Neonatal Resuscitation

John E. Wimmer, Jr
Pediatr. Rev. 1994;15;255-265
DOI: 10.1542/pir.15-7-255

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and
trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, Illinois, 60007. Copyright 1994 by the American Academy of Pediatrics. All rights reserved.
Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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ARTICLE

Neonatal
John

Resuscitation

E. Wimmer,

FOCUS

Jr,

MD*

QUESTIONS

1. What are the most important

aspects of neonatal
resuscitation?
2. How should delivery
rooms be
equipped
and staffed to provide
effective
neonatal
resuscitation?
3. What
are the correct
procedures
to follow for cardiopulmonary
resuscitation
in an infant?
4. What
are the major
reasons for
carefully
observing
and evaluating
infants
who have required
resuscitation at birth?
5. Except
for infants who are extremely
premature
or who have
severe congenital
anomalies,
what
is the long-term
prognosis
for
most children
who are resuscitated?

Introduction
Prompt,
skillful
resuscitation
of distressed
neonates
in the immediate
postpartum
period
is one of the most
important
responsibilities
of the practicing pediatrician.
The potential
for
death or life-long
morbidity
is high
in these vulnerable
infants,
but it can
be reduced
dramatically
by effective
intervention.
Because
many of these
situations
are unpredictable,
all deliveries should
be attended
by at least
one person
skilled
in neonatal
resuscitation,
and additional
help should
be readily
available.
Although
a certain
amount
of practice is needed
to master
and maintain
the necessary
manual
dexterity
skills,
the vast majority
of neonatal
resuscitations
are relatively
simple
procedures.
Most depressed
infants
respond
to ventilation
with oxygen;
only a few require
chest compressions
or medication.
Vascular
access usually
is not needed,
and most
infants
can be ventilated
adequately
by bag and mask.
Advance
preparation and adherence
to a few basic
principles
are the keys to effective
intervention.
The role of the pediatrician
should
go beyond
maintaining
expertise
in
neonatal
resuscitation
and responding
to emergencies.
Pediatricians
should

*,4ssociate
Carolina
Greenville,

Pediatrics

Professor
University
NC.

in Review

of Pediatrics,
School

East

of Medicine,

Vol.

15

No.

July

be teachers
and role models
for obstetricians,
nurses,
and other health
professionals
involved
in perinatal
care. They should
participate
in planning for and monitoring
the performance of neonatal
resuscitation.
They
also must provide
acute care and follow-up
for resuscitated
infants.
Pediatricians
also must be prepared
to provide
knowledgeable
guidance
for the health-care
team and parents
in making
some very difficult
decisions.
For example,
when is the baby
too small or the anomalies
too severe
to justify
resuscitation?
Or, when
should
resuscitative
efforts
be
stopped
in the unresponsive
infant?
Responsible
decision
making
in these
cases must be individualized,
but
should
be based on accurate,
up-todate knowledge
of outcome
statistics
and realistically
available
treatment
options.
To standardize
and disseminate
the
teaching
of neonatal
resuscitation
further, the American
Academy
of Pediatrics and American
Heart Association developed
the Neonatal
Resuscitation
Program
in 1987 (see Suggested
Reading).
This program
teaches
the basic concepts
and manual skills required
in delivery
room
resuscitation.
Its format
is adaptable
to various
types of health-care
providers.
Periodic
updates
are based on
the recommendations
of the Emergency
Cardiac
Care Committee.
It is
an excellent
resource
and should
be
incorporated
into regular
inservice
education
programs.
Its illustrations
especially
are instructive.
The following
discussion
of preparation
for
and procedure
of neonatal
resuscitation is based largely
on this program.

Background
TRANSITION
POSTNATAL

FROM FETAL
PHYSIOLOGY

TO

Successful
adaptation
from intrauterine to extrauterine
life truly is a remarkable
process,
the result of a
complicated
sequence
of interrelated
physiologic
changes.
The most immediate
of these changes
involve
ventilation
and circulation,
and understanding
them is relevant
to neo1994

natal resuscitation.
The fetus is entirely
dependent
on
placental
blood flow for gas exchange;
at delivery,
cardiorespiratory
independence
must be established
quickly.
Although
well-developed
breathing
movements
occur intermittently in utero,
the lungs are filled
with fluid and receive
very little
blood.
Pulmonary
vascular
resistance
is high, with almost
90% of the right
ventricular
output
shunting
across
the
ductus
arteriosus.
On the other hand,
systemic
vascular
resistance
is low,
partly because
40% of the combined
ventricular
output
flows to the low
resistance
placenta.
During
delivery,
compression
of
the infants
thorax
expels
fluid from
the mouth
and upper airways.
Various factors
stimulate
vigorous
crying,
which
inflates
the lungs.
The
air-liquid
interface
is established,
surfactant
is released,
and a number
of
major hemodynamic
changes
are triggered.
Pulmonary
vascular
resistance
drops,
blood
flow to the lungs increases
significantly,
oxygenation
increases,
and right-to-left
shunting
is
reduced
markedly
across
the ductus
arteriosus
and foramen
ovale.
Fetal
lung fluid is absorbed
into the pulmonary
circulation.
Removing
the
low-resistance
placenta
by clamping
the umbilical
cord increases
systemic
resistance.
Within
minutes,
the
changes
that result in ventilation
and
perfusion
of the lungs allow them to
assume
the role of gas exchange
that
was performed
prenatally
by the placenta.

COMPLICATIONS

OF TRANSITION

Numerous
factors
may interfere
with
the sequence
of events
in normal
transition.
Antepartum
problems
may
be due to long-standing
maternal
illness or obstetric
complications,
or
acute-onset
intrapartum
complications
may arise (Table
1). Most of these
lead to decreased
placental
blood
flow and, thus, decreased
oxygen
delivery to the fetus,
causing
chronic
or
acute asphyxia
or both. In other
cases,
fetal adaptation
may be impaired
by maternal
drugs,
birth injury,
infection,
or intrinsic
fetal

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255

NEONATOLOGY
Resuscitation

Antepartum

Factors

Maternal
diabetes
Pregnancy-induced
hypertension
Chronic
hypertension
Previous
Rh sensitization
Previous
stillbirth
Bleeding
in second
or third trimester
Maternal
infection
Hydramnios
Oligohydramnios
Intrapartum

drugs

Factors

Elective
or emergency
cesarean
section
Abnormal
presentation
Premature
labor
Rupture
of membranes
more than
24 h prior to delivery
Foul-smelling
amniotic
fluid
Precipitous
labor
Prolonged
labor (>24
h)
Prolonged
second
stage of labor
(>2 h)
Reproduced
with permission.
American
Heart Association.

