A Baby Is Born at 34 Weeks Gestation. After the Initial Steps of Resuscitation

Neonatal Resuscitation: An Update

TALKAD Southward. RAGHUVEER, MD, Wesley Medical Center and Pediatrix Medical Group of Kansas, Wichita, Kansas

Am Fam Physician. 2011 Apr 15;83(8):911-918.

Abstract
Neonatal Resuscitation Team
Planning and Preparation
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

Article Sections

Abstruse
Neonatal Resuscitation Team
Planning and Preparation
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Direction
References

Advisable resuscitation must exist available for each of the more than 4 meg infants born annually in the United States. Ninety percentage of infants transition safely, and information technology is upwardly to the doctor to assess hazard factors, place the nearly 10 per centum of infants who demand resuscitation, and respond accordingly. A team or persons trained in neonatal resuscitation should be promptly bachelor to provide resuscitation. The Neonatal Resuscitation Program, which was initiated in 1987 to identify infants at risk of needing resuscitation and provide loftier-quality resuscitation, underwent major updates in 2006 and 2010. Amid the most important changes are to non intervene with endotracheal suctioning in vigorous infants born through meconium-stained amniotic fluid (although endotracheal suctioning may exist advisable in nonvigorous infants); to provide positive pressure ventilation with one of three devices when necessary; to begin resuscitation of term infants using room air or blended oxygen; and to accept a pulse oximeter readily available in the delivery room. The updated guidelines also provide indications for breast compressions and for the use of intravenous epinephrine, which is the preferred route of administration, and recommend not to use sodium bicarbonate or naloxone during resuscitation. Other recommendations include confirming endotracheal tube placement using an exhaled carbon dioxide detector; using less than 100 percent oxygen and adequate thermal support to resuscitate preterm infants; and using therapeutic hypothermia for infants born at 36 weeks' gestation or afterward with moderate to astringent hypoxic-ischemic encephalopathy.

Nearly ten percent of the more than 4 million infants born in the The states annually need some assistance to begin breathing at nativity, with approximately i percent needing extensive resuscitation1,2 and well-nigh 0.ii to 0.three percent developing moderate or severe hypoxic-ischemic encephalopathy.3 Bloodshed in infants with hypoxic-ischemic encephalopathy ranges from half dozen to 30 pct, and meaning morbidity, such as cerebral palsy and long-term disabilities, occurs in twenty to xxx per centum of survivors.4 The Neonatal Resuscitation Program (NRP), which was initiated in 1987 to identify infants at gamble of respiratory depression and provide high-quality resuscitation, underwent major updates in 2006 and 2010.1,5–seven

SORT: KEY RECOMMENDATIONS FOR Exercise

Clinical recommendation	Prove rating	References
A squad or persons trained in neonatal resuscitation should be promptly available at all deliveries to provide complete resuscitation, including endotracheal intubation and administration of medications.	C	9
If the infant's heart rate is less than 100 beats per minute and/or the infant has apnea or gasping respiration, positive pressure ventilation via face mask should be initiated with 21 percent oxygen (room air) or composite oxygen using a self-inflating bag, menses-inflating bag, or T-slice device while monitoring the aggrandizement pressure.	C	5, vi
If the baby's middle rate is less than 60 beats per infinitesimal after effective positive force per unit area ventilation, so chest compressions should be initiated with continued positive pressure level ventilation (3:i ratio of compressions to ventilation; 90 compressions and xxx breaths per infinitesimal).	C	5–7
Exhaled carbon dioxide detectors can exist used to confirm endotracheal tube placement in an babe.	C	five, vi
In the resuscitation of an infant, initial oxygen concentration of 21 per centum is recommended.	C	5, vi
If the infant's heart rate is less than 60 beats per minute after adequate positive pressure level ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended.	C	1, 2, v, 6
Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation.	C	1, 2, 5, 6
Therapeutic hypothermia is recommended in infants born at 36 weeks' gestation or subsequently with evolving moderate to severe hypoxic-ischemic encephalopathy.	C	5–7
Intrapartum suctioning is not recommended in infants born through meconium-stained amniotic fluid. Endotracheal suctioning may be useful in nonvigorous infants with respiratory depression born through meconium-stained amniotic fluid.	C	1, 2, five

Neonatal Resuscitation Team

Abstract
Neonatal Resuscitation Team
Planning and Training
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Direction
References

