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 cease resuscitative efforts
  • 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 <24-wk gestation or 400 g
    • Anencephaly
    • Babies with confirmed chromosomal abnormalities
    • 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
      Pulse (Heart Rate [HR])Score
      00
      <100 bpm1
      >100 bpm2
      RespirationScore
      Absent0
      Slow, irregular1
      Good, crying2
      Activity (Muscle Tone)Score
      Limp0
      Some flexion1
      Active motion2
      Grimace (Reflex Irritability)Score
      No response0
      Grimace1
      Cough, sneeze, cry2
      Appearance (Color)Score
      Blue or pale0
      Pink body, blue extremities1
      All pink2

Etiology

  • Fetal–maternal gas exchange is facilitated by 2 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 atrium and aorta, bypassing the fetal lungs
  • The 1st 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 shunt
  • 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 2nd or 3rd trimester
    • Maternal infection
    • Maternal cardiac, renal pulmonary, thyroid, or neurologic disease
    • Polyhydramnios or oligohydramnios
    • Premature rupture of membranes
    • Postterm 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 2nd 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

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