Testbook

Nonreassuring
fetal heart rate
patterns
Use of general
anesthesia
Uterine
tetany
Narcotics
administered
to mother
within
4 h of delivery
Meconium-stained
amniotic
fluid
Prolapsed
cord
Abruptio
placentae
Placenta
previa

of Neonatal

abnormalities.
Regardless
of the underlying
cause,
interference
with normal transition
delays
the onset of
effective
breathing
and postnatal
circulatory
changes.
These
delays,
in
turn, can lead to or worsen
asphyxia,
creating
a vicious
cycle that can end
in hypoxic-ischemic
injury.
The goal
of resuscitation
is to interrupt
this
cycle before
serious,
irreversible
damage
is done.
The fetus responds
to asphyxia
by
redistributing
blood flow and increasing tissue oxygen
extraction.
Vascular resistance
increases
in the skin,
skeletal
muscle,
viscera,
and kidney,
reducing
blood flow to these organs
and preserving
flow to the heart,
brain,
and adrenal
glands.
Ongoing
asphyxia
eventually
overcomes
these
compensatory
mechanisms,
however,
and depresses
myocardial
contractility and cardiac
output.
Hypoxia
and
acidosis
also enhance
ductal
patency
and increase
pulmonary
vascular
resistance,
counteracting
the normal
postnatal
increase
in pulmonary
blood flow. Ventilatory
effort is decreased
both by central
nervous
systern depression
and by the direct
effects
of hypoxia
and acidosis
on
256

Post-term
gestation
Multiple
gestation
Size-dates
discrepancy
Drug therapy,
eg:
Reserpine
Lithium
carbonate
Magnesium
Adrenergic-blocking
Maternal
drug abuse

Resuscitation,

1987,

1990.

Copyright

the diaphragm
and other respiratory
muscles.
If hypoxia
and acidosis
are prolonged,
neuronal
death occurs,
resulting in permanent
brain damage.
Myocardial
injury may result in cardiogenic
shock or tricuspid
valve regurgitation.
Persistent
pulmonary
hypertension
(persistent
fetal circulation)
is a common
pulmonary
consequence
of asphyxia,
resulting
from the prolonged
vasoconstriction
of pulmonary
arterioles.
The kidneys
and gut also are particularly
susceptible to asphyxia,
manifested
by acute
tubular
necrosis
and necrotizing
enterocolitis,
respectively.
Other organ
systems
also may be involved.
However,
the fetus and newborn
are very tolerant
of transient
asphyxia.
Unless
prolonged
asphyxia
has occurred
in utero,
timely
and effective
resuscitation
prevents
the onset of permanent
organ damage
and
generally
confers
an excellent
longterm prognosis.
INCIDENCE

OF TRANSITIONAL

COMPLICATIONS
Some degree
of resuscitative
intervention
is required
in approximately

10% of newborn
infants
during
the
transitional
period
immediately
after
birth.
Most of these infants
are the
products
of high-risk
pregnancies,
but many perinatal
complications
occur unexpectedly.
Systematic
screening for obstetric
risk factors,
judicious
use of ultrasonography
and
other sophisticated
prenatal
diagnostic methods,
and intrapartum
monitoring can predict
the need for
neonatal
resuscitation
in about 80%
of the cases.
In the other 20%, the
need for resuscitation
is a surprise.
Some of these infants
have abnormalities that escaped
prenatal
detection;
in others,
the complications
arise late
in labor or during
the delivery
itself.
Most low-risk
infants
are born
in community
hospitals
without
neonatal intensive
care facilities;
the others are born in level II or level III
hospitals,
but without
neonatal
staff
in attendance.
Therefore,
it is important for all hospitals
that have deliveiy services
to have a contingency
plan for unanticipated
infant resuscitations.
The need for improvement
in neonatal resuscitation
is indicated
by the
ongoing
significance
of asphyxia
as a
cause of neonatal
mortality
and morbidity.
Asphyxia
and its complications account
for about 4% of
neonatal
intensive
care unit admissions nationwide.
Many of these infants die or are disabled
permanently.
Approximately
50% have sustained
antepartum
damage
that cannot
be
ameliorated
by postnatal
resuscitation. In the other 50%,
however,
asphyxia
occurs
acutely
either during
labor or shortly
after birth.
Prompt
resuscitation
could prevent
long-term
morbidity
in many of these infants.
They are the target population
for efforts to increase
the availability
of
expert
resuscitation.

Preparation
ADVANCE

PREPARATION

Long-term
planning
is a prerequisite
for successful
neonatal
resuscitation.
Considerations
include
education
and
on-the-job
training
of personnel,
acquisition
and maintenance
of the
proper
equipment
and supplies,
and
development
of policies
and procedures.
The Neonatal
Resuscitation
Program is readily
available
from the

Pediatrics

in Review

Vol.

15

Downloaded from http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

No.

July

1994

P-=

Resuscitation

checked
regularly
for completeness
and working
order.
For example,
the
expiration
dates should
be reviewed
for medications,
and batteries
and
bulbs should
be checked.
Used items
should
be replaced
after each resuscitation procedure.
The resuscitation
area must be well-lighted
and provide
adequate
space;
temperature
control;
and sources
of oxygen,
suction,
and
electrical
support.
Visual
aids that

dated cats. The knowledge

and skills
taught
in didactic
programs
must be
applied
clinically
in the delivery
room under the supervision
of experienced personnel.
Competence
in
hands-on
resuscitation,
including
both decision-making
and technical
skills,
should
be demonstrated.
Resuscitation
equipment
and supplies (Table
2) must be stored
in a
designated,
accessible
location
and

American
Academy
of Pediatrics
and
is an appropriate
educational
tool for
nurses,
respiratory
therapists,
and
emergency
medical
technicians
as
well as for physicians.
It is particularly well-suited
for orientation
of
new staff and periodic
reviews
and
mock codes.
Endotracheal
intubation
skills can be learned
and maintained
by practicing
on anatomically
accurate models
or on anesthetized,
Se-

Suction
Equipment
Bulb syringe
Mechanical
suction
Suction
catheters
5 (or 6), 8, 10 Fr
8 Fr feeding
tube and 20-cc syringe
Meconium
aspirator
Bag-and-Mask
Equipment
Infant resuscitation
bag with a pressure-release
valve
100% oxygen
Face masks
newborn
and premature
sizes (cushioned
Oral airways
newborn
and premature
sizes
Oxygen
with flow meter and tubing
-

or pressure
rim

gauge;

masks

the bag

must

be capable

of delivering

90%

to

preferred)

Intubation
Laiyngoscope
Extra bulbs
Endotracheal
Stylet
Scissors
Gloves

Equipment
with straight
blades
No. 0 (preterm)
and batteries
for laiyngoscope
tubes
sizes 2.5, 3.0, 3.5, 4.0 mm
-

and

No.