A 1987 written report showed that nearly 78 percent of Canadian hospitals did not take a neonatal resuscitation team, and physicians were called into a pregnant number of community hospitals (69 percent) for neonatal resuscitation because they were not in-house.8 National guidelines in the The states and Canada recommend that a team or persons trained in neonatal resuscitation be promptly available for every nascence.9,10 Actual institutional compliance with this guideline is unknown. In small-scale hospitals, a nonphysician neonatal resuscitation team is one fashion of providing in-house coverage at all hours. NRP-certified nurses, nurse practitioners, and respiratory therapists take demonstrated the chapters to lead resuscitations.xi–13 However, it is recommended that an NRP-certified physician be nowadays in the hospital when a high-risk commitment is anticipated.11–13 One study provides an outline for physicians interested in developing a neonatal resuscitation team.xiv

Breakdowns in teamwork and communication can atomic number 82 to perinatal expiry and injury.xv Team training in simulated resuscitations improves performance and has the potential to ameliorate outcomes.16,17 Ultimately, existence able to perform purse and mask ventilation and piece of work in coordination with a team are important for effective neonatal resuscitation.

Planning and Grooming

Abstract
Neonatal Resuscitation Squad
Planning and Grooming
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

Important aspects of neonatal resuscitation are the infirmary policy and planning that ensure necessary equipment and personnel are nowadays before delivery.1 Anticipation and preparation are essential elements for successful resuscitation,18 and this requires timely and accurate advice between the obstetric team and the neonatal resuscitation team. Physicians who provide obstetric care should be aware of maternal-fetal run a risk factors1 and should appraise the risk of respiratory depression with each delivery.19 The obstetric team should inform the neonatal resuscitation squad of the risk status for each delivery and proceed to focus on obstetric intendance. Once the neonatal resuscitation team is summoned to the delivery room, it is important to obtain a pertinent history; assign roles to each team member; check that all equipment is bachelor and functional,ane including a pulse oximeter and an air/oxygen blender6; optimize room temperature for the infant; and turn on the warmer, low-cal, oxygen, and suction.

Outline of Resuscitation

Abstract
Neonatal Resuscitation Team
Planning and Training
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

Resuscitation of an baby with respiratory low (term and preterm) in the commitment room (Figure one) focuses on airway, breathing, circulation, and medications. 5 Equally presently every bit the infant is delivered, a timer or clock is started. Once the infant is brought to the warmer, the head is kept in the "sniffing" position to open the airway. The airway is cleared (if necessary), and the infant is stale. Breathing is stimulated by gently rubbing the infant's back. The wet cloth beneath the infant is changed.five Respiratory effort is assessed to see if the infant has apnea or gasping respiration, and the heart rate is counted by feeling the umbilical string pulsations or past auscultating the heart for six seconds (e.g., heart rate of half dozen in half dozen seconds is sixty beats per minute [bpm]). The eye charge per unit should be verbalized for the team.

Figure 1.

Download PDF

Algorithm outlining neonatal resuscitation. (PPV = positive pressure level ventilation; SpO₂ = oxygen saturation as measured by pulse oximetry.)

Reprinted with permission from Kattwinkel J, Perlman JM, Aziz Grand, et al. Part fifteen: Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3):S910.

If the heart rate is less than 100 bpm and/or the baby has apnea or gasping respiration, positive pressure ventilation (PPV) via face mask is initiated with 21 percent oxygen (room air) or blended oxygen, and the pulse oximeter probe is applied to the right hand/wrist to monitor heart rate and oxygen saturation.5,6 The centre rate is reassessed after xxx seconds, and if information technology is less than 100 bpm, PPV is optimized to ensure adequate ventilation, and heart rate is checked again in thirty seconds.v–7 If the heart rate is less than 60 bpm afterwards 30 seconds of effective PPV, chest compressions are started with connected PPV with 100 pct oxygen (3:ane ratio of compressions to ventilation; xc compressions and thirty breaths per minute) for 45 to sixty seconds.v–7 If the heart rate continues to be less than sixty bpm despite adequate ventilation and chest compressions, epinephrine is administered via umbilical venous catheter (or less optimally via endotracheal tube).five–7

Depending on the skill of the resuscitator, the infant can be intubated and PPV delivered via endotracheal tube if chest compressions are needed or if bag and mask ventilation is prolonged or ineffective (with no chest ascension).five Center rate, respiratory effort, and color are reassessed and verbalized every thirty seconds as PPV and chest compressions are performed. In one case the center charge per unit increases to more than 60 bpm, chest compressions are stopped. When the heart charge per unit increases to more than than 100 bpm, PPV may be discontinued if in that location is effective respiratory try.5 Oxygen is decreased and discontinued once the infant's oxygen saturation meets the targeted levels (Figure one).5

If there is no heartbeat subsequently 10 minutes of adequate resuscitative efforts, the squad can cease further resuscitation.ane,5,6 A member of the team should keep the family informed during the resuscitation process. Table 1 lists show and recommendations for interventions during neonatal resuscitation.1,ii,5–7,20–43

Tabular array 1.

