Resuscitation of the newborn is required to some extent in nearly
10% of all births. Extensive resuscitation is required
in about 1%. Delivery room resuscitation is required for
>50% of the high-risk population of very-low-birth-weight
(<1500 grams) newborns. With proper antenatal and intrapartum
surveillance, the potential need for active resuscitation at birth
can be identified before birth. Unfortunately, the arrival of a
newborn to the ED is never planned. This chapter reviews the principles
of emergency resuscitation of neonates.
The transition from intrauterine to extrauterine life is a treacherous time.
Even the normal laboring process places significant stress upon
the placental-fetal unit. Blood flow and, therefore, oxygen delivery
is transiently impaired during uterine contractions. Compression
of the umbilical cord, when it occurs, further impairs circulatory
flow. Although antenatal/intrapartum US imaging, along
with fetal heart tone monitoring, has permitted better surveillance
of fetal well-being, prediction of fetal status at birth remains
inexact. Complications of labor, such as preterm delivery and/or
prolonged rupture of membranes, breech or transverse fetal position,
placental abruption, and umbilical cord problems, such as a nuchal
cord (cord wrapped around the neck) or true knots in the cord, can
significantly heighten the risk to the fetus. For further discussion,
see Chapter 105, Emergency Delivery.
Once delivery occurs, the newborn still faces a variety of risks
as the transition to extrauterine life unfolds. Requirements of
this transition include the onset of respiration, absorption of
lung fluid, reduction of pulmonary vasculature resistance to allow
flow to the pulmonary vascular circuit, and closure of the ductus
arteriosus. The transition from the sterile intrauterine environment
to the extrauterine world teeming with bacteria places a further
potential burden on the newborn.
A brief history should be obtained from the mother that includes
the date of last menstrual period/estimation of gestational
age, number of previous pregnancies and living children, history
of diabetes, hypertension or pregnancy-related problems, prenatal
care (yes/no), history of prolonged rupture of membranes,
fever, and meconium-stained fluid.
Even before initiation of the ABCs of resuscitation, place the
newborn in an environment that provides a neutral thermal environment
using a preheated radiant heat source. Place the infant on its back
in the warmer. Then, gently dry the newborn with a warm towel while preparing to initiate resuscitation. Very-low-birth-weight
newborns may also be better maintained in a normothermic state by
placement in polyethylene bags that have been developed for that
purpose. Hyperthermia should also be avoided, as it may precipitate
apnea and worsen hypoxic-ischemic injury.
Position the head in the sniffing position to help open the airway.
Suction the nose and mouth with a bulb syringe or mechanical
suction with an 8F suction catheter. An Apgar score can then be
calculated. If the infant is crying, pink, has spontaneous respirations,
and has a heart rate (HR) faster than 100 beats/min, no
further treatment is likely needed.
Expanded Apgar Scoring
The Apgar scoring system has been used for generations to assist
medical personnel in assessing newborns and the response to resuscitation.
The newborn is evaluated ...