This page is about Newborn Resuscitaion in Delivery Room and is intended for Doctors esp Pediatricians, neonatologist and General Physicians who care for newborns in their General Practice.

RESUSCITATION OF NEWBORN
Introduction
Effective resuscitation of the newborn infant requires adequate training & preparation of staff involved in the care women in labour, a knowledge of maternal & intrapartum risk factors that may influence the postnatal course of the infant, and adequate and functioning equipment for resuscitation of the newborn. "As poor cardiorespiratory adaptation at birth (low Apgar scores) cannot be predicted in the majority of cases, all staff involved in care during labour should be skilled in resuscitation .

Incidence and risk factors
Need for resuscitation: 258 221 live born and 1 823 stillborn infants were born in Australia in 1995. Of these, the majority were born in a conventional labour ward setting, with 4 199 born in birth centres and 869 home births notified. Ventilatory assistance by intermittent positive pressure respiration through a bag and mask or after intubation was recorded for 6.2 - 18.6% of infants in various states of Australia. Endotracheal intubation was recorded for 1.1 - 2.3% of deliveries and narcotic antagonists to counteract respiratory depression due to maternal narcotic analgesics were recorded for 1.1 - 1.9% of infants born in various states of Australia in 1995 Incidence of low Apgar scores: In 1995 in Australia (except Victoria), an Apgar score of 0-3 was recorded in 2.8% of live births at 1 minute and 0.3% at 5minutes . Antenatal prediction of need for resuscitation: only about half of the infants needing resuscitation are predicted by antenatal history or signs during labour On basic principles the assessment should include a history of maternal and intrapartum risk factors for problems that may affect the infant including pre-existing medical conditions in the mother, problems of pregnancy, abnormalities identified antenatally in the fetus, the presence of meconium stained liquor, CTG abnormalities, scalp pH, maternal indicators of infection, presentation and method of delivery.

The neonatal staff should attend all high-risk deliveries including:
Preterm infants < 35 weeks gestation
Multiple births
Infants with significant congenital malformation diagnosed antenatally
Abnormal CTG or scalp pH < 7.20
Thick (particulate) meconium stained liquor
Breech delivery
Instrumental delivery (not uncomplicated low forceps or vacuum lift-out)
Caesarian section under general anaesthetic . Emergency caesarian section
Consequences:
Complications of neonatal resuscitation. reported complications from appropriately applied resuscitative techniques are rare in neonates. The potential benefits of appropriately applied resuscitative techniques far outweigh any potential harms.

                Interventions
1. Equipment needed for resuscitation:
Radiant warmer
Warm towel and blankets
Resuscitation bag and mask:
Self-inflating bags (infant Laerdal) should have a reservoir attached to deliver more than 40-60% oxygen. Use 100% oxygen at 2 liters / minute. The �pop-off� valves vary greatly in maximal pressure delivered before the valve automatically opens. Anaesthetic bags with T-piece may deliver inappropriate pressures in inexperienced hands and require careful training in their use . The resuscitation mask should comfortably cover the mouth & nose whilst sitting on top of the chin. Circular silicone masks result in less air-leak and are easier to clean . Black rubber triangular masks have hard edges, which may cause ocular damage and should not cover the eyes.
Endotracheal tubes (see tube sizes and lengths )
Laryngoscopes
Stethoscope
Oxygen source and tubing
Suction source, tubing and size 6/8/10 FG Y-suction catheters and �meconium aspirators�.
Magill forceps for tracheal intubation (especially by the nasal route)

2. Minimize heat loss:
Prevention of cooling reduces the mortality of low birth weight infants Infants gain and loose heat by 4 modalities: evaporation, radiation, convection and conduction. Steps taken in the delivery room to prevent heat loss that have been shown to be effective include:
Radiant heater
Dry the infant (and wrapping in warm blankets when resuscitation completed)
Plastic covering to prevent evaporation,
If resuscitation not required - early skin to skin contact with mother under warm blankets in term infants

3. Assessment at delivery:
Dry and stimulate the infant after delivery. The Apgar score is used to document post-natal adaptation at 1and 5 minutes (and at 10, 15 and 20 minutes if < 8 at 5 minutes). Heart rate, respiratory efforts, tone, reflex irritability and colour guide resuscitation. Infants with low Apgar scores, or persisting cyanosis and/or bradycardia and/or irregular respiratory effort should receive assistance.
Infants with both blue (1o) apnoea (apnoeic, flaccid and cyanosed with heart rate < 100 bpm; Apgar score = 1), and white (2o) apnoea (apnoeic, flaccid and pallid with heart rate < 100; Apgar score = 1) can be recognised almost immediately after birth7, 8 and resuscitation commenced without delay. Check for pulse of either umbilical arteries, apex beat or by auscultation.

4. Suctioning of the airway:
There is no evidence to support routine suctioning of the upper airway or stomach in newborn infants. The oropharynx then the nasopharynx should be suctioned on delivery of the head if there is thick (particulate) meconium stained liquor or blood is visible at the infant�s mouth.
If thick meconium is present, the initial resuscitative step of an infant who has not established respiration is to suction the trachea. See Meconium stained liquor.

