Neonatal Resuscitation

This section covers resuscitation of the neonate. Neonatal resuscitation is:

• Required in ~5%
  The majority need gentle manoeuvres; drying, stimulation, warming. Need for:
  • Intubation and ventilation is unlikely
  • Compressions is rare
    Those who require compressions generally do badly.
• Required more commonly in premature infants
  Poor alveolar expansion and reduced surfactant impair transition to adult circulation.

Assessment

• A
  • Patency
    Crying indicates patency.
  • Presence of blood/meconium
    Suction if present.
• B
  • Colour
    
    • Normal to remain “hypoxic” for first 10 minutes of life
      Bluish hands and feet are normal.
• C
  • HR > 130
• E
  • Spontaneous flexion and movements are sign of good tone
    Suggest unlikely to be compromised.
  • Heat loss prevention is essential

APGAR Score

Evaluation of a newborn:

• Used to determine whether they need medical intervention
  Poor scores at later times (e.g. 10-30 minutes post-delivery) do correlate with poor neurological outcome.
• Based on five criteria
• Performed at 1, 5, and 10 minutes post-delivery
• Scored out of 10
  0, 1, or 2 points in each category.

Criterion	0
Appearance	Blue or pale
Pulse	Absent
Grimace	No response
Activity	None
Respiration	Absent

Management

Follows an ABC approach:

• A
  • Place supine
  • Dry and stimulate
  • Head neutral/slightly extended
  • Intubation can be considered if:
    • Unable to BMV
    • No detectable heart rate
• B
  • Commence CPAP with room air if HR >100 and there is laboured breathing or persistent cyanosis
  • Commence PPV with room air if HR ⩽100 after drying and stimulation
    Generally Pip 30, PEEP 5, at a rate of 40-60/minute.
  • Transition to 100% oxygen if:
    • SpO₂ is ⩽70% at 5 minutes
    • HR ⩽100/min after 1 minute of PPV
    • Preparing for intubation
    • HR ⩽60/min and chest compressions indicated
• C
  • Commence chest compressions at 100-120 per minute if:
    Need for chest compressions mostly occurs if PPV has not been performed correctly.
    • HR ⩽60/min despite adequate PPV with supplementary oxygen
  • Adrenaline 10-30µg/kg (0.1-0.3mL/kg of 1:10,000 solution) if HR < 60
  • Consider 10mL/kg IV crystalloid if blood loss suspected
• E
  • Warm
    • Radiant warmer
    • Polyethylene bag if ⩽1500g

Target SpO₂

A rough rule of thumb is that the lower limit at birth is 60%, and ↑ by ~5% every minute.

SpO₂ should be measured pre-ductally, i.e. on the right arm or ear:

Time (minutes)	Saturation
1	60-70%
2	65-85%
3	70-90%
4	75-90%
10	80-90%

Equipment

• General
  • Resuscitation trolley
  • Light source
  • Timer
• A
  • Suction and suction tubing
  • Oxygen masks
  • T-piece
  • Ventilation system
    • Neopuff
    • Self-inflating bag
    • Flow-inflating bag
  • Laryngoscope
  • ETT
    In a range of sizes: 2.5-4.0.
  • Magill neonatal forceps
  • Sterile scissors
• B
  • Medical air
  • Medical oxygen
  • Flowmeters and tubing
• C
  • Fluid
  • Adrenaline
• E
  • Overhead warmer
  • Warmed towel
  • Polyethylene bag
    

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References