Evidence and Recommendations for Interventions During Neonatal Resuscitation

Intervention	Evidence	Recommendation
Treatment of infants born through meconium-stained amniotic fluid
Intrapartum suctioning	A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the take a chance of meconium aspiration syndrome.twenty	Intrapartum suctioning is not recommended with articulate or meconium-stained amniotic fluid.i,2,v,6
Endotracheal suctioning	A randomized trial showed that endotracheal suctioning of vigorous* infants built-in through meconium-stained amniotic fluid is not beneficial.21	Endotracheal suctioning of vigorous* infants is not recommended.1,2,5,6 Endotracheal suctioning of nonvigorous infants born through meconium-stained amniotic fluid may be useful.1,2,5
Endotracheal suctioning	A nonrandomized trial showed that endotracheal suctioning did not subtract the incidence of meconium aspiration syndrome or mortality.22
Ventilation strategies for term infants
Assisted ventilation device	Ventilation using a catamenia-inflating bag, self-inflating pocketbook, or T-piece device can be effective.23	A self-inflating bag, menses-inflating purse, or T-piece device tin be used to deliver positive force per unit area ventilation.1,6
Initial breaths	The primary objective of neonatal resuscitation is effective ventilation; an increase in center rate indicates effective ventilation.24	Auscultation should exist the primary ways of assessing middle rate, and in infants needing respiratory back up, the goal should be to bank check the heart rate by auscultation and by pulse oximetry.6 Initial PIP of 20 cm H_twoO may be constructive, but a PIP of 30 to forty cm H₂O may exist necessary in some infants to achieve or maintain a centre rate of more than 100 bpm.v Ventilation rates of xl to sixty breaths per infinitesimal are recommended.5,6
Exhaled carbon dioxide detectors to ostend endotracheal tube placement	A prospective study showed that the utilise of an exhaled carbon dioxide detector is useful to verify endotracheal intubation.25	Use of an exhaled carbon dioxide detector in term and preterm infants is recommended to confirm endotracheal tube placement.5,half-dozen
Laryngeal mask airway	A randomized written report showed similar success in providing effective ventilation using either laryngeal mask airway or endotracheal tube.26	Laryngeal mask airway should be considered if bag and mask ventilation is unsuccessful, and if endotracheal intubation is unsuccessful or not viable.five,six
Use of CPAP	Utilize of CPAP for resuscitating term infants has not been studied.5	No evidence exists to back up or refute the employ of mask CPAP in term infants.2,5
Use of PEEP	No studies have examined PEEP vs. no PEEP when positive pressure ventilation is used after birth.five	PEEP should be used if suitable equipment is available, such as a flow-inflating bag or T-piece device.v
Supplemental oxygen: 100 vs. 21 percent (room air)	At that place is a reduction of mortality and no evidence of damage in term infants resuscitated with 21 percentage compared with 100 percent oxygen.five,vi,27	Delivery rooms should have a pulse oximeter readily bachelor.5–7 A pulse oximeter is recommended when supplemental oxygen, positive pressure ventilation, or CPAP is used.5–vii Supplemental oxygen should exist administered using an air/oxygen blender.five–vii It is recommended to brainstorm resuscitation with 21 percentage oxygen, and increase the concentration of oxygen (using an air/oxygen blender) if oxygen saturation is low5–vii (meet Figure ane). It is recommended to increase oxygen concentration to 100 percent if the heart rate continues to be less than lx bpm (despite effective positive pressure ventilation) and the babe needs breast compressions.5–7
Ventilation strategies for preterm infants
Initial breaths	Premature animals exposed to cursory high tidal book ventilation (from loftier PIP) develop lung injury, impaired gas exchange, and decreased lung compliance.28	Initial PIP of 20 to 25 cm H₂O should be used; if the eye charge per unit does non increment or chest wall movement is non seen, college pressures can exist used. Excessive chest wall movement should be avoided.2,6
Use of CPAP	In a randomized trial, the use of mask CPAP compared with endotracheal intubation and mechanical ventilation in spontaneously animate preterm infants decreased the risk of bronchopulmonary dysplasia or death, and decreased the employ of surfactant, but increased the rate of pneumothorax.29	In spontaneously breathing preterm infants with respiratory distress, either CPAP or endotracheal intubation with mechanical ventilation may exist used.1,5,vi
Supplemental oxygen	Preterm infants less than 32 weeks' gestation are more likely to develop hyperoxemia with the initial use of 100 percent oxygen, and develop hypoxemia with 21 percent oxygen compared with an initial concentration of thirty or ninety percentage oxygen.xxx,31	In preterm infants less than 32 weeks' gestation, an initial oxygen concentration of more than 21 percent (xxx to 40 percent), just less than 100 percent should be used. The goal should be to achieve oxygen saturation targets shown in Figure 1.5,half-dozen
Chest compressions
During resuscitation	A combination of breast compressions and ventilation resulted in better outcomes than ventilation or compressions lonely in piglet studies.vi,32	When breast compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.v–7 Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the dorsum, and should be centered over the lower one-third of the sternum.5,6
	A 3:i ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies.6,33
	The breast pinch technique of using two thumbs, with the fingers encircling the chest and supporting the back, achieved improve results in swine models compared with the technique of using two fingers, with a 2d hand supporting the back.5,half dozen,34
Medications
Route and dose of epinephrine	In a case series, endotracheal epinephrine (0.01 mg per kg) was less effective than intravenous epinephrine.35	If the infant'due south center rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (one:10,000 solution) should be given intravenously. If epinephrine is administered via endotracheal tube, a dose of 0.05 to 0.1 mg per kg (1:10,000 solution) is needed.one,ii,5-7 ,
Route and dose of epinephrine	Higher doses (0.05 to 0.1 mg per kg) of endotracheal epinephrine are needed to achieve an increment in blood epinephrine concentration.36
Volume expansion	In a retrospective written report, book infusion was given more oft for slow response of bradycardia to resuscitation than for overt hypovolemia.37	Early on volume expansion with crystalloid (ten mL per kg) or red claret cells is indicated for blood loss when the heart rate does not increase with resuscitation.5,6
Naloxone	There was no departure in Apgar scores or blood gas with naloxone compared with placebo.38	Use of naloxone is non recommended as office of initial resuscitation of infants with respiratory low in the commitment room.1,ii,5,half dozen
Sodium bicarbonate	In a randomized trial, the use of sodium bicarbonate in the delivery room did not improve survival or neurologic upshot.39	Very rarely, sodium bicarbonate may exist useful after resuscitation.6
Postresuscitation direction
Induced therapeutic hypothermia	Randomized trials have shown that infants born at 36 weeks' gestation or after with moderate to severe hypoxic-ischemic encephalopathy who were cooled to 92.iii°F (33.5°C) inside six hours after birth had significantly lower mortality and less disability at eighteen months compared with those not cooled.twoscore,41	Term or near term infants with evolving moderate to severe hypoxic-ischemic encephalopathy should exist offered therapeutic hypothermia.5–seven
Glucose	In a retrospective review, early hypoglycemia was a risk cistron for brain injury in infants with acidemia requiring resuscitation.42	Intravenous glucose infusion should be started before long after resuscitation to avoid hypoglycemia.5,6
Resuscitation of preterm infants
Temperature control	Hypothermia at birth is associated with increased mortality in preterm infants.	It is recommended to comprehend preterm infants less than 28 weeks' gestation in polyethylene wrap after nascence and place them under a radiant warmer. Hyperthermia should exist avoided.1,2,vi
Temperature control	Wrapping, in improver to radiant heat, improves admission temperature of preterm infants.43	Delivery room temperature should be set at at least 78.8°F (26°C) for infants less than 28 weeks' gestation.6