5. Assisted ventilation:
Initiate ventilation with 100% oxygen for infants with:
At or soon after birth blue or white apnoea (infants with bradycardia [heart rate < 100], and/or apnoea and no tone) .After stimulation for infants with persisting bradycardia, cyanosis, poor respiratory effort, significant respiratory distress and/or low Apgar scores (4 at 1 min).
Bag and mask ventilation:
Use 100% oxygen Ventilate the infant at 30-60 breaths per minute, ensuring adequate chest expansion
Tracheal intubation:
No trial has directly compared bag and mask resuscitation with endotracheal tube and bag resuscitation, although, in experienced hands, ventilation by endotracheal tube is likely to be more effective than ventilation by facemask Indications for endotracheal tube intubation include:
Tracheal suctioning for meconium
Failure to provide adequate ventilation using a bag and mask despite adequate attempts at obtaining an airway
Preterm delivery < 28 weeks,
Respiratory distress likely to require continued ventilatory support
Congenital abnormalities on a case by case basis (eg diaphragmatic hernias)

6. Combined external cardiac compression and assisted ventilation:
Check for pulse: either umbilical arteries, apex beat or by auscultation.
Perform cardiac massage: if initial heart rate is < 60-bpm or remains 60-80 bpm after initiation of adequate ventilation8, 9
Chest compression:
Compress the chest 1/3rd of its depth, at Rate of 120 compressions per minute, by
Compressing the lower half of sternum either by:
Encircling the chest with both hands and using 2 thumbs (higher blood pressure and better coronary perfusion in pigs10 , or by Using 2 fingers over the lower sternum8, 9 Avoid the chest margins and xiphisternum and do not restrict chest re-expansion.
Combined chest compression and ventilation:
This should result in at least 90 compressions and 30 breaths per minute, preferably by: Alternating 3 compressions with 1 breath (ie 3:1 ratio: c-c-c-v-c-c-c-v-c-c-c-v)

7. Assess the response:
Reassess the response to ventilation every 30-60 seconds
Continue to ventilate until there is an adequate response - crying or adequate sustained spontaneous breathing and heart rate > 100 bpm, Continue to give cardiac compressions until heart rate > 80 bpm

8. Failure to respond to resuscitation:
If there is an initial heart beat this is usually due to inadequate ventilation:
If bag and mask ventilation: ensure an adequate airway (chin lift and slight head tilt) If endotracheal tube: usually a misplaced endotracheal tube (ie oesophageal). Always check for adequacy of chest expansion, and check and recheck the endotracheal tube position. If not above then may be blocked endotracheal tube, blocked airway or severe lung disease. Change tube under suction and then increase ventilatory effort.

9. Vascular access:
Use umbilical vein where possible,
Alternative routes include: peripheral vein (eg scalp vein), femoral vein, or endotracheal (ETT) routes, All drugs may be given IV but only adrenaline and Naloxone may be given via the ETT (also atropine and lignocaine but not used in neonatal resuscitation), The umbilical artery and subclavian veins should be avoided where possible due to the potential complications of these routes.

Drugs in resuscitation:
Naloxone: should be restricted to use in infants who are considered to be depressed by opiates given to the mother in labour (within 4 hours of delivery), who require active resuscitation in the newborn period, and/or who continue to have inadequate spontaneous respiratory effort.
Dose: Naloxone 200 micrograms (= 0.5mls) via intravenous or intramuscular injectionDo not give Naloxone to infants of narcotic dependent mothers.
Adrenaline: there is little evidence to guide the use of adrenaline in neonatal resuscitation. Case series have documented the potential for normal outcomes in both term and preterm infants given adrenaline during newborn resuscitation11, 12 suggest that high dose adrenaline (0.2 mg/kg) may be more effective than low dose adrenaline (0.01 mg/kg) during paediatric resuscitation14 < and the successful resuscitation of neonates using ETT adrenaline15 . No data exists in neonates supporting the use of high-dose adrenaline and no trials compare the use of ETT and intravenous adrenaline.Dose:Adrenaline 0.05 mg/kgintravenously (UVC) = 0.5 ml/kg of 1:10 000 adrenaline, or If unable to obtain rapid venous access give: adrenaline 0.05 mg/kg via ETT = 0.5 ml/kg of 1:10 000 adrenaline.
Repeat dose once if no response after 60 seconds.
Bicarbonate: Trials of bicarbonate therapy in newborn infants have been limited to low-birth-weight or premature infants. They suggest early (within 30 minutes) alkali therapy is preferable to delayed (> 2 hours) therapy16 , and infants receiving rapid bicarbonate (< 5 minutes) may have higher mortality when compared to infants receiving slow bicarbonate therapy17 Observational studies have linked hypertonic bicarbonate therapy with intraventricular haemorrhage in preterm infants18, 19 .Obtain an early blood gas after resuscitation.Bicarbonate should be restricted to post-resuscitation correction of acidosis. See acidosis
Dextrose: glucose has not been shown in animal models or adult humans to change the outcomes of cardiopulmonary resuscitation20, 21 No trial of glucose for resuscitation exists for neonates. Neonates requiring CPR should have an early blood sugar estimate after resuscitation and correction of hypoglycaemia if BSL < 2.0 mmol/L (see hypoglycaemia
Calcium and atropine: there is no evidence to support the use of these agents during neonatal resuscitation.
Volume replacement in resuscitation:
Volume replacement is not routine in neonatal resuscitation. Animal& observational data in neonates suggest a relationship between rapid volume replacement and intraventricular haemorrhage and patent ductus arteriosus The only clinical trial of volume expansion was with FFP in preterm neonates which failed to demonstrate an effect on autopsy diagnosed neonate. Beware the pale, tachycardic infant who may have co-existing hypovolaemia, especially if preceded by antepartum haemorrhage, placental abruption, vasa praevia or uterine rupture.
Concealed feto-maternal haemorrhage also occurs.
Diagnosis: clinical suspicion may be confirmed by urgent cord, venous or arterial haematocrit.
Treatment: Early and adequate blood volume replacement may improve outcomes in fetal haemorrhagic shock. If hypovolaemia is suspected: give Normal Saline or NSA 4% 10-20 mls/kg over 10-30 minutes and titrate against response.
If haemorrhagic shock suspected: give whole blood or packed red cells in 15 mls/kg aliquots titrated against response. Consider O Negative uncross-matched blood for severely compromised infants. Serial haematocrits may be used to determine adequacy of red cell replacement.
Arrhythmias in neonates: these are rarely a primary problem at neonatal resuscitation. See arrhythmia or hyperkalaemia.

