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The cornerstone of neonatal resuscitation is the prompt recognition of the newborn who is failing to breathe and perfuse organs effectively. Immediately after birth, the newborn should be dried, gently suctioned, and assessed for: adequate respiratory effort (versus apnea); a heart rate above 100 beats/min; good muscle tone (as opposed to flaccidity); skin color that indicates effective cardiac output (rather than cyanosis); and evidence of full-term versus pre-term birth.
The neonate who lacks some of these findings should be professionally managed, with warming, gentle stimulation (e.g., rubbing its back gently with a towel to stimulate effective breathing) and airway suctioning. When apnea, hypothermia, respiratory distress, bradycardia, or poor skin perfusion is evident, evidenced-based interventions (e.g., those recommended by the Neonatal Resuscitation Program of the American Academy of Pediatrics and the AHA) should be begun immediately.
Positive-pressure ventilation (PPV), with breaths supplied via a bag mask device, effectively resuscitates most infants at risk for neonatal asphyxia. Those who have meconium in the upper airways (evidenced by meconium staining of the amniotic fluid), as well as inadequate breathing, slow heart rate, and poor muscle tone, require endotracheal intubation and suctioning, preferably by an experienced practitioner.
Most neonates respond favorably to airway and ventilatory management, breathe spontaneously, and maintain a heart rate above 100 beats/min. Chest compressions should be begun only if the heart rate remains below 60 beats/min despite 30 sec of PPV with 100% oxygen. Chest compressions should cease when the heart rate is above 60 beats/min, but PPV should be continued until the heart rate is above 100 beats/min and the newborn has begun to breathe on his own. PPV should always accompany chest compressions and be coordinated so that a breath is provided after every third compression. After 30 sec of PPV and chest compressions, the compressions should be stopped and the heart rate evaluated while PPV is continued. If there is no palpable pulse at the base of the umbilical cord, PPV should be stopped and the chest auscultated to determine the heart rate.
Chest compressions are most effective when the sternum is depressed to a depth equal to one third of the anteroposterior chest diameter of the newborn. The preferred technique is to use the thumbs to depress the sternum, with the hands encircling the newborn’s thorax. An alternative is to perform compressions with two fingers on the same hand, so that the umbilical vein can be cannulated by another resuscitator. Ninety compressions a minute should be coordinated with 30 positive-pressure breaths, with care taken to avoid simultaneous compressions and ventilations.
Access to the circulation can be gained through the umbilical vein or intraosseously into the tibia. Normal saline or lactated Ringer’s solution is the preferred fluid. Narcotic antidotes should be given to reverse any depression in respiratory or neurological status from maternal narcotic overdose. Inotropes such as epinephrine should be used when ventilation and chest compressions do not revive the dying infant.
In prolonged resuscitations, blood gases should be drawn to help guide additional therapies.
Resuscitative interventions that have not proved to be helpful include the use of high-dose epinephrine, the induction of cerebral hypothermia, and the use of carbon dioxide detectors on the endotracheal tube.
Resuscitation should not be initiated for children born with severe anomalies incompatible with life, e.g., anencephaly or birth weights of less than 400 g. Resuscitative efforts that do not resolve apnea and pulselessness after more than 10 min are rarely successful in newborns. In these circumstances, efforts may be discontinued.