Interventions

Abstract
Neonatal Resuscitation Team
Planning and Preparation
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

POSITIVE PRESSURE VENTILATION

If the infant's heart charge per unit is less than 100 bpm, PPV via face mask (not mask continuous positive airway pressure) is initiated at a rate of 40 to 60 breaths per minute to achieve and maintain a heart rate of more than than 100 bpm.1,2,5–7 PPV can be administered via menstruation-inflating bag, self-inflating bag, or T-piece device.1,6 At that place is no major advantage of using one ventilatory device over some other.23 Thus, each institution should standardize its equipment and train the neonatal resuscitation team appropriately.

If the infant needs PPV, the recommended arroyo is to monitor the inflation pressure and to initiate PPV using a peak inspiratory pressure (PIP) of 20 cm H₂O for the kickoff few breaths; however, a PIP of 30 to twoscore cm H_iiO (in some term infants) may be required at a charge per unit of 40 to threescore breaths per minute.5,6 The best measure of acceptable ventilation is prompt improvement in heart rate.24 Auscultation of the precordium is the primary means of assessing heart rate, but for infants requiring respiratory back up, pulse oximetry is recommended.5,6 However, if the centre rate does not increase with mask PPV and there is no breast ascent, ventilation should be optimized by implementing the post-obit six steps: (i) conform the mask to ensure a good seal; (2) reposition the airway by adjusting the position of the head; (3) suction the secretions in the mouth and nose; (4) open the mouth slightly and motion the jaw forrad; (5) increase the PIP enough to move the chest; and (6) consider an alternating airway (endotracheal intubation or laryngeal mask airway).v PIP may exist decreased when the heart rate increases to more than lx bpm, and PPV may be discontinued one time the heart charge per unit is more than 100 bpm and there is spontaneous animate.