Management after resuscitation
Seek the cause of the arrest and treated specifically.
Complications of the resuscitation procedure should be sought, including air leaks (pneumothorax, pneumomediastinum or pneumopericardium), oesophageal injury and blood loss from organ damage (eg liver).
Obtain cord arterial and venous blood gas analysis (may be obtained from placental vessels -veins cross arteries). Perform Apgars at 1 and 5� and every 5� until Apgar .
Document time to sustained spontaneous respiration.
Obtain early arterial blood gas and BSL. Correct persisting acidosis and hypoglycaemia.
Respiratory support: continue ventilation till adequate sustained spontaneous respiration and without severe respiratory distress. Ventilate to ensure adequate oxygenation and normocarbia. Monitor vital organ function:
cardiac dysfunction as determined by hypotension or poor cardiac output (ECHO); renal dysfunction (oliguria < 0.5 mls/kg/hour or creatinine 120 mmol/L);
hepatic dysfunction (abnormal LFTs); and
cerebral dysfunction (hypoxic-ischaemic encephalopathy and seizure).

Cessation of cardiopulmonary resuscitation:
The decision to cease cardiopulmonary resuscitation should be based on cause of arrest, response to resuscitation, & remediable factors. Death or severe neurological abnormality is predicted by a failure to obtain a heart rate by 10 minutes (Apgar score 0 at 10�) despite adequate resuscitation and failure to respond to adrenaline. A search of the literature has failed to reveal a single infant with Apgar score of 0 at 10 minutes who was normal at follow up with the majority not able to be resuscitated or becoming a neonatal death.

                                     Key Points
Steps in Neonatal resuscitation
1.Stimulate and dry infant Use dry towel    .
2.Suction upper airway If meconium / blood present .
3.Check responsiveness Heart rate (umbilical artery pulse) / respiration /    colour / tone / activity (Apgar at 1') .
4.Obtain airway Slight head tilt / chin lift .
5. Breathing If cyanosed / poor respiratory effort / bradycardia / low Apgar - then: Bag and mask 30-60 breaths / minute 15-20 cm H20 inspiratory pressure to: Ensure chest expansion 100% oxygen
6. Check response Every 30-60 seconds
7. Chest compression If initial heart rate < 60 bpm or < 80 after adequate ventilation Compress 1/3rd of chest diameter .Encircle chest with hands and compress lower sternum with thumbs, or use fingers over lower sternum (avoid xiphisternum / costal margins) Rate = 120 compressions / minute Breaths 30-60 / minute, or Alternate 3:1 compressions:breath (ccc-b-ccc-b)
8. Endotracheal intubation Initially if meconium liquor, or if no response to bag and mask ventilation .if no response check ETT tube position!
9. Intravenous access Umbilical vein or peripheral vein (eg scalp vein)
10. Adrenaline 1: 10 000 (0.01 mg/ml) IVI = 0.5 mls/kg of 1:10 000, or via ETT
11. Check response Umbilical artery pulse / apex / auscultation
12. Repeat Adrenaline If heart rate < 80 bpm
13. Cessation of CPR Depends on antecedent events, response to resuscitation and remediable factors .No heart rate at 10 minutes or no response to adrenaline indicates poor prognosis .
       Management after resuscitation
Apgars 5 minutely till > 7, time to sustained spontaneous respiration, respiratory, cardiac, neurological and renal status. Check early ABG and BSL. Consider NaHCO3 if acidosis (mls 4.2% NaHCO3 = 0.3 x weight kg x BE over 30-60 minutes). Give: glucose 10% 5 mls/kg over 5-10 minutes if BSL < 2.0 mmol/L