Initial Resuscitation
Supplementary Oxygen
Supplementary Oxygen Versus Room Air
There is currently insufficient evidence to specify the concentration of oxygen to be used at initiation of resuscitation. After initial steps at birth, if respiratory efforts are absent or inadequate, lung inflation/ventilation should be the priority. Once adequate ventilation is established, if the heart rate remains low, there is no evidence to support or refute a change in the oxygen concentration that was initiated. Rather the priority should be to support cardiac output with chest compressions and coordinated ventilations. Supplementary oxygen should be considered for babies with persistent central cyanosis. Some have advocated adjusting the oxygen supply according to pulse oximetry measurements to avoid hyperoxia, but there is insufficient evidence to determine the appropriate oximetry goal because observations are confounded by the gradual increase in oxyhemoglobin saturation that normally occurs following birth. Excessive tissue oxygen may cause oxidant injury and should be avoided, especially in the premature infant.
Peripartum Management of Meconium
Intrapartum Suctioning
Routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born with meconium-stained amniotic fluid is no longer recommended.
Tracheal Suctioning
Meconium-stained, depressed infants should receive tracheal suctioning immediately after birth and before stimulation, presuming the equipment and expertise is available. Tracheal suctioning is not necessary for babies with meconium-stained fluid who are vigorous.
Ventilation Strategies
Initial Breaths
Establishing effective ventilation is the primary objective in the management of the apneic or bradycardic newborn infant in the delivery room. In the bradycardic infant, prompt improvement in heart rate is the primary measure of adequate initial ventilation; chest wall movement should be assessed if heart rate does not improve. Initial peak inflating pressures necessary to achieve an increase in heart rate or movement of the chest are variable and unpredictable and should be individualized with each breath. If pressure is being monitored, an initial inflation pressure of 20 cm H2O may be effective, but a pressure >30 to 40 cm H2O may be necessary in some term babies. If pressure is not being monitored, the minimal inflation required to achieve an increase in heart rate should be used. There is insufficient evidence to recommend optimal initial or subsequent inflation times.
Assisted Ventilation Devices
A self-inflating bag, a flow-inflating bag, or a T-piece mechanical device designed to regulate pressure as needed can be used to provide bag-mask ventilation to a newborn.
Laryngeal Mask Airway (LMA)
The LMA may enable effective ventilation during neonatal resuscitation if bag-mask ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible. There is insufficient evidence to recommend use of the LMA as the primary airway device during neonatal resuscitation or in the settings of meconium-stained amniotic fluid, when chest compressions are required, or for the delivery of drugs into the trachea.
Ventilation Strategies for Preterm Infants
Providers should avoid creation of excessive chest wall movement during ventilation of preterm infants immediately after birth. Although measured peak inflation pressure does not correlate well with volume delivered in the context of changing respiratory mechanics, monitoring of inflation pressure may help provide consistent inflations and avoid unnecessarily high pressures. If positive-pressure ventilation is required, an initial inflation pressure of 20 to 25 cm H2O is adequate for most preterm infants. If prompt improvement in heart rate or chest movement is not obtained, then higher pressures may be needed.
Use of Continuous Positive Airway Pressure (CPAP) or Positive End-Expiratory Pressure (PEEP)
There is insufficient data to support or refute the routine use of CPAP during or immediately after resuscitation in the delivery room.
Exhaled Carbon Dioxide (CO2) Detectors to Confirm Tracheal Tube Placement
Tracheal tube placement must be confirmed after intubation, especially in infants with a low heart rate that is not rising. Exhaled CO2 detection is useful to confirm tracheal tube placement. During cardiac arrest, if exhaled CO2 is not detected, tube placement should be confirmed with direct laryngoscopy.
Medications
Epinephrine
Route and Dose of Epinephrine
Despite the lack of human data, it is reasonable to continue to use epinephrine when adequate ventilation and chest compressions have failed to increase the heart rate to >60 beats per minute. Use the intravenous (IV) route for epinephrine as soon as venous access is established. The recommended IV dose is 0.01 to 0.03 mg/kg. If the tracheal route is used, give a higher dose (up to 0.1 mg/kg). The safety of these higher tracheal doses has not been studied. Do not give high doses of intravenous epinephrine.
Volume Expansion
Crystalloids and Colloids
In consideration of cost and theoretical risks, an isotonic crystalloid solution rather than albumin should be the fluid of choice for volume expansion in neonatal resuscitation.
Other Drugs
Naloxone
Naloxone is not recommended as part of the initial resuscitation of newborns with respiratory depression in the delivery room. Before naloxone is given, providers should restore heart rate and color by supporting ventilation. The preferred route should be IV or intramuscular. Tracheal administration is not recommended. There is no evidence to support or refute the current dose of 0.1 mg/kg.
Supportive Therapy
Temperature Control
Maintenance of Body Temperature
Very low birth weight preterm babies remain at risk for hypothermia. Consider the use of plastic bags or plastic wrapping under radiant heat as well as standard techniques to maintain temperature. All initial resuscitation steps, including intubation, chest compression, and insertion of lines, can be performed with these temperature-controlling interventions in place.
Postresuscitation Management
Temperature
Hyperthermia
The goal is to achieve normothermia and to avoid iatrogenic hyperthermia in babies who require resuscitation.
Therapeutic Hypothermia
There is insufficient data to recommend the routine use of systemic or selective cerebral hypothermia after resuscitation of infants with suspected asphyxia. Further clinical trials are needed to confirm that treatment with cooling is beneficial, to identify infants who will benefit most, and to determine the most effective method and timing of cooling.
General Supportive Care
Glucose
Based on available evidence, the optimal range of blood glucose concentration to minimize brain injury following asphyxia and resuscitation cannot be defined. Infants requiring resuscitation should be monitored and treated to maintain glucose in the normal range.
Timing of Cord Clamping
No recommendation can be made about the timing of cord clamping when resuscitation is required.
Withholding or Discontinuing Resuscitative Efforts
A consistent and coordinated approach to individual cases by obstetric and neonatal teams and parents is an important goal. Not starting resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not be hesitant to withdraw support when functional survival is highly unlikely. The following guidelines must be interpreted according to current regional outcomes and societal principles:
- When gestation, birth weight, or congenital anomalies are associated with almost certain early death and an unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples from the published literature from developed countries include:
- Extreme prematurity (gestational age <23 weeks or birth weight <400 g)
- Anomalies such as anencephaly and confirmed trisomy 13 or 18
- In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated.
- In conditions associated with uncertain prognosis, when there is borderline survival and a relatively high rate of morbidity, and where the burden to the child is high, the parents' views on starting resuscitation should be supported.
If there are no signs of life after 10 minutes of continuous and adequate resuscitative efforts, it may be justifiable to stop resuscitation.