The usefulness of positive end-expiratory pressure during PPV for term infant resuscitation has not been studied.half-dozen A recent study showed that utilize of mask continuous positive airway pressure for resuscitation and treatment of respiratory distress syndrome in spontaneously animate preterm infants reduced the need for intubation and subsequent mechanical ventilation without increasing the adventure of bronchopulmonary dysplasia or death.29 In a preterm infant needing PPV, a PIP of 20 to 25 cm H₂O may exist adequate to increment heart rate while avoiding a higher PIP to prevent injury to preterm lungs, and positive cease-expiratory pressure may be benign if suitable equipment is available.6

ENDOTRACHEAL INTUBATION

Endotracheal intubation is indicated in very premature infants; for suctioning of nonvigorous infants born through meconium-stained amniotic fluid; and when bag and mask ventilation is necessary for more than 2 to three minutes, PPV via face up mask does not increase heart rate, or chest compressions are needed. If skilled health care professionals are bachelor, infants weighing less than 1 kg, 1 to 3 kg, and 3 kg or more than can be intubated with 2.5-, iii-, and 3.5-mm endotracheal tubes, respectively. one Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. The exhaled carbon dioxide detector changes from purple to yellow with endotracheal intubation, and a negative result suggests esophageal intubation.5,6,25 Clinical indicators of endotracheal intubation, such as condensation in the tube, chest wall movement, or presence of bilateral equal breath sounds, have non been well studied.

LARYNGEAL MASK AIRWAY

When attempts at endotracheal intubation are unsuccessful, laryngeal mask airway (size 1) is an alternative for providing PPV in infants weighing more 2 kg or in infants greater than 34 weeks' gestation.5,six,26

CONCENTRATION OF OXYGEN

Neonatal resuscitation aims to restore tissue oxygen commitment earlier irreversible damage occurs. Traditionally, 100 percent oxygen has been used to achieve a rapid increment in tissue oxygen in infants with respiratory depression. Withal, costless radicals are generated when successful resuscitation results in reperfusion and restoration of oxygen delivery to organs.44 Utilise of 100 percent oxygen may increase the load of oxygen free radicals, which tin can potentially lead to end-organ damage. Contempo clinical trials have shown that infants resuscitated with 21 percent oxygen compared with 100 percent oxygen had significantly lower mortality (at one week and one month) and were able to establish regular respiration in a shorter time; the rates of encephalopathy and cerebral palsy were similar in the two groups.45–49 The 2010 NRP guidelines recommend starting resuscitation of term infants with 21 percent oxygen or blended oxygen and increasing the concentration of oxygen (using an air/oxygen blender) if oxygen saturation (measured using a pulse oximeter) is lower than recommended targets ( Figure 1 ).v Oxygen concentration should exist increased to 100 pct if the heart rate is less than 60 bpm despite effective ventilation, and when chest compressions are necessary.five–7

Breast COMPRESSIONS

If the baby's heart rate is less than sixty bpm, the commitment of PPV is optimized and applied for 30 seconds. The eye rate is reassessed,6 and if it continues to be less than 60 bpm, synchronized chest compressions and PPV are initiated in a three:1 ratio (3 compressions and i PPV).5,six Chest compressions tin can exist washed using two thumbs, with fingers encircling the chest and supporting the dorsum (preferred), or using two fingers, with a 2nd hand supporting the dorsum.five,6 Compressions should be delivered to the lower one-third of the sternum to a depth of approximately one-3rd of the anteroposterior diameter.5,half-dozen The eye charge per unit is reassessed at 45- to 60-2d intervals, and chest compressions are stopped in one case the eye charge per unit exceeds sixty bpm.v,6

Medications

Abstract
Neonatal Resuscitation Team
Planning and Preparation
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

Epinephrine is indicated if the baby's heart rate continues to be less than 60 bpm afterwards 30 seconds of adequate PPV with 100 pct oxygen and chest compressions. It is important to proceed PPV and breast compressions while preparing to deliver medications. The neonatal epinephrine dose is 0.01 to 0.03 mg per kg (1:10,000 solution) given intravenously (via umbilical venous catheter).1,2,5,six If there is whatsoever filibuster in securing venous access, epinephrine can exist given via endotracheal tube at a higher dose of 0.05 to 0.10 mg per kg (1:10,000 solution), followed by intravenous dosing, if necessary, as soon as access is established.5