1 (newborn)

Medications
Epinephrine
1:10 000
3-cc or 10-cc ampules
Naloxone
hydrochloride
0.4 mg/mL
1-mL ampules
or 1.0
Volume
expander
one or more of these:
Albumin
5% solution
Normal
saline
Ringer
lactate
Sodium
bicarbonate
4.2%
(5 mEq/10
cc)
10-cc ampules
Dextrose
10%
250 cc
Sterile
water
30 cc
Normal
saline
30 cc
-

mg/mL

2-mL

ampules

Miscellaneous
Radiant
warmer
Stethoscope
Cardiotachometer
with ECG oscilloscope
(desirable)
Adhesive
tape
#{189}or #{190}-inchwidth
Syringes
I cc, 3 cc, 5 cc, 10 cc, 20 cc, 50 cc
Needles
25, 21, 18
Alcohol
sponges
Umbilical
artery catheterization
tray
Umbilical
tape
Umbilical
catheters
3#{189},5 Fr
3-way
stopcocks
5 Fr feeding
tube
-

Reproduced

Pediatrics

with

permission.

in Review

Textbook

of Neonatal

Resuscitation,

1987,

1990.

Copyright

American

Heart

Association.

Vol. 15
No. 7 July 1994
Downloaded
from
http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

257

NEONATOLOGY
Resuscitation
note endotracheal
tube sizes,
medication doses,
and resuscitation
procedures should
be posted
prominently.
Administrative
scheduling
policies
should
ensure
the presence
of one
person
who has proven
resuscitation
ability
at all deliveries.
Patient
care
procedures
must include
screening
for antepartum
risk factors
and ongoing assessment
to detect the onset of
intrapartum
complications
(Table
1).
Contingency
plans should
be established for unexpected
problems,
so
that persons
not involved
in preliminary resuscitative
efforts
know how
to summon
back-up
assistance.
Extra
supplies
and personnel
may be
needed
in cases of unexpected
multiplc births.
Such plans should
address
the desirable
response
time for these
emergencies,
and adherence
to this
should
be monitored.
IMMEDIATE
PREPARATION
Certain
minimal
preparations
are appropriate
for all deliveries,
even in
normal
term pregnancies
that have no
risk factors.
The radiant
warmer
should
be preheated,
warm blankets
or towels
set out, suction
and oxygen
sources
checked,
and resuscitation
supplies
quickly
surveyed.
The
proper
size face mask should
be located and the resuscitation
bag
tested.
Further
preparations
may be mdicated by risk factors
or the onset of
intrapartum
complications.
If meconium staining
is noted,
for example,
an individual
skilled
in endotracheal
intubation
must be called,
the laryngoscope
checked,
and a meconium
aspirator
and at least two endotracheal tubes prepared.
In high-risk
situations,
at least two individuals
having
resuscitation
experience
should
be present,
with at least one
being skilled
in intubation.
The delivery room should
be warmed,
especially for preterm
infants.
An
appropriate-size
endotracheal
tube
should
be removed
from the package
and cut to a length of 13 cm, and a
stylet should
be inserted
(if desired).
Depending
on the anticipated
problems, it may be advisable
to prepare
epinephrine
or other medications
and
to decide
on probable
doses and
routes of administration.
If the need
for vascular
access
is anticipated,
an
umbilical
catheter
tray should
be prepared.
258

In situations
of high risk, members
of the resuscitation
team should
discuss possible
problems
and resuscitative strategy
before
the delivery.
A
team leader should
be designated
and
roles assigned.
Such communication
helps reduce
anxiety
and confusion,
decreases
the chances
of medication
errors or other iatrogenic
complications, and generally
improves
the
flow of the resuscitation.
When serious
problems
are anticipated,
the parents
should
be counseled,
ideally
by both the obstetrician
and the pediatrician.
They should
be
informed
as completely
as possible
of
the potential
complications,
interventions, and prognosis.
Such discussion
should
be realistic
and honest,
with
the risk for their infant(s)
neither
minimized
nor exaggerated.

Procedure
INITIAL

(Figure

1)

1. Overiiew

of meconium-stained
and is discussed

in de-

taillater.
After the umbilical
cord is clamped
and cut, the infant should
be placed
on a preheated
radiant
warmer
and
dried quickly
with warm towels,
with
special
attention
to the head and
face. Wet towels
should
be replaced
with dry, prewarmed
linens.
The infant then should
be placed
supine
or
on its side with its neck in a neutral
position
(Trendelenburg
position
is
no longer
recommended).
A small
blanket
or towel neck roll under the
shoulders
may help prevent
neck
flexion
and airway
occlusion.
The infants upper airway
should
be cleared
by suctioning
the mouth
first, then
the nose. This can be done with
either
a bulb syringe
or mechanical
suction
device
and an 8 or 10 French
catheter.
Suctioning
should
be limited to 5 seconds
at a time.
EVALUATION-DECISION-ACTION

STEPS

The condition
and responsiveness
of
an infant during
the first few seconds
after birth usually
indicate
the degree
of depression
and, thus, the extent
of
resuscitative
efforts
that will be
needed.
Assessment,
therefore,
should
begin immediately,
that is, simultaneously
with the initial steps of
stabilization.
Muscle
tone, color,
and
respiratory
effort may even be apparent prior to completion
of the delivery. Decisions
cannot
be delayed
until the 1-minute
Apgar
score is obtained.
The sequence
of actions
is al-

FIGURE

tered in cases
amniotic
fluid

of resuscitation

CYCLE
These
initial steps should
be performed
in all infants
and should
take
30 seconds
or less. By this time, the
initial evaluation
also should
be completed and the first decision
made regarding
resuscitative
action.
From
this point on, the procedure
should
follow
a cycle of evaluation,
decision, action,
and re-evaluation.
For
example,
the first decision
is whether
to begin positive
pressure
ventilation.
It is based on an evaluation
of
breathing
first and then heart rate. If

in the delivety

Pediatrics

room.

in Review

Vol.

15

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No.

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1994

NEONATOLOGY
Resuscitation
breathing
is effective
and the pulse is
100 beats/mm
or greater,
positive
pressure
ventilation
is not needed
and
color should
be evaluated.
If cyanosis
is noted,
oxygen
should
be administered.
FREE

FLOW

OXYGEN

Free flow oxygen

can be given via
oxygen
tubing
with a flow rate of
5 L/min.
The tube should
be held
about
#{189}
inch from the infants
nose.
Alternatively,
an oxygen
mask or
anesthesia
bag having
oxygen
tubing
attached
could be used. Once the infant becomes
pink, the oxygen
tubing
can be withdrawn
gradually,
and one
can observe
for a recurrence
of cyanosis.
POSITIVE

PRESSURE

VENTILATION

Positive
pressure
ventilation
(PPV)
should
be started
if the infant is not
breathing
effectively
after the initial
steps listed previously.
Brief,
gentle
tactile
stimulation
may be tried by
slapping
the soles of the feet or rubbing the back.
If the infant has not
responded
to the stimulation
of
drying,
positioning,
and suctioning,
however,
PPV most likely is needed;
more vigorous
stimulation
will only
delay appropriate
resuscitation.
The evaluation
is simple:
Is the infant either apneic
or gasping?
If so,
the decision
also is simple:
Begin
PPV with 100% oxygen.
Further
evaluation,
such as auscultation
of
the heart,
is not needed
to make this
decision
and should
be deferred.
On
the other hand,
if the infant appears
to be breathing
effectively,
the heart
rate should
be checked.
A heart rate
less than 100 beats/mm
also is an indication
to begin PPV with 100%
oxygen
immediately.
[Note:
A second skilled
person
to assist in the resuscitation
should
be called
if PPV is
indicated.J
BAG-MASK

