Emergently manage the ill newbornin the delivery room
Emergently manage the ill newbornin the delivery room: Excerpt from Avoiding Common Pediatric Errors
Author:
Sarika Joshi, MD
What to Do - Take Action
Pediatricians should be familiar with the management of newborn infants in
the delivery room. The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC)
updated the prior 1992 recommendations established after the Fifth National Conference on CPR and ECC. The most important aspect of this
management is the establishment of adequate ventilation.
At birth, the newborn must make the dramatic transition from placental gas exchange and fluid-filled lungs to pulmonary gas exchange with
air-filled lungs. The lungs expand, pulmonary blood flow increases, and
pulmonary vascular resistance decreases. Some antepartum factors associated with risk for the newborn's transition to be difficult include maternal
diabetes, pregnancy-induced hypertension, poly-or oligohydramnios, and
premature rupture of membranes. Some intrapartum risk factors for the
newborn to have a difficult transition are breech presentation, premature
labor, chorioamnionitis, or meconium-stained amniotic fluid.
It is recommended that at least one person skilled in neonatal resuscitation attend every delivery, and that another person, able to perform a
complete resuscitation, should be immediately available. About 1% to 10%
of newborns require some form of assisted ventilation. The need for intervention is based on evaluation of the newborn's respirations, heart rate, and
color. Gasping and apnea indicate the need for assistance with ventilation.
Heart rate, which is most easily assessed by feeling the pulsations at the
base of the umbilical cord, should be greater than 100 beats per minute.
The newborn should be pink, although acrocyanosis is a normal finding
at birth. Neonatal resuscitation can be broken down into four categories
of intervention: (a) basic steps, (b) ventilation, (c) chest compressions, and
(d) administration of medications and fluids.
The basic steps of neonatal resuscitation include warming the infant,
clearing the airway, stimulation, and oxygen administration. Heat loss increases the newborn's need for oxygen consumption. To prevent heat loss,
the newborn should berapidly driedundera radiantwarmer,with continued
removal of the wet linens. Airway clearance involves the appropriate positioning of the infant, with the newborn placed on its back or side with the
head neutral or somewhat extended, and the removal of secretions, by wiping away from the nose and mouth. If suctioning is necessary, a bulb syringe
is generally adequate, with the mouth being suctioned prior to the nose to
minimize the risk of aspiration. If a suction catheter is required, care must be
taken to avoid long or aggressive suctioning, as stimulation of the posterior
pharynx can result in a vagal response and bradycardia. If the amniotic fluid
is stained with meconium, the newborn's mouth and nose are suctioned on
delivery of the head. In depressed infants (e.g., poor respirations, muscle
tone, or heart rate), drying and suctioning are delayed, and the newborn is
immediatelyintubatedfortrachealsuctioning,aprocessthatisrepeateduntil
the airway is cleared of meconium or until further resuscitation is required.
The two remaining basic steps include stimulation and oxygen administration. The goal of stimulation is for the newborn to start and continue adequate respirations. Usually the drying and suctioning that accompanies each
resuscitation is all that is required to stimulate the child. If these interventions are not adequate, then gentle rubbing of the newborn's back or flicking
the soles of the feet can be employed. One hundred percent oxygen should
be administered to all newborns requiring resuscitation to treat hypoxia.
If the infant's respiratory effort remains depressed, positive pressure
ventilation should be initiated. Additional indications for positive pressure
ventilation include gasping, apnea, heart rate <100 beats per minute, and
central cyanosis. For the majority of newborns, a bag and mask provide satisfactory ventilation, which is best measured by watching for bilateral chest
expansion. Forty to 60 breaths per minute, or 30 if the infant also requires
chestcompressions,shouldbeprovided.Anorogastrictubeshouldbeplaced
to avoid gastric inflation. After 30 seconds, the infant should be reassessed. If
spontaneous respirations are still inadequate, or the heart rate is <100 beats
per minute, bag-mask ventilation should be continued. If a bag and mask
cannot provide satisfactory ventilation, the newborn should be intubated.
Chest compressions are indicated if, despite satisfactory ventilation with
100% oxygen for 30 seconds, heart rate is <60 beats per minute. Compressions are delivered on the lower third of the sternum with two thumbs on
the sternum and fingers encircling the chest and back. The chest should be
compressed to a third of its anteroposterior diameter. Chest compressions
and breaths should be delivered in a 3:1 ratio with 90 compressions and 30
breaths per minute. After 30 seconds, the infant is reassessed. Compressions
should continue until heart rate is >60 beats per minute.
Epinephrine is indicated if, despite satisfactory ventilation with 100%
oxygen and chest compressions for 30 seconds, the heart rate remains
<60 beats per minute. Intravenous or endotracheal epinephrine should be
administered every 3 to 5 minutes as indicated, at a dose of 0.1 to 0.3 mL/kg
of a 1 to 10,000 dilution. Volume expansion, with normal saline or Ringer's
lactate, should be considered in any newborn who fails to respond to resuscitation, especially if blood loss or shock is suspected. The fluids should be
given over 5 to 10 minutes with an initial dose of 10 mL/kg.
Although most newborns require nothing more than basic steps in the
delivery room, pediatricians should be comfortable with more advanced
neonatal resuscitation. Establishment of adequate ventilation is the key, because bradycardia is usually the result of poor lung inflation and hypoxia.
Suggested Readings
Kattwinkel J, Niermeyer S, Nadkarni V, et al. ILCOR advisory statement: resuscitation of
the newly born infant. An advisory statement from the pediatric working group of the
International Liaison Committee on Resuscitation. Circulation. 1999;99:1927–1938.
Niermeyer S, Kattwinkel J, Van Reempts P, et al. International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care: International Consensus on Science. Contributors and
Reviewers for the Neonatal Resuscitation Guidelines. Pediatrics. 2000;103(3):E29.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Childbirth
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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