood loss. 

Drugs such as sodium bicarbonate and atropine are not recommended in the course of resuscitation. Naloxone is not recommended in the initial steps of the management of respiratory depression, and a 2018 Cochrane review found insufficient evidence to determine the safety and efficacy of this drug in neonates. 

If the infant fails to respond to resuscitation or suddenly deteriorates after an initial response, pneumothorax must be ruled out. Although pneumothorax may be clinically suspected by finding unilateral diminished breath sounds on auscultation, breath sounds are well-transmitted across the precordium and the presence of bilateral breath sounds can be misleading. Transillumination of the chest may be used but is often limited by the lack of an immediately available intense light source and the inability to sufficiently darken the room. Additionally, a pneumothorax may be misdiagnosed in small infants with thin skin or missed in large infants with thick skin. A chest x-ray typically takes too much time to be of practical benefit during resuscitation, but bedside ultrasonography offers the possibility of an accurate and rapid diagnosis. Because pneumothorax is a reversible cause of unresponsiveness to resuscitation, bilateral thoracentesis should be considered on empirical grounds even in the absence of a definite diagnosis.

In some cases, thoracentesis is diagnostic and therapeutic for an unsuspected pleural effusion.

Algorithm for resuscitation of neonates

* PPV: Initiate resuscitation with room air. If SpO2 targets are not achieved, titrate inhaled oxygen concentration upward.

† 3:1 compression:ventilation ratio with a total of 90 compressions and 30 breaths/minute. Compressions and ventilations are delivered sequentially, not simultaneously. Thus, give 3 compressions at a rate of 120/minute, followed by 1 ventilation over 1/2 second.

CPAP = continuous positive airway pressure; ECG = electrocardiography; ETT = endotracheal tube; HR = heart rate; PPV = positive pressure ventilation; SpO2 = oxygen saturation; UVC = umbilical venous catheter.

Adapted from the American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care–Part 13: Neonatal Resuscitation. ECCguidelines.heart.org. © Copyright 2015 American Heart Association, Inc.

Algorithm for resuscitation of neonates

No resuscitation

In some cases, resuscitation may not be appropriate: 

  • Infants with known lethal anomalies diagnosed before birth: Consult with the family well before the delivery to arrive at a mutually agreeable plan. 

  • Extremely premature infants: Follow institutional guidelines, bearing in mind that prenatal gestational age estimates are often not precise.

In infants with unsuspected severe anomalies discovered at delivery, an initial diagnosis and/or prognosis may be inaccurate, so resuscitation should be attempted.

When possible, a neonatologist should be involved in threshold of viability decisions. Obstetric dating data should be obtained directly from the mother as well as from the mother’s records and used to independently calculate the estimated date of confinement and possible range of gestational age. Discussion with parents should take into account current local and national outcomes data based on expected gestational age and birthweight (if known), fetal sex, singleton/multifetal gestation status, and antenatal treatment with corticosteroids. In cases in which there is a range of acceptable approaches, the parents’ input is the most important factor in determining whether to attempt resuscitation. In cases in which resuscitation clearly is not indicated, a decision for comfort care should be made by the providers, and the parents should not be offered a false choice of resuscitation.

The goal of resuscitation for most families and physicians is the survival of the infant without severe morbidity. An infant who is born without any detectable vital signs and fails to recover any sign of life in spite of appropriate resuscitation for > 10 minutes is unlikely to achieve this goal, and discontinuation of resuscitation under such circumstances is considered reasonable according to guidelines in the Textbook of Neonatal Resuscitation (1). However, there are no firm guidelines as to how long resuscitation should be continued when there is persistent severe bradycardia, or on what to do when the heart rate increases after resuscitation has been stopped. In such cases, the appropriateness of intervention should be evaluated in light of the goals of treatment.

General reference

  • 1. Weiner GM, ed: Textbook of Neonatal Resuscitation, ed. 7. Elk Grove Village, American Academy of Pediatrics and the American heart Association, 2016.

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