1% of neonates require extensive resuscitation and 10% require some assistance to begin breathing at birth.

Newborns that do not spontaneously breathe or cry or have good muscle tone are likely to require resuscitation. Neonates who require resuscitation are more likely to have one or more of the following features:

• <37 weeks EGA
• Meconium stained amniotic fluid
• Infected amniotic fluid
• Mother who is febrile
• Other factors such as intrauterine distress

At least one person should be designated, skilled and immediately available to resuscitate any newborn requiring resuscitation. Steps in order they should be provided are [Each step provided for 30 seconds then neonate is reassessed and if needed progress to the next step]:

1. Provide warmth, position, clear airway, dry & stimulate and reposition
2. Provide ventilations (neonatal BVM w/ 100% O2)
3. Provide chest compressions (HR <60)
4. Fluid resuscitation and/or epinephrine
5. Consideration of endotracheal intubation

* Consider bedside glucometer for hypoglycemia

Notes on Ventilation

• Positive pressure ventilation using neonatal BVM at 40-60/min with 100% Oxygen
• Initial inflating pressures of 30-40 cm H2O are typical
• Preterm infants require lower volumes and pressures and may be more susceptible to lung damage

Indications for Placement of Endotracheal Tube (ETT)

• When suctioning of meconium is needed
• When respirations not supported (or prolonged) via BVM
• When ETT route for medications needed
• When chest compressions are needed
• Conditions where ETT is expected to be needed:
• Very low birth wt <1000 grams
• Diaphragmatic hernia

Chest Compressions

• HR<60 despite stimulation, warmth, drying and 30 seconds of ventilation with 100% O2
• Technique preferred is compression to lower 1/3^rd of sternum with 2 thumbs with hands encircling the chest
• Alternative technique; index and middle finger to lower 1/3^rd of sternum

Medications/Fluids

• Rarely needed; typically lack of ventilation and oxygenation is the cause of bradycardia and other instability
• If HR<60 despite ventilation/oxygenation and chest compressions, fluids and/or epinephrine may be indicated
• Epinephrine dosing:0.01-0.03 mg/kg/dose IV (0.1 mg/kg by ETT) q3-5 minutes
• Fluids:LR or NS 10 mL/kg given IVP in a syringe; may be repeated (caution in premature infants, as large volumes of rapid infusions are associated with intraventricular hemorrhage).
• Naloxone:Only rarely indicated; supportive care is favored, but if given in the case of opiate related depressed state 0.1 mg/kg IV or IM (may need to be repeated).
• Dextrose:D10W 5-10 mL/kg (0.5-1 gram/kg) should be used for infants who are hypoglycemic (<40 mg/dL).

Notes on Meconium Stained Fluid

The standard care is to provide Endotracheal suctioning for neonates in the event they are not vigorous (weak respiratory efforts, HR<100 bpm, poor muscular tone) and this should be provided immediately after birth. For vigorous neonates; suctioning should not routinely be provided.

Notes on Discontinuing Resuscitation

With 10 minutes of adequate resuscitative efforts and no heart beat & no respiratory effort; discontinuation of resuscitation may be considered. In these cases, even in the event of response to resuscitation; there remains an almost inevitable outcome of mortality or severe neurodevelopmental disability.

Source: Circulation 2005;112. 2005 AHA Guidelines for CPR and ECC.