Resuscitation

Index1. Introduction:2. Incidence and risk factors

Need for resuscitationAntenatal prediction of need for resuscitation

3. Consequences: Complications of neonatal resuscitation4. Equipment needed for resuscitation5. Algorithm for neonatal resuscitation

Assessment at deliveryMinimise heat lossSuctioning of the airwayAssisted ventilationTracheal intubationCombined external cardiac compression and assisted ventilationAssess responseFailure to respond to resuscitationVascular access

6. Drugs in resuscitation7. Volume replacement in resuscitation8. Cord blood sampling9. Management after resuscitation

10. Cessation of cardiopulmonary resuscitation11. Key points12. References

1. Introduction:

Effective resuscitation of the newborn infant requires adequate training and preparation of staff involved in the care of women inlabour, a knowledge of maternal and intrapartum risk factors that may influence the postnatal course of the infant, andadequate and functioning equipment for resuscitation of the newborn. "As poor cardiorespiratory adaptation at birth (low Apgarscores) cannot be predicted in the majority of cases, all staff involved in care during labour should be skilled in resuscitation ofthe newborn".1

2. Incidence and risk factors:

Need for resuscitation:In 2009 in Australia, a total 294,540 women gave birth to 299,220 babies. There were 296,791 livebirths and 2,341 fetal deaths. 8.2% of babies were born preterm (before 37 completed weeks of gestation) and 0.9% post-term(42 weeks gestation or more). Most women (68.5%) had a vaginal birth, and of these, 82.9% did not involve the use ofinstruments. Overall, 31.5% of women gave birth by caesarean section. Overall, 6.2% of live born babies were of low birthweight (less than 2,500 grams). Less than 1.5% of live born babies had a low Apgar score. The perinatal death rate was 9.8per 1,000 births in 2009, which comprised fetal and neonatal death rates of 7.8 per 1,000 births and 3.0 per 1,000 live birthsrespectively.2.

Suction and oxygen therapy were the most common types of resuscitation used. Just over one-quarter (28.1%) of babiesrequired some form of resuscitation at birth, although most of these babies (71.3%) required only suction or oxygen therapy.Ventilatory assistance by intermittent positive pressure respiration (IPPR) through a bag and mask or after endotrachealintubation was performed for at least 7.2% of all live births. External cardiac massage and ventilation was provided for a

minority of babies (0.3%).2.

Antenatal prediction of need for resuscitation: only about half of the infants needing resuscitation are predicted by antenatalhistory or signs during labour1,3. International guidelines on neonatal resuscitation4 and College guidelines5 state that anappropriately trained practitioner should be present at all births (including caesarean section) and an advanced skillspractitioner present for high risk deliveries. Assessment should include a history of maternal and intrapartum risk factors thatmay affect the infant including pre-existing medical conditions in the mother, problems of pregnancy, abnormalities identifiedantenatally in the fetus, the presence of meconium stained liquor, CTG abnormalities, scalp pH or lactate, maternal indicators ofinfection, presentation and method of delivery.

Neonatal medical/tNNP staff should attend all high-risk deliveries including:

Preterm infants < 35 weeks gestation6

Multiple birthsInfants with significant congenital malformation diagnosed antenatallyAbnormal CTG or scalp pH < 7.21 or scalp lactate > 4.2mmol/L7, 8

Thick (particulate) meconium stained liquorBreech deliveryInstrumental delivery (not uncomplicated low forceps or vacuum lift-out)Caesarean section under general anaestheticEmergency caesarean sectionOpioids administered to the mother within 4 hours of deliveryOther situations where there is concern of infant compromise

Deliveries requiring attendance of an advanced skills practitioner - HDU registrar / tNNP:

All those requiring neonatal medical / tNNP staff attendance until their basic resuscitation training is assessed ascompetent.Delivery <33 weeks gestation6

Category 1 and 2/30 urgent caesarean sectionsThick (particulate) meconium stained liquor present in early labour or associated with abnormal CTG or scalp pH < 7.21or scalp lactate > 4.2 mmol/L7, 8

Known maternal condition or fetal abnormality with potential to affect adaptationOther situations where there is concern of infant compromise

Deliveries requiring attendance of neonatal Fellow or Consultant on duty:

Delivery <30 weeks,Prolonged fetal bradycardia (<100 for >5 minutes),Known severe fetal abnormalityOther situations as requested by obstetric or neonatal staff

3. Consequences:

Complications of neonatal resuscitation: reported complications from appropriately applied resuscitative techniques areuncommon in neonates and infants.9, 10 The potential benefits of appropriately applied resuscitative techniques far outweighany potential harm. Infants should be surveyed for potential injury post resuscitation particularly airway injury after difficultintubation attempts11 and rib and organ injury after chest compressions.10, 12, 13

4. Equipment needed for resuscitation:

This should be functionally checked immediately before all newborn resuscitation. (Remember Heat Oxygen LightSuction).