ENDOTRACHEAL

INTUBATION

The most common

reason
for endotracheal
intubation
is for direct tracheal suctioning
of meconium.
Some
infants
may require
early intubation
because
they do not respond
well to
bag-mask
ventilation.
Many experts
also recommend
early intubation
for
small preterm
infants
because
they
are likely to need ventilatory
support

VENTILATION

Most infants
can be ventilated
effectively by using a bag and mask,
although
in some cases endotracheal
intubation
is necessary
or preferred.
Even if intubation
is anticipated,
it
may be preferable
to defer this procedure until the infant has been partially resuscitated
by bag-mask
ventilation.
To begin bag-mask
ventiPediatrics

lation,
first recheck
the infants
position, which
should
be supine
with the
head slightly
extended
or neutral
(Figure
2). An appropriate-size
mask
should
be selected
and fitted over the
infants
mouth
and nose. The mask
should
be applied
tightly
enough
to
achieve
a good seal. The first ventilation should
have a prolonged
inspiratory phase (about
5 sec) and
inspiratoly
pressure
of 30 to 40 cm
H20. Ventilations
should
be given at
a rate of 40 to 60 per minute.
Adequacy
of ventilations
is determined
primarily
by observing
chest wall
movement,
which
should
be visible
but gentle
(rather
than vigorous),
and
by auscultating
breath
sounds.
The most common
problems
with
bag-mask
ventilation
are inadequate
seal of the mask on the face and improper
position
of the infants
head,
such as neck flexion.
Persistent
obstruction
of the airway
may require
further
suctioning.
Malfunction
of the
bag, particularly
the pop-off
valve,
also should
be considered.
Finally,
inspiratory
pressure
should
be increased
as needed
to ventilate
adequately
or endotracheal
intubation
should
be performed.
[Note:
If bagmask ventilation
is performed
for 2
minutes
or more,
an 8 French
orogastric
tube should
be inserted
to alleviate
gastric
distention.}

in Review

FIGURE
ventilation.

2. Position

for

bag.mask

and surfactant
replacement
therapy.
Intubation
is preferred
in prolonged
resuscitations;
it is easier
to coordinate ventilations
with chest cornpressions,
and it minimizes
gastric
distention.
Finally,
patients
who have
a known
or suspected
diaphragmatic
hernia
should
be intubated
immediately to avoid gastrointestinal
distention and progressive
lung
compression.
Because
of these possibilities,
intubation
equipment
and supplies
must
be readily
accessible
in every delivery room.
Batteries
and light bulbs
should
be checked
regularly
and supplies replenished
after use. Charts
indicating
the proper
endotracheal
tube
size and depth of insertion,
both
based on the infants
estimated
weight,
also should
be available
(Table 3). Persons
skilled
in the procedure should
be present
at the delivery
of any high-risk
infant,
including
meconium-stained
and preterm
infants,
and must always
be immediately
available
for unexpected
problems.
Once effective
ventilation
has been
established
(whether
by bag and
mask or by endotracheal
tube),
it
should
be continued
for 15 to 30 seeonds.
The first evaluation-decisionaction
cycle has now been cornpleted;
the next cycle begins
with
evaluation
of the heart rate. If the
pulse is greater
than 100 beats/mm,
no additional
measures
are indicated.
PPV should
be continued
until the infant begins
to breathe
effectively.
It
then can be discontinued
gradually
by tapering
the rate and inspiratory
pressure,
observing
for the adequacy
of spontaneous
breathing,
and monitoring
the heart rate.
CHEST

COMPRESSIONS

If the heart rate remains

less than 80
beats/mm
and is not increasing
noticeably
despite
15 to 30 seconds
of
adequate
ventilation
with oxygen,
chest compressions
should
be started.
PPV should,
of course,
be continued
and should
be interposed
with the
compressions,
as described
below.
The lower part of the sternum
should be compressed
at a point just
below the nipple line, taking care not
to depress
the xiphoid
process.
Either
of two acceptable methods may be
used (Figure
3)-the
resuscitators
overlapping thumbs may be used to
compress the sternum with the fin-

VoL 15
No. 7 July 1994
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from
http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

259

NEONATOLOGY

Resuscitation

WEIGHT

GESTATIONAL

<l000g

AGE

SIZE

<28wk

2.5mm

1000-2000

28-34

wk

3.0

mm

2000-3000

34-38

wk

3.5

mm

>3000g

>38wk

3.5-4.0

DEPTH OF INSERTION
(FROM UPPER LIP)

WEIGHT
1kg

7cm

2kg

8cm

3kg

9cm

4kg

10cm

Reproduced
with permission.
American
Heart Association.

Textbook

of Neonatal

gers encircling
the chest,
or the index
and middle
fingers
of one hand may
be used for compressions
while the
other hand supports
the infants
back.
With either method,
the sternum
should
be compressed
#{189}
to #{190}
inch
with a smooth,
regular
rhythm.
The
fingers
or thumbs
should
not lose
contact
with the chest during
relaxation.
Simultaneous
delivery
of chest
compressions
and PPV may impair
the effectiveness
of ventilation.
Chest
compressions
and ventilations,
therefore, should
be interposed
at a 3:1
ratio. The combined
rate of events
should
be 120 per minute,
that is, 90
compressions
and 30 ventilations.
Proper
timing
of these events
requires
close cooperation
between
the

Thumb
thumbs

m#{149}thod: Use
to compress

the

your

fingers

to support

the intants

back.

and

use both

sternum

j
Two-flnger
the sternum
infants
back

FIGURE

260

mm

mithod:
and use

Use the tips ot two fingers

of one hand to compress
your other hand or a very firm surface
to support
tie

3. Technique

for

chest

compressions.

as needed.
Although
the endotracheal
route is faster,
drug delivery
may be
impaired
by the presence
of unabsorbed
lung fluid,
intracardiac
rightto-left
shunting,
or adherence
to the
endotracheal
tube. Dilution
1 : 1 with
normal
saline (thereby
doubling
the
volume
to be administered)
may improve delivery
by this route.
If response
is poor to endotracheal
administration, an umbilical venous
catheter
should
be inserted
as soon as
possible
so that epinephrine
can be
given intravenously.