Naloxone is not recommended during neonatal resuscitation in the commitment room; infants with respiratory depression should exist resuscitated with PPV.ane,two,5,6 Volume expansion (using crystalloid or ruby-red blood cells) is recommended when claret loss is suspected (e.thousand., pale skin, poor perfusion, weak pulse) and when the infant's heart charge per unit continues to be low despite effective resuscitation.five,6 Sodium bicarbonate is not recommended during neonatal resuscitation in the delivery room, because it does non improve survival or neurologic outcome.6,39

Meconium-Stained Amniotic Fluid

Abstract
Neonatal Resuscitation Team
Planning and Grooming
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

Approximately 7 to 20 percent of deliveries are complicated by meconium-stained amniotic fluid; these infants have a two to ix pct risk of developing meconium aspiration syndrome.50 Oral and nasopharyngeal suction on the perineum is non recommended, considering it has not been shown to reduce the take a chance of meconium aspiration syndrome.twenty In the absenteeism of randomized controlled trials, there is insufficient evidence to recommend changing the current practice of intubation and endotracheal suction in nonvigorous infants (as defined past decreased heart rate, respiratory effort, or muscle tone) born through meconium-stained amniotic fluid.1,2,five Even so, if attempted intubation is prolonged or unsuccessful, and bradycardia is present, bag and mask ventilation is advised.5,half dozen Endotracheal suctioning of vigorous infants is not recommended.1,ii,5,six

Withholding and Discontinuing Resuscitation

Abstract
Neonatal Resuscitation Team
Planning and Training
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Direction
References

Withholding resuscitation and offering comfort intendance is appropriate (with parental consent) in certain infants, such as very premature infants (born at less than 23 weeks' gestation or weighing less than 400 1000) and infants with anencephaly or trisomy 13 syndrome.v If there is no detectable heart charge per unit later on ten minutes of resuscitation, it is appropriate to consider discontinuing resuscitation.5,6

Postresuscitation Management

Abstract
Neonatal Resuscitation Team
Planning and Preparation
Outline of Resuscitation
Interventions
Medications
Meconium-Stained Amniotic Fluid
Withholding and Discontinuing Resuscitation
Postresuscitation Management
References

Intravenous glucose infusion should be started soon after resuscitation to avert hypoglycemia.5,half-dozen In addition, infants born at 36 weeks' gestation or later with evolving moderate to severe hypoxic-ischemic encephalopathy should be offered therapeutic hypothermia, using studied protocols, within vi hours at a facility with capabilities of multidisciplinary intendance and long-term follow-upward.5–7

To see the full article, log in or purchase access.

The Authors

show all author info

TALKAD S. RAGHUVEER, MD, is a staff neonatologist at Wesley Medical Heart and Pediatrix Medical Group of Kansas, both in Wichita, Kan.; and an acquaintance professor of pediatrics at the Academy of Kansas School of Medicine–Wichita....

AUSTIN J. COX, MD, is a senior resident in the Department of Pediatrics at Tripler Army Medical Center, Honolulu, Hawaii.

Address correspondence to Talkad S. Raghuveer, MD, Department of Neonatology, Wesley Medical Center, 550 N. Hillside, Wichita, KS 67214 (email: raghuveer.talkad3@gmail.com). Reprints are not available from the authors.

Author disclosure: Nothing to disembalm.

The opinions and assertions contained herein are the private views of the authors and are non to be construed equally official or as reflecting the views of the U.S. Army Medical Department or the U.Due south. Army Service at large.

The authors give thanks the post-obit physicians for their suggestions and comments: Sarah Lentz-Kapua, Doctor, Tripler Army Medical Center, Honolulu, Hawaii; Robert Oh, Physician, MPH, Tripler Ground forces Medical Heart; Barry Bloom, MD, Wesley Medical Center, Wichita, Kan.; and Satyan Lakshminrusimha, Physician, Women and Children's Hospital of Buffalo, NY.

REFERENCES

show all references

1. Kattwinkel J, ed. Textbook of Neonatal Resuscitation. 5th ed. Dallas, Tex.: American Heart Association; 2006. ...

two. The International Liaison Commission on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation. Pediatrics. 2006;117(5):e978–e988.

3. Wyatt JS, Gluckman PD, Liu PY, et al.; CoolCap Report Grouping. Determinants of outcomes later on head cooling for neonatal encephalopathy. Pediatrics. 2007;119(5):912–921.

4. Dixon K, Badawi N, Kurinczuk JJ, et al. Early on developmental outcomes after newborn encephalopathy. Pediatrics. 2002;109(1):26–33.

5. Kattwinkel J, Perlman JM, Aziz M, et al. Function fifteen: Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122 (18 suppl 3):S909–S919.

6. Perlman JM, Wyllie J, Kattwinkel J, et al. Neonatal Resuscitation Chapter Collaborators. Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care scientific discipline with treatment recommendations. Circulation. 2010;122(sixteen suppl 2):S516–S538.

