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
      00
      <100 bpm1
      >100 bpm2
      RespirationScore
      Absent0
      Slow, irregular1
      Good, crying2
      Muscle ToneScore
      Limp0
      Some flexion1
      Active motion2
      Reflex IrritabilityScore
      No response0
      Grimace1
      Cough, sneeze, cry2
      ColorScore
      Blue or pale0
      Pink body, blue extremities1
      All pink2

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

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