OTHER

MEDICATIONS

Volume

Expanders

Poor perfusion
in asphyxiated
infants
is more often a result of myocardial
dysfunction
than hypovolemia.
In
fact, many asphyxiated
infants
are
resuscitators
and counting
aloud,
normovolemic
or hypervolemic,
and
one-and-two-and-three-and-bagvolume
expansion
might be detrimenand....
tal. Particular
caution
should
be used
After the chest compressions
and
in giving
volume
expanders
to prePPV have been performed for 30 sec- term infants
because
of their susceponds,
the next evaluation-decision-ac- tibility
to intracranial
hemorrhage.
tion begins.
Again,
this decision
is
Hypovolemia
may be a factor,
howbased on evaluation
of the heart rate.
ever, due to either occult
blood
loss
If the pulse has increased at least to
(eg, fetal-maternal
transfusion)
or in
80 beats/mm,
chest compressions
can
the case of obvious
hemorrhage.
Volbe stopped,
with PPV continuing
unume expansion,
therefore,
is justified
til the heart rate is 100 beats/mm
and
in patients
who have known
or suseffective
respiratory
effort is seen.
pected
blood
loss and poor response
to other resuscitative
measures.
0Medications
(Table
4)
negative
reconstituted
whole
blood
crossmatched
with the mother
is
EPINEPHRINE
ideal, but not usually
available.
Colbids such as 5% albumin
can be
Epinephrine
should
be given if the
given,
as can normal
saline or Ringer
heart rate remains
below
80 beats/
lactate.
Any
of
these
usually
are
mm despite
30 seconds
of PPV and
given
in
boluses
of
10
mL/kg
over 5
chest compressions.
Persistent
bradyto 10 minutes.
If acute blood
loss
cardia
indicates
that the infant has
sufficient
to cause shock and neonaundergone
prolonged
and severe
astal
depression
has occurred,
much
phyxia,
and the myocardium
is unalarger
volumes
will
be
necessary
and
ble to deliver
oxygen
to itself even
emergency-release
0-negative
blood
with the assistance
of compressions.
(uncrossmatched)
may be justified.
Because
of its alpha-adrenergic
action, epinephrine
induces
peripheral
Sodium
Bicarbonate
vasoconstriction,
improving
perfusion
pressure
to the heart and brain.
It
Controversy
surrounding
the use of
bicarbonate
is growing,
but it is still
also has inotropic
and chronotropic
recommended
in prolonged
neonatal
effects
and is indicated
in cases of
resuscitations
for infants
refractory
to
asystole.
The dose of epinephrine is 0.01 to other measures.
When
used, it should
be diluted
with sterile
water to a con0.03 mg/kg of estimated weight,
centration
of 0.5 mEq/mL
and ingiven as 0.1 to 0.3 mL/kg in a
1:10 000 solution either endotrafused slowly
at a rate of 1 mEq/kg
per minute.
The recommended
dose
cheally
or intravenously.
This dose
is 2 mEqfkg.
may be repeated every 3 to 5 minutes
Resuscitation,

1987,

1990.

Copyright

Pediatrics

in Review

Vol.

15

Downloaded from http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

No.

July

1994

I
L

NEONATOLOGY
Resuscitation

Naloxone

Hydrochloride

mothers
are addicted
it is contraindicated

Maternal
narcotic
analgesia
can cause
neonatal
depression
with decreased
respiratory
effort and muscle
tone,
but infants
who exhibit
these symptoms usually
have a good heart rate
and perfusion
at birth. They typically
respond
well to ventilation
alone,
but
have prolonged
respiratory
depression
when PPV is weaned.
If this presentation is seen and the mother
has received
a narcotic
within
the 4 hours
before
delivery,
naloxone
hydrochloride should
be given.
The dose is 0.1
mg/kg
and can be given endotracheally
or intravenously.
Because
these patients
have good perfusion,
it
also can be given
intramuscularly
or
subcutaneously.
(Patients
who have
poor perfusion
probably
do not have
simple
narcotic
depression,
and naloxone
should
be deferred.)
The duration of naloxones
action
is shorter
than that of many narcotic
analgesics, so respiratory
depression
may
recur in these patients,
and they
should
be monitored.
Naloxone
can
induce
seizures
or other manifestations of withdrawal
in infants
whose

Calcium

to narcotics,
in these cases.

men to prevent
accidental
removal,
and medications
can be infused.
During
resuscitations,
catheters
often are inserted
hurriedly
without
optimal
sterile
technique
or precise
localization.
These
catheters,
therefore, usually
should
be removed
once
the infant has been stabilized
and
other vascular
access
has been obtamed.

so

and Atropine

Calcium
and atropine
are not recommended
in delivery
room resuscitation. These
medications
may be used
for specific
indications
in some neonatal resuscitations
(eg, hyperkalemia), but these conditions
do not
occur immediately
after birth.
UMBILICAL

SUMMARY

VESSEL

(FIGURE

CATHETERIZATION
In the uncommon
situations
in which
vascular
access
is needed
for neonatal resuscitation,
umbilical
vein catheterization
is recommended.
The
umbilical
vein is distinguished
easily
from the two umbilical
arteries;
it is
a larger caliber
vessel
having
a thin
wall and possibly
a flattened
appearance. The arteries,
in contrast,
are
smaller,
thick-walled,
and round.
A
3.5 or 5 French
radiopaque
catheter
having
a single end hole should
be
inserted
2 to 3 cm or until a free
flow of blood can be aspirated.
The
catheter
should
be taped to the abdo-

:
MEDICATION

CONCENTRATION
TO ADMINISTER

Epinephrine

1:10

Volume
expanders

PREPARATION

000

1 mL

Whole
blood
5% Albumin
Normal
saline
Ringer
lactate

Sodium
bicarbonate

0.5 mEq/mL
(4.2%
solution)

Naloxone

0.4

mglmL

Pediatrics

in Review

Vol.

endotracheally;
Textbook

15

No.

1M
intramuscularly;
of Neonatal
Resuscitation,

10 mLlkg
IV

Give

20 mL
or
two 1O-mL
prefilled
syringes

2 mEq/kg
IV

Give slowly,
2 mm

I mL

0.1 mg/kg
(0.25 mLfkg)
IV, ET,
IM, SQ

Give

0.1 mg/kg
(0. 1 mL/kg)
IV, ET,
IM, SQ

IV,

ia/v

1994

SQ
1987,

subcutaneously
1990. Copyright

RATE/PRECAUTIONS
Give

1.0 mg/mL

IV = intravenously;
ET
Reproduced
with permission.

DOSAGE/ROUTE
0.1-0.3
mL/kg
IV or ET

40 mL

1)

This cascade
of resuscitative
measures-oxygen
to PPV to chest cornpressions
to epinephrine-will
be
effective
in almost
all salvageable
infants.
(A few uncommon
conditions
that may require
special
interventions
in the delivery
room are discussed
separately.)
Each step of the resuscitation
is based on a straightforward
evaluation
that indicates
the success
or failure
of the infant to respond
to
the previous
step. At any point in
this progression
the infant may begin
to breathe
effectively
and have a
heart rate greater
than 100 beats/mm,
in which
case support
may be withdrawn
cautiously
in essentially
the

rapidly

May dilute 1:1 with

normal
saline
if giving
ET
over

5-10

mm

Give by syringe
drip

or IV

over

Give only if infant

being ventilated
effectively

American

Heart

at least
is

rapidly

ET preferred
IM, SQ acceptable

Association.

