Resuscitation, Neonate

Basics

Description

Annually, almost 1 million deaths worldwide are related to birth asphyxia. ∼10% of newborns require some assistance at birth and 1% of newborns require extensive resuscitation
An APGAR score (Activity, Pulse, Grimace, Appearance, Respiration) is calculated for all infants at 1 and 5 min of life
- The APGAR score is a tool used to quantify an infant's clinical status. It should not be utilized to predict outcomes or guide resuscitation
- 5 categories with score of 0, 1, or 2 assessed at 1 and 5 min
- Do not wait to assign APGAR scores before starting resuscitation
- An APGAR score that remains a 0 after 10 min of resuscitation suggests that further resuscitation is unlikely to be successful and may be a useful tool in determining when to withdraw care

The health care provider and parents of a high-risk newborn must discuss the appropriateness of resuscitative measures. This is ideally done prior to delivery:

Newborns confirmed to be <23-wk gestation or 400 g
Anencephaly
Babies with confirmed trisomy 13 or 18

A physician is not ethically or legally required to perform futile or potentially harmful interventions, or to withhold beneficial treatment at the request of the parents

Heart Rate (HR)	Score
0	0
<100 bpm	1
>100 bpm	2

Respiration	Score
Absent	0
Slow, irregular	1
Good, crying	2

Muscle Tone	Score
Limp	0
Some flexion	1
Active motion	2

Reflex Irritability	Score
No response	0
Grimace	1
Cough, sneeze, cry	2

Color	Score
Blue or pale	0
Pink body, blue extremities	1
All pink	2

Etiology

Fetal–maternal gas exchange is facilitated by two right-to-left shunts:
- Ductus arteriosus: Deoxygenated blood flows from the pulmonary artery to the descending aorta, bypassing the carotid arteries
- Foramen ovale: Oxygenated blood flows from the placenta, through the fetal vasculature, into the right atria and is shunted through the foramen ovale to the left atria and aorta, bypassing the fetal lungs
The first spontaneous respirations by the infant initiate a cascade of physiologic changes including fluid clearance from the alveoli, lung expansion, decrease in pulmonary vascular resistance, and closure of the right-to-left shunts
Any problem with the respiratory effort, airway, or lung function portends a problematic transition to extrauterine life, leading to neonatal hypoxia and the need for resuscitation. Hypoxia may initially cause tachypnea followed by primary apnea

Antepartum risk factors associated with the need for resuscitation include:

Maternal diabetes
Pregnancy-induced or chronic hypertension
Anemia
Previous fetal or neonatal death
Bleeding in second or third trimester
Maternal infection
Maternal cardiac, renal pulmonary, thyroid, or neurologic disease
Polyhydramnios or oligohydramnios
Premature rupture of membranes
Post-term gestation
Multiple gestation
Size–dates discrepancy
Drug therapy
Maternal substance abuse
Fetal malformation
Diminished fetal activity
No prenatal care
Maternal age <16 or >35 yr

Intrapartum risk factors associated with need for resuscitation include:

Emergency C-section
Forceps or vacuum assist
Breech or other abnormal presentation
Premature labor
Precipitous labor
Chorioamnionitis
Prolonged rupture of membranes
Prolonged second stage of labor
Fetal bradycardia
Nonreassuring fetal heart tracing
General anesthesia
Uterine tetany
Narcotics administered to mother within 4 hr of delivery
Meconium-stained amniotic fluid
Prolapsed cord
Abruptio placenta
Placenta previa

There's more to see -- the rest of this topic is available only to subscribers.