7. Kattwinkel J, Perlman J. The Neonatal Resuscitation Plan: the evidence evaluation process and anticipating edition 6. NeoReviews. 2010;11:673–680.

8. Chance GW, Hanvey L. Neonatal resuscitation in Canadian hospitals. CMAJ. 1987;136(6):601–606.

9. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Care of the neonate. In: Lockwood CJ, Lemons JA, eds. Guidelines for Perinatal Care. 6th ed. Elk Grove Hamlet, Sick.: American Academy of Pediatrics; 2007:205–249.

10. Family-Centered Maternity and Newborn Care: National Guidelines. Ottawa, Canada: Health Canada; 2000.

11. Kimberlin LV, Kucera VS, Lawrence Lead, Newkirk A, Stenske JE. The function of the neonatal intensive care nurse in the delivery room. Clin Perinatol. 1989;sixteen(4):1021–1028.

12. Noblett KE, Meibalane R. Respiratory care practitioners as main providers of neonatal intubation in a community hospital: an analysis. Respir Intendance. 1995;forty(ten):1063–1067.

13. Bailey C, Kattwinkel J. Establishing a neonatal resuscitation team in community hospitals. J Perinatol. 1990;ten(3):294–300.

14. Aziz Yard, Chadwick 1000, Downton Thou, Baker Grand, Andrews W. The development and implementation of a multidisciplinary neonatal resuscitation squad in a Canadian perinatal eye. Resuscitation. 2005;66(1):45–51.

15. The Joint Commission. Preventing baby death and injury during delivery. Sentinel Event Alert. July 21, 2004. Upshot no. 30. http://world wide web.jointcommission.org/sentinel_event_alert_issue_30_preventing_infant_death_and_injury_during_delivery/. Accessed April 28, 2010.

16. Thomas EJ, Taggart B, Crandell S, et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. J Perinatol. 2007;27(vii):409–414.

17. Halamek LP. The imitation commitment-room environs as the future modality for acquiring and maintaining skills in fetal and neonatal resuscitation. Semin Fetal Neonatal Med. 2008;13(6):448–453.

xviii. American Heart Association, American Academy of Pediatrics. 2005 American Middle Clan (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: neonatal resuscitation guidelines. Pediatrics. 2006;117(5):e1029–e1038.

19. Aziz K, Chadwick Chiliad, Bakery Yard, Andrews W. Ante- and intra-partum factors that predict increased need for neonatal resuscitation. Resuscitation. 2008;79(3):444–452.

twenty. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates earlier delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004;364(9434):597–602.

21. Wiswell TE, Gannon CM, Jacob J, et al. Commitment room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000;105(i pt i):i–7.

22. Al Takroni AM, Parvathi CK, Mendis KB, Hassan S, Reddy I, Kudair HA. Selective tracheal suctioning to prevent meconium aspiration syndrome. Int J Gynaecol Obstet. 1998;63(three):259–263.

23. Bennett S, Effectively NN, Rich W, Vaucher Y. A comparison of three neonatal resuscitation devices. Resuscitation. 2005;67(1):113–118.

24. Dawes GS. Foetal and Neonatal Physiology: A Comparative Study of the Changes at Birth. Chicago, Sick.: Twelvemonth Book Medical Publishers, Inc.; 1968.

25. Aziz HF, Martin JB, Moore JJ. The pediatric disposable end-tidal carbon dioxide detector role in endotracheal intubation in newborns. J Perinatol. 1999;19(2):110–113.

26. Esmail N, Saleh M, Ali A. Laryngeal mask airway versus endotracheal intubation for Apgar score improvement in neonatal resuscitation. Egypt J Anesthesiol. 2002;18:115–121.

27. Davis PG, Tan A, O'Donnell CP, Schulze A. Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet. 2004;364(9442):1329–1333.

28. Hillman NH, Moss TJ, Kallapur SG, et al. Brief, large tidal book ventilation initiates lung injury and a systemic response in fetal sheep. Am J Respir Crit Care Med. 2007;176(half dozen):575–581.

29. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; Money Trial Investigators. Nasal CPAP or intubation at birth for very preterm infants [published correction appears in N Engl J Med. 2008;358(14):1529]. N Engl J Med. 2008;358(7):700–708.

xxx. Wang CL, Anderson C, Leone TA, Rich West, Govindaswamy B, Finer NN. Resuscitation of preterm neonates by using room air or 100% oxygen. Pediatrics. 2008;121(half dozen):1083–1089.

31. Escrig R, Arruza L, Izquierdo I, et al. Accomplishment of targeted saturation values in extremely depression gestational age neonates resuscitated with depression or high oxygen concentrations: a prospective, randomized trial. Pediatrics. 2008;121(5):875–881.