1. Radiant warmer2. Pulse oximeter and probe3. Warm towel and blankets4. Polyethylene wrap for infants <28 weeks or <1500g5. An interruptible t-piece Neopuff is the primary method of IPPV for resuscitation at RPA: preset peak inspiratory pressure

(PIP) 20 cmH2O; end expiratory pressure (EEP) 5 cmH2O [relief valve maximum pressure 40 cmH2O].6. Resuscitation bag and mask:

1. All resuscitaires should have a self-inflating bag (infant Laerdal) which needs a reservoir attached to deliver morethan 40-60% oxygen. The pop-off valve (set at 35cmH2O) varies greatly in maximal pressure delivered beforethe valve automatically opens. They do not provide positive end expiratory pressure.

2. The resuscitation mask should comfortably cover the mouth and nose whilst sitting on top of the chin. Circularsilicone masks result in less air-leak1414 and are easier to clean.

7. Endotracheal tubes size 2.0, 2.5, 3.0, 3.5, 4.0 (see tube sizes and lengths)8. Laryngoscopes (as a guide, size 00 for under 27/40s, 0 for 27/40s to 32/40s, 1 for infants over 32/40)9. Stethoscope

10. Pedi-Cap end-tidal CO2 detector.11. Oxygen source and tubing use piped / wall oxygen / air with blender preferentially. Check oxygen / air bottles have

adequate supply for transport.12. Low flow suction source (set 100 mmHg),15 tubing and size 10 FG Y-suction catheter and meconium aspirator.13. Magill forceps for tracheal intubation (especially by the nasal route)14. Surfactant administration - infant feeding catheter 3-5FG, tape measure, surfactant, 5 ml syringe and drawing up needle

(see surfactant guidelines) as required15. Meconium aspirator

In addition, the following equipment should be available, replaced after use and checked each shift:

1. Adrenaline 1:10 000 ampoule2. Syringe and drawing up needles3. Normal saline ampoule and normal saline fluid bag4. Umbilical catheter (3.5 and 5 FG); linen tie; tape; 3-way tap5. Dressing pack and sterile gloves

5. Algorithm for neonatal resuscitation:

a. Assessment at delivery:

Newborn infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3characteristics:4

Term gestation?Crying or breathing?Good muscle tone?

If the answer to all 3 of these questions is yes, the baby does not need resuscitation and should not be separated fromthe mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintaintemperature. Observation of breathing, activity, and colour should be ongoing.4

Dry and stimulate the infant after delivery. The Apgar score16 is used to document postnatal adaptation at 1and 5minutes (and at 10, 15 and 20 minutes if < 8 at 5 minutes). It includes: Heart rate, respiratory efforts, tone, reflexirritability and colour, which guide resuscitation.

Assessment of heart rate should be done by intermittently auscultating the precordial pulse. When a pulse is detectable,palpation of the umbilical pulse can also provide a rapid estimate of the pulse and is more accurate than palpation atother sites.4

Infants with low Apgar scores, or persisting cyanosis and/or bradycardia and/or irregular respiratory effort should receiveassistance.4

Infants with both blue (1O) apnoea (apnoeic, flaccid and cyanosed with heart rate < 100 bpm; Apgar score = 1), andwhite (2O) apnoea (apnoeic, flaccid and pallid with heart rate < 100; Apgar score = 1) can be recognised almostimmediately after birth17, 18 and resuscitation commenced without delay.

b. Minimize heat loss:

Prevention of cooling reduces the mortality of low birth weight infants.19-24 Infants gain and lose heat by 4 modalities:evaporation, radiation, convection and conduction. Steps taken in the delivery room to prevent heat loss that have beenshown to be effective include:

1. If resuscitation is not required - early skin to skin contact with mother under warm blankets in term infants.25, 26

2. Dry the infant (and wrap in warm blankets when resuscitation completed)3. Radiant heater4. Polyethylene wrap for infants <28/40 or <1500g4 (see thermoregulation guideline)5. Plastic covering when moving the resuscitaire.

Avoid overheating, particularly with infants wrapped in polyethylene under radiant heaters. Infant temperature should bemonitored carefully as soon as the infants is stabilised with initial resuscitation. Hyperthermia has been associated withexacerbation of cerebral injury following ischaemic injury in animal studies6; infants born to febrile mothers have beenfound to have an increased risk of death, respiratory depression, seizures and cerebral palsy.27

In term asphyxiated infants, therapeutic cooling improves outcome reducing mortality and disability.28 If an infant meetscriteria for cooling, this should be discussed after initial stabilisation. See Moderate systemic hypothermia for thetreatment of neonatal hypoxic ischaemic encephalopathy (HIE) guideline. If the baby is not cooled, overheating shouldbe avoided.

c. Suctioning of the airway:

There is no evidence to support routine suctioning of the upper airway or stomach in newborn infants and reports ofinjury indicate the potential for harm.15, 29 Suctioning of the upper airways should be restricted to who have obvious

obstruction to spontaneous breathing.