Downloaded from http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

261

[
L

NEONATOLOGY

Resuscitation
A#{149}

reverse
order.
be monitored
ing a thorough
uation

The infant then should

closely
while undergopostresuscitation
eval-

Special

Cases

MECONIUM-STAINED

FLUID

Although
meconium
staining
occurs
in approximately
12% of deliveries,
only a few of the involved
infants
develop
clinical
meconium
aspiration
syndrome
(MAS).
MAS is characterized by small airway
obstruction,
with air-trapping
and inflammatory
pneumonitis;
pneumothorax
and persistent
pulmonary
hypertension
are
serious
complications.
MAS is most
common
in asphyxiated
infants
who
have thick, particulate,
pea soup
meconium
staining.
These infants
have passed
meconium
before
birth,
presumably
because
of stress,
and
have aspirated
it before
or during
the
birth. The added
insult of aspirated
meconium
in an already
compromised
infant may exacerbate
hypoxia
and acidosis,
thus increasing
pulmonary vascular
resistance.
The appearance
of meconiumstained
amniotic
fluid changes
the
approach
to resuscitation
significantly.
These deliveries
must be attended
by at least one person
skilled
in endotracheal
intubation.
During
delivery
the infants
nose, mouth,
and posterior
pharynx
should
he suetioned
thoroughly
as soon as the head
clears
the perineum,
before
delivery
of the shoulders
and thorax.
In
breech
presentations,
the infant
should
he suctioned
as soon as possible following
completion
of the delivery.
Suctioning
must take
precedence
over the usual initial
steps of stabilization.
The goal is to
remove
meconium
before
the onset
of respirations;
therefore,
drying,
positioning,
or any type of stimulation
should
be deferred
until the airway
is
suctioned.
If the infant is apneic
or depressed
or if the meconium
staining
is thick
and particulate,
he or she should
be
intubated
and suctioned
endotracheally
as quickly
as possible.
Because thick, viscous
meconium
cannot
be removed
adequately
via
suction
catheters,
the endotracheal
tube itself is used for suctioning.
Special
meconium
aspirator
adaptors

262

PRETERM
INFANT
RESUSCITATION

are used to connect

the endotracheal
tube to the suction
tubing
for this
purpose
(Figure
4). The endotracheal
tube should
be withdrawn
slowly
while suctioning
is continued.
If meconium
is obtained
from the trachea,
the infant should
be reintubated
for
further
suctioning.
This process
should
be repeated
as necessary,
ideally until suctioning
produces
no
more meconium.
If the infant is severely
depressed,
having
profound
bradycardia
and cyanosis or pallor,
discretion
must be
used in deciding how long to delay
PPV and other resuscitative measures.
The potential
benefits
of removing
meconium
and decreasing
the
risk of severe
MAS must be weighed
against
the danger
of prolonging
hypoxia and acidosis.
Finally,
after the
airways
have been cleared
and the infant stabilized,
the infants
stomach
should
be suctioned
to prevent
regurgitation
and aspiration
of meconium.
To summarize
this controversial
issue, current
consensus
recommends
endotracheal
suctioning
of meconium-stained
infants
unless
ALL of
the following
three conditions
are
met:
Thorough
intrapartum suctioning of the pharyax has been
done prior to delivery
of the
thorax;
2. Meconium
staining
is thin and
watery;
and
3. The infant is vigorous,
with no
need for PPV.
[Note:
As with other resuscitative
procedures,
universal
precautions
should
be observed
with meconiumstained
infants.
DeLee
traps or other
methods
of mouth
suctioning
should
not be used.J

Because
preterm
births present
special challenges
in resuscitation,
these
deliveries
should
take place in level
II or III hospitals
whenever
possible.
These
patients
are much more likely
to need resuscitation,
especially
those
weighing
less than 1500 g. As many
as 80% of these very low-birthweight
infants
require
resuscitation.
Also,
preterm
infants
are much more
susceptible
to hypothermia,
respiratory insufficiency,
and intracranial
hemorrhage.
The approach
to resuscitation,
therefore,
is different.
Particular care should
be taken to minimize
heat loss, and the ambient
temperature in the delivery
room should
be
increased.
Respiratory
transition
is compromised by noncompliant
lungs,
decreased
strength
of respiratory
muscles
and drive,
and increased
chest wall compliance.
These
infants,
therefore,
are more likely to need
PPV, and early endotracheal
intubation may shorten
the stabilization
time. Some investigators
recommend
automatic
intubation
for all infants
below a certain birth weight, such as
1250 g.
Special
care must be exercised
in
the administration
of buffer or volume expanders
to small preterm
infants because
the germinal
matrix
vasculature
is fragile
in these patients.
Rapid changes
in intravascular
volume
and osmolarity
superimposed
on hypoxic
and ischemic
insults
increase
the risk of germinal
matrix
and intraventricular
hemorrhage.
Decisions
to give bicarbonate
or volume
expansion
should
take these risks into
account.
If they are necessary,
these
medications
must be given at the
proper
rates and dilutions.

FULL-TERM
RESPONSE
IS POOR

FIGURE

4. Meconium

aspirator

adaptor.

INFANT
WHOSE
TO RESUSCITATION

When
unexpected
respiratory
failure
is encountered
in a full-term
infant
who has no risk factors,
unusual
etiologies
should
be suspected.
Depending
on the extent
of prenatal
diagnostic
studies,
major anomalies
may not have been ruled out. Depending
on the extent
of intrapartum
monitoring,
perinatal
asphyxia
may
have gone undetected. As the infant

Pediatrics

in Review

VoL

15

Downloaded from http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

No.

July

1994

NEONATOLOGY

Resuscitation
is being resuscitated,
underlying
causes
should
be considered,
especially those having
implications
for
the resuscitation/stabilization
procedure.
Diaphragmatic
hernia
and other
causes
of pulmonary
hypoplasia
occasionally
cause this uncommon
dinical dilemma.
Other congenital
anomalies
of the respiratory
tract, ineluding
choanal
atresia,
laryngeal
or
tracheal
obstructions,
and cystic adenomatoid
malformation
of the lung,
would
be less likely.
Differential
diagnosis
also should
include
occult
hemorrhage
with hypovolemic
shock
and unsuspected
sepsis.
A cursory
physical
examination
may provide
the first clues.
Patients
who have diaphragmatic
hernia
may
look normal
at first glance,
but their
heart sounds
are auscultated
best in
the right chest in most cases (most
defects
occur in the left hemi-diaphragm,
with herniated
bowel
forcing
mediastinal
structures
to the right),
and the abdomen
may be flat or seaphoid.
Pulmonary
hypoplasia
should
be suspected
if there are signs of in.
trauterine
constraint
(flattened,
deviated
nose; low-set,
crumpled
ears;
small chin; positional
deformities
of
the extremities).
Other dysmorphic
features
may suggest
lethal malformations
or chromosomal
syndromes.
Abdominal
distention,
masses,
or ascites may be apparent.
Pallor,
mottling, and poor perfusion
or pulses
may be due to acute blood loss. Malodorous
amniotic
fluid may indicate
chorioamnionitis
and sepsis.
Pertinent
negative
findings
from
the prenatal
history
may be helpful.
A normal
karyotype,
normal
fetal ultrasonographic
findings,
and other
prenatal
studies
narrow
the differential significantly.
Obstetric
estimates
of amniotic
fluid volume
might raise
or lower the index of suspicion
for
certain
anomalies.
Gross examination
of the placenta
in the delivery
room also may provide clues.
Membranes
may be opacified from chorioamnionitis
or may
have amnion nodosum.
These granular nodules
are found sticking
to the
amnion
in cases of severe
oligohydramnios
and often are associated
with pulmonary
hypoplasia.
Retroplacental
hemorrhage
or lacerations
of
the cord or placenta
may explain
hypovolemic
shock.
Placental
infarcPediatrics

in Review

Vol.

