How is neonatal resuscitation managed in the delivery room?

How is neonatal resuscitation managed in the delivery room?

Within the first 20 seconds of birth, the neonate should be placed under a radiant warmer and actively dried (Figure 64.2). The mouth and nose should be suctioned. Respiratory effort and adequacy should be assessed within the first 30 seconds of birth. If there are adequate sponta-neous respirations, the heart rate should then be assessed. If there is no respiratory effort, inadequate respiratory effort (central cyanosis), or the neonate is gasping, positive-pressure ventilation (PPV) with 100% oxygen should be initiated at a rate of 40–60 breaths per minute with initial peak inspiratory pressures of 30–40 cm H₂O. Endotracheal intubation should be performed if bag-and-mask ven-tilation is inadequate, a congenital diaphragmatic hernia is suspected, or if there is a need for prolonged intubation.

An endotracheal tube (3.0–3.5 mm ID) may also be placed if a route for administration of resuscitative drugs is needed.

The heart rate should be checked after 15–30 seconds of PPV. If the heart rate is less than 60 beats per minute chest compressions should be started at 120 compressions per minute. Chest compressions can be accomplished in two ways:

·   Place both thumbs on the lower sternum while the other fingers encircle the neonate supporting the back.

·   Place two fingers of one hand on the lower sternum while the other hand supports the back.

The first method is preferred. Compressions should be about one third of the depth of the chest. More impor-tantly, compression depth should be sufficient to produce a palpable pulse. There should be a 3:1 ratio of compres-sions to ventilations. Heart rate should be reassessed every 30 seconds. Since cardiac depression is usually a result of inadequate respirations, once oxygenation and ventilation is restored the heart will in most cases resume normal function.

If after 30 seconds of manual ventilation and chest com-pressions (90 seconds after birth) the heart rate remains below 60 beats per minute, epinephrine should be administered. Epinephrine 1:10,000 at a dose of 0.01–0.03 mg/kg can be given either intravenously or endotracheally. The epinephrine may be diluted to 1–2 cc with normal saline for endotracheal administration. This should be repeated every 3–5 minutes as indicated (Table 64.1).

Additional resuscitative measures may include volume expansion with an isotonic crystalloid solution or colloids for the hypovolemic infant. Hypovolemia should be suspected in the infant who is not responding to the usual resuscitative measures or whose physical examination is consistent with shock. The initial dose of fluid is 10 cc/kg as a bolus. Additional fluid management should be based on clinical assessment.

Naloxone, a narcotic antagonist, is indicated for the respiratory-depressed neonate born within 4 hours of the mother receiving opioids. The recommended dose is 0.1 mg/kg and may be given by the intravenous, endotra-cheal, intramuscular, or subcutaneous route. Naloxone is not given to a neonate of a mother who is narcotic-addicted because it may precipitate withdrawal in the neonate. Once naloxone is given, the neonate must be observed for recur-rence of apnea because the duration of action of the opioid may exceed the effect of the naloxone.

Sodium bicarbonate should not be used routinely during resuscitation of the neonate. It is indicated only after prolonged resuscitation and documented metabolic acidosis on arterial blood gas. Adequate ventilation and circulation should be established prior to its administra-tion. The recommended dose is 1–2 mEq/kg of a 0.5 mEq solution.

When meconium is present in the amniotic fluid, specific steps should be taken to limit the risk of meconium aspiration (Figure 64.3). When the head of the neonate is delivered and prior to the neonate’s first breath, suctioning of the mouth, pharynx, and nose should be done. Despite this suctioning, there is a subset of neonates who will have meconium in the trachea despite the absence of sponta-neous respirations. It is presumed that this occurred in utero. If there is meconium-stained amniotic fluid and the neonate is vigorous after delivery, there is no need to per-form tracheal suctioning because it does not improve out-come. In fact, there may be complications associated with tracheal suctioning such as laryngeal trauma. However, if the neonate should develop respiratory or cardiac depres-sion subsequently, suctioning of the trachea should pre-cede PPV. In the neonate who has respiratory and/or cardiac depression (heart rate 60–100 beats per minute) at birth, direct laryngoscopy should be performed to suction the hypopharynx and to intubate the trachea for suctioning of any residual meconium that may be present.

Repeated intubations and suctioning should be performed until there is minimal meconium recovered or the heart rate is less than 60 beats per minute. During this maneuver, an assistant should be monitoring the heart rate continu-ously. Even if there is still meconium, once the heart rate is less than 60 beats per minute, resuscitative measures should be initiated immediately.

It is important that all the equipment and pharmaco-logic agents necessary for resuscitation efforts are available and of the appropriate size (Table 64.2).