32. Berg RA, Hilwig RW, Kern KB, Ewy GA. "Bystander" chest compressions and assisted ventilation independently improve outcome from piglet asphyxial pulseless "cardiac arrest." Circulation. 2000;101(xiv):1743–1748.

33. Srikantan SK, Berg RA, Cox T, Tice L, Nadkarni VM. Outcome of onerescuer compession/ventilation ratios on cardiopulmonary resuscitation in infant, pediatric and developed manikins. Pediatr Crit Care Med. 2005;6(iii):293–297.

34. Houri PK, Frank LR, Menegazzi JJ, Taylor R. A randomized, controlled trial of two-thumb vs 2-finger chest compression in a swine infant model of cardiac abort. Prehosp Emerg Intendance. 1997;1(2):65–67.

35. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the commitment room. Pediatrics. 2006;118(3):1028–1034.

36. Crespo SG, Schoffstall JM, Fuhs LR, Spivey WH. Comparison of two doses of endotracheal epinephrine in a cardiac abort model. Ann Emerg Med. 1991;xx(3):230–234.

37. Wyckoff MH, Perlman JM, Laptook AR. Use of volume expansion during delivery room resuscitation in almost-term and term infants. Pediatrics. 2005;115(4):950–955.

38. Bonta BW, Gagliardi JV, Williams Five, Warshaw JB. Naloxone reversal of mild neurobehavioral depression in normal newborn infants after routine obstetric analgesia. J Pediatr. 1979;94(1):102–105.

39. Lokesh 50, Kumar P, Murki Southward, Narang A. A randomized controlled trial of sodium bicarbonate in neonatal resuscitation-effect on firsthand consequence. Resuscitation. 2004;60(ii):219–223.

40. Shankaran Due south, Laptook AR, Ehrenkranz RA, et al.; National Plant of Kid Health and Homo Evolution Neonatal Inquiry Network. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. Due north Engl J Med. 2005;353(15):1574–1584.

41. Azzopardi DV, Strohm B, Edwards AD, et al.; TOBY Study Grouping. Moderate hypothermia to care for perinatal asphyxial encephalopathy [published correction appears in N Engl J Med. 2010;362(11):1056]. N Engl J Med. 2009;361(fourteen):1349–1358.

42. Salhab WA, Wyckoff MH, Laptook AR, Perlman JM. Initial hypoglycemia and neonatal brain injury in term infants with severe fetal acidemia. Pediatrics. 2004;114(2):361–366.

43. Vohra S, Roberts RS, Zhang B, Janes G, Schmidt B. Heat Loss Prevention (HeLP) in the delivery room: a randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. J Pediatr. 2004;145(6):750–753.

44. Blomgren K, Hagberg H. Free radicals, mitochondria, and hypoxia-ischemia in the developing brain. Free Radic Biol Med. 2006;twoscore(3):388–397.

45. Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth One thousand, Saugstad OD. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res. 1993;34(half dozen):809–812.

46. Ramji S, Rasaily R, Mishra PK, et al. Resuscitation of asphyxiated newborns with room air or 100% oxygen at nascency: a multicentric clinical trial. Indian Pediatr. 2003;40(6):510–517.

47. Saugstad OD, Ramji S, Irani SF, et al. Resuscitation of newborn infants with 21% or 100% oxygen: follow-upward at 18 to 24 months. Pediatrics. 2003;112(two):296–300.

48. Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair two study. Pediatrics. 1998;102(ane):e1.

49. Vento M, Asensi M, Sastre J, García-Sala F, Pallardó FV, Viña J. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates. Pediatrics. 2001;107(4):642–647.

l. Velaphi S, Vidyasagar D. Intrapartum and postdelivery management of infants born to mothers with meconium-stained amniotic fluid: evidence-based recommendations. Clin Perinatol. 2006;33(ane):29–42.

This article is 1 in a series on "Advanced Life Back up in Obstetrics (ALSO)," initially established past Mark Deutchman, MD, Denver, Colo. The series is now coordinated past Patricia Fontaine, Dr., MS, Also Managing Editor, Minneapolis, Minn., and Larry Leeman, Physician, MPH, Likewise Associate Editor, Albuquerque, NM.

Copyright © 2011 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing information technology online may make ane printout of the material and may use that printout just for his or her personal, non-commercial reference. This fabric may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in whatsoever medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

MOST RECENT Effect

Feb 2022

Access the latest issue of American Family Physician

Read the Outcome

Email Alerts

Don't miss a unmarried issue. Sign up for the free AFP email table of contents.

lowehasy1949.blogspot.com

Source: https://www.aafp.org/afp/2011/0415/p911.html