15

No.

July

tions or atrophy
may be signs of
chronic
abruption
or other placental
vascular
disease.
In some of these conditions,
the
resuscitation
procedure
is altered.
Infants suspected
of diaphragmatic
hernia should
be intubated
immediately,
and gastric
decompression
should
be
started.
Patients
whose
lungs are hypoplastic
will require
vigorous
ventilation,
with higher
pressures
and
faster rates than usual.
These
infants
also will be more likely to develop
pneumothorax.
Volume
replacement
may be necessary
to revive
patients
whose
blood
loss has been acute.
Evidence
of severe,
uncorrectable
anomalies
may influence
the decision
to discontinue
resuscitation
in unresponsive
infants.

Emergency
Resuscitation

Department

Infants
sometimes
are delivered
in
hospital
emergency
departments
or
arrive there shortly
after birth; they
may be more likely than others
to
have complications
and need resuscitation.
Therefore,
contingency
plans
should
be established
for these infrequent but potentially
critical
situations.
Recognizing
that these settings
are
not ideal for newborn
resuscitation,
steps should
be taken to minimize
this possibility.
Admitting
procedures
should
be designed
to avoid delays
and to get women
in labor to the delivery room quickly
(if the facility
has one). Rescue
squad personnel
should
learn where
to take these
women
and recently
delivered
infants.
In some facilities
the delivery
room may be the best place for resuscitation
and evaluation
of outborn
infants.
As is the case for unexpected
complications
in the delivery
room,
advance
preparation
for neonatal
resuscitation
in the emergency
department
is essential.
Physicians,
emergency
medical
technicians,
nurses,
and other staff should
be
trained
in at least the preliminary
steps (eg, using the Neonatal
Resuscitation
Program).
A well-equipped
area should
be designated
for infant
resuscitation.
Charts
and other visual
aids may be helpful
reminders
of
basic procedures
and drug dosages.
The arrival
of a newborn
infant or
1994

mother
delivering
in the emergency
department
should
trigger
a preplanned sequence of events. Any
available
pediatric
back-up
and delivcry room or neonatal
staff should
be
notified.
A brief history
should
be
obtained,
if possible,
asking
a few
simple
questions:
Is this a premature
delivery?
Are there twins?
Is there
meconium
staining
of the amniotic
fluid? Are there any known
pregnancy complications?
Other steps are
similar
to those in the delivery
room
(see Immediate
Preparation).
Particular care with postresuscitation
management
must be taken with infants
resuscitated
prior to arrival
at the
hospital.
These
infants
should
be
evaluated
carefully,
both to assure
the adequacy
of the resuscitation
and
to rule out secondary
complications
such as pneumothorax
due to PPV.

Postresuscitation
Management
Newborn
infants
who have required
resuscitation
must be observed
carefully after stabilization.
Further
management
is determined
by the
underlying
condition(s)
responsible
for the need for resuscitation,
the severity
of asphyxia,
and the extent
of
secondary
postasphyxial
damage.
While
this evaluation
is underway,
the infant should
be watched
closely
by monitoring
vital signs and the cardiorespiratory
status frequently,
and
feedings
should
be withheld.
In addition to the infants
respiratory
status,
careful
attention
should
be paid to
the circulation/perfusion,
neurologic
condition,
and urine output.
Intravenous fluids
(usually
10% glucose
water)
should
be started
in most
cases,
and modest
fluid restriction
is
advisable.
Patients
requiring
ongoing
ventilatory
support
and those having
serious
or unresolved
underlying
problems
should
be admitted
to a tertiary level neonatal
unit.
The diagnostic
approach
includes
history,
physical
examination,
and
laboratory
and radiographic
studies.
Review of the obstetric and intrapartum history
may be enlightening,
with seemingly
insignificant
details
becoming
important
in retrospect.
A
thorough
physical
examination
may
reveal
subtle
abnormalities
not noted
in the haste of the resuscitation.
At a
minimum,
laboratory
studies
include

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263

NEONATOLOGY
Resuscitation
blood gases,
blood glucose,
and hematocrit.
A chest radiograph
can help
explain
the underlying
etiology
as
well as indicate
a secondary
complication.
Further
laboratory
tests, imaging studies,
or subspecialty
consultation
may be suggested
by
this baseline
assessment
or by further
clinical
observation.
Severity
of the insult is indicated
by the resuscitative
efforts
required.
The length of time PPV is required
before
the onset of spontaneous
respirations
is directly
proportional
to
the duration
of the preceding
asphyxia.
The need for more vigorous
resuscitation
(eg, chest compressions,
medications)
also implies
a more serious insult.
Neurologic
depression
or
cardiorespiratory
instability
are ominous signs,
as is the presence
of a
severe
metabolic
acidosis
in the mitial blood gas studies.
Postresuscitation
treatment
frequently
includes
ventilatory
support,
intravascular
volume
expansion,
vasopressors,
glucose
infusion,
and anticonvulsants.
Metabolic
acidosis
that
persists
despite
restoration
of adequate oxygenation
and circulation
may be buffered
with sodium
bicarbonate.
Umbilical
arterial
and venous
catheters
often are useful.
Fluid management
may be difficult
when attempting
to correct
hypoglycemia
or
improve
perfusion
in the face of cardiac or renal dysfunction.
Other specific treatments
would
be indicated
by the underlying
problems,
such as
antibiotics,
surfactant
replacement
therapy,
or surgery.
The need for
long-term
follow-up
will be determined by the previously
mentioned
assessments
and signs of renal or
neurologic
compromise.

fants unless they are too small.

A
decision
to terminate
efforts
eventually will become
appropriate
in some
unresponsive
infants.
These decisions
to withhold
or withdraw
resuscitation
are very difficult.
The pediatrician
must weigh
potential
risks and benefits of each case individually,
using
all available
information
in the context of currently
available
treatment
and realistic
outcome
projections.
HOW

The major determinants

of poor outcome in resuscitated
neonates
are extreme prematurity,
severe
congenital
anomalies,
and prolonged
asphyxia
with permanent
neurologic
damage.
In the absence
of these conditions,
the vast majority
of infants
survive
without
sequelae.
If uncorrectable,
severe
anomalies
have been diagnosed prenatally,
discussion
with the
parents
should
guide delivery
room
treatment.
In other cases,
the general
approach
should
be to begin aggressive resuscitation
on all depressed
in-

264

IS TOO

SMALL?

