Birth

Infant is term gestation, amniotic fluid clear, breathing/crying, good muscle tone?

Yes: Warm, clear airway, dry, assess color and observe

NO: Warm, position/clear airway, dry, stimulate, reposition

Evaluate respirations, HR, color

• If breathing, HR>100 & Pink Observe
• If breathing, HR>100 & Cyanosis Oxygen [If Pink with this, observe, if persistent cyanosis then BVM with 100% Oxygen and reassess every 30 seconds, if HR60 then chest compressions]
• If apnea or HR100 BVM with 100% oxygen [If HR60 then chest compressions also]

In cases of reassessment in 30 seconds where HR<60 despite chest compressions and ventilation, administer Epinephrine and/or Volume resuscitation and consider endotracheal intubation.

Endotracheal intubation may be considered earlier in select cases.

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.