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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.

Thermal Regulation

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.

Clear the Airway

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 System

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 ...

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