1 Policies
regarding
the lower limits
of viability
vary among
institutions
and change
at the same institutions
every few years.
The pediatrician
must know current
community
standards
and outcome
statistics.
Level
I or smaller
hospitals
may rely on
their referral
centers
for these standards.
Some authors
also have suggested
using physical
signs of
immaturity
(eg, fused eyelids)
or
birth trauma
(extensive
bruising)
along with the birth weight.
2. Very small infants
( < 750 g)
who require
more than PPV in the
delivery
room are unlikely
to survive. Those
who do survive
usually
spend many months
in intensive
care
and have a high incidence
of severe
morbidity.
3. Parental
wishes
must be considered, within
the limits of reasonable
medical
decision
making.
If at all
possible,
the pediatrician
and parents
should
discuss
the options
before delivery and agree on the resuscitative
approach
based on available
information. It may be helpful
to have the
parents
tour the neonatal
unit to see
premature
infants
and the intensive
care unit environment.
.

WHEN

Prognosis

SMALL

scores
of 0 survive
and that about
50% of these survivors
apparently
are
normal.
Only slight increases
in mortality and morbidity
are seen in patients failing
to respond
at 5 minutes,
but some studies
show worse
results
in those patients
who remain
unresponsive
after 10 minutes
of resuscitation. Dramatic
increases
in both
death and severe
sequelae
are seen in
patients
requiring
15 minutes
or
longer
of resuscitation
before
responding.
Based on these statistics,
it seems
reasonable
to continue
vigorous
resuscitative
efforts
for 10 to 15 mmutes. In the absence
of mitigating
factors,
more prolonged
resuscitation
of unresponsive
infants
probably
is
futile.
Furthermore,
inappropriate
prolongation
of resuscitation
may be
ill-advised
because
of the occasional
survival
of a profoundly
damaged
infant.

TO QUIT?

Aside from cases of extreme

prematurity and severe
anomalies,
some infants have suffered
such profound
and prolonged
asphyxia
that either
death or severe
disability
is inevitable. The duration
of asphyxia
is directly proportional
to the duration
of
PPV required
before
the onset of
spontaneous
respiratory
efforts.
It
follows,
therefore,
that salvageable
infants
will begin breathing
within
a
certain
length of time into the resuscitation
procedure.
Outcome
studies
have shown
that about 50% of infants who have 1-minute
Apgar

Conclusion
Neonatal
resuscitation
is required
fairly frequently
in hospital
delivery
rooms,
usually
(but not always)
in
high-risk
pregnancies.
Fortunately,
the majority
of infants
respond
quickly
to simply
clearing
of the airway and short-term
ventilatory
assistance. The consequences
of
inadequate
or delayed
intervention,
however,
are grave:
death or permanent disability.
Pediatricians,
therefore, must become
experts
in
delivery
room resuscitation.
Furthermore,
they must work with obstetricians,
nurses,
and administrators
to
assure
that this crucial
treatment
is
available
to all infants
who need it.
Use of educational
resources
such as
the Neonatal
Resuscitation
Program
and consultation
with nearby
tertiary
referral
centers
are recommended
to
achieve
this goal.

SUGGESTED

READING

Bloom
RS. Delivery
room resuscitation
of the
newborn.
In: Fanaroff
A, Martin
R, eds.
Neonatal-Perinatal
Medicine:
Diseases
of
the Fetus and infant.
St. Louis,
Mo: Mosby
Year Book;
1992;301-324
Bloom
RS, Cropley
C. In: Chameides
L and
AHA/AAP
Neonatal
Resuscitation
Steering
Committee,
eds. Testbook
of Neonatal
Resuscitation.
Dallas,
Tex: American
Heart
Association;
1990
Burchfield
Di, Berkowitz
ID, Berg RA,
Goldberg
RN. Medications
in neonatal
resuscitation.
Ann Emerg Med.
1993;22:435-439

Pediatrics

in Review

Vol.

15

Downloaded from http://pedsinreview.aappublications.org by Ana Acosta on September 20, 2010

No.

July

1994

NEONATOLOGY

Resuscitation
Davis
Di. How aggressive
should
delivery
room cardiopulmonary
resuscitation
be for
extremely
low birth weight
neonates?
Pediatrics.
1993;92:447-450
Guidelines
for cardiopulmonary
resuscitation
and emergency
cardiac
care. Emergency
Cardiac
Care Committee
and
Subcommittees,
American
Heart
Association.
Part VII. Neonatal
resuscitation.
JAMA.
1992;268:2276-2281

PIR QUIZ
1 . With the onset of respiration
at
birth,
which
one of the following
physiologic
changes
occurs?
A. An air-liquid
interface
is established.
B. Oxygenation
decreases.
C. Pulmonary
vascular
resistance
increases.
D. Shunting
through
the foramen
ovale increases.
E. Surfactant
is absorbed.
2.

Pediatrics

in Review

Of those infants
who require
resuscitative
intervention
at birth,
the
percentage
who were previously
thought
to be at low risk for perinatal complications
is closest to:
A. 0.1%
B. 1%
C. 5%

D.

10%

E.

20%

3.

An infant born at term is stimulated

and suctioned
and the skin is dried
quickly.
Evaluation
under a radiant
warmer
reveals
gasping
respirations;
heart rate, 90 beats/mm;
and moderate cyanosis.
Of the following,
the
most appropriate
next step is:
A. Administration
of oxygen
by
nasal canula.
B. Chest compression.
C. Continued
tactile
stimulation.
D. Positive
pressure
ventilation
with
oxygen.
E. Repeated
suctioning
of the oropharynx.

4.

During
infant
resuscitation,
the most
appropriate
use of epinephrine
is to
administer
it when:
A. The heart rate is less than 80
beats/mm
after 15 seconds
of
positive
pressure
ventilation
(PPV)
and chest compression
B. The heart rate is less than 80
beats/mm
after 30 seconds
of
PPv and chest compression
C. The heart rate remains
between
80 and 90 beats/mm
after 15
seconds
of PPV and chest compression
D. The heart rate remains
between
80 and 90 beats/mm
after 30
seconds
of PPV and chest compression
E. The heart rate does not increase
to at least 100 beats/mm
after 15
seconds
of PPV and chest compression

5.

If there is meconium
staining
of the
amniotic
fluid at delivery,
it is most
appropriate
to suction
the infants
nose,
mouth,
and posterior
pharynx
as soon as:
A. The head is delivered.
B. The shoulders
are delivered.
C. The umbilical
cord is clamped.
D. The infant can be placed
on the
mothers
abdomen.
E. The infant
can be placed
under
a
warmer.

Vol. 15
No. 7 http://pedsinreview.aappublications.org
July 1994
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from
by Ana Acosta on September 20, 2010

265

Neonatal Resuscitation
John E. Wimmer, Jr
Pediatr. Rev. 1994;15;255-265
DOI: 10.1542/pir.15-7-255

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