Meconium stained liquor:

Suctioning as the head delivers when meconium is present is no longer routinely recommended as a largemulticentre randomised trial has shown this makes no difference to outcome.30 However if thick meconiumappears to be in the mouth causing obstruction, it should be suctioned out.Suctioning below the cords when thick meconium is in the liquor:

In the absence of randomized, controlled trials, there is insufficient evidence to recommend a change inthe current practice of performing endotracheal suctioning of non-vigorous babies with meconium-stainedamniotic fluid. However, if attempted intubation is prolonged and unsuccessful, bag-mask ventilation shouldbe considered, particularly if there is persistent bradycardia.29

If the baby is vigorous and breathing established, do not attempt to suction below the cords as there isevidence that this does not reduce the incidence or severity of meconium aspiration and may do harm.31

d. Assisted ventilation:

Effective ventilation is the most important part of neonatal resuscitation in an infant that has not established regularbreathing and good heart rate following initial drying and stimulation.

In an RCT, there was no significant difference in SpO2 at 5 minutes after birth in infants < 29 weeks gestation

given PPV with a T-piece or a self inflating bag.32

Start with interrupted t-piece intermittent positive pressure ventilation (IPPV):

The mask should cover the mouth and nose, but not be as high as the eyes and it should sit below the mouth onthe chin. There should be a good seal. The head position should be neutral or sniffing (not overly extending theneck), with jaw thrust if needed to help open the airway.Ventilate at 30 60 breaths per minute PIP 20 cmH2O EEP 5cmH2O.29

If heart rate and colour do not improve with mask IPPV, check that the airway is adequate (appropriate headposition) and the seal of the mask is good, and that the chest is moving higher inflation pressures may beneeded. If mask IPPV is not producing a response, intubation could be attempted. Call for assistance.Although current neonatal resuscitation guidelines recommend using visual assessment of chest wall movementsto guide the choice of inflating pressure during positive pressure ventilation, observers tended to underestimatetidal volume by 3.5mL and agreement between clinical assessment and measured V(Te) was generally poor.33

Oxygen use with ventilation (IPPV and mask or via endotracheal tube):

Oximetry should be used when resuscitation can be anticipated, when positive pressure is administered for morethan a few breaths, when cyanosis is persistent, or when supplementary oxygen is administered.34 Place a pulseoximeter on the right arm/hand (preductal SpO2). Applying the sensor to the infant before connecting it to thecable yields the fastest acquisition of accurate HR data.35Preductal targeting of SpO2 should approximate physiological levels see targeted preductal SpO2 after birthFigure Newborn Resuscitation Algorithm.For term and near term infants (32-36 weeks weeks): Start in air and adjust clinically as needed increasingafter 30 seconds if there is a poor response, and decreasing as able as colour/oxygen saturations improve (seebelow).

Conflicting meta-analyses come to different conclusions regarding evidence for use of air versus oxygen forinitial resuscitation.36, 37 Meta-analysis of 8 controlled trials (1,500 patients) reported the evidence is basedmainly on quasi-randomized studies with unblinded resuscitators and found no significant difference indeath (RR 1.35, 95% CI 0.97 to 1.88; P = 0.08), hypoxic/ischemic encephalopathy (RR 1.03, 95% CI 0.86to 1.23; P = 0.74), or requiring tracheal intubation was (RR 0.85, 95% CI 0.69 to 1.05; P = 0.12).37

For very preterm infants 9<32 weeks): Start in 30(-40%) FiO2 and adjust clinically as needed increasing after30 seconds if there is a poor response, and decreasing as able as colour/oxygen saturations improve (seebelow).

Titrating from an initial oxygen concentration of 100% was more effective than giving a static concentrationof 100% oxygen in maintaining preterm infants in a target oxygen saturation range.38 Initiating

resuscitation with 21% oxygen resulted in a high treatment-failure rate.38, 39 However, Use of oximetrytargeting allows for physiological targeting of oxygen in preterm infants with small trials suggesting startingat 30% instead of 90% and titrating results in appropriate SpO2 targeting in most infants.40, 41

A preliminary meta-analysis42 of trials of lower versus higher early SpO2 targeting found higher survivalrates at 36 weeks postmenstrual age in infants born <28 weeks of gestation and randomly assigned tooxygen saturation (SpO2) targets of 91 to 95% rather than 85 to 89% while breathing supplementaloxygen. Until longer-term data on survival and morbidity are available, it is prudent not to target a SpO2

85 to 89% in infants born earlier than 28 weeks of gestation.42

e. Tracheal intubation:

Indications for endotracheal tube intubation include:

Tracheal suctioning for meconium if infant born through thick meconium and non-vigorous (no respiratory effort)4

Failure to provide adequate ventilation using a bag and mask despite adequate attempts at obtaining an airway4

Prophylactic surfactant (infants born <27 weeks gestation)43 (see preterm and term surfactant guidelines)Respiratory distress44, 45 likely to require continued ventilatory support (see preterm and term surfactantguidelines)Congenital abnormalities as indicated (eg diaphragmatic hernias)4

Endotracheal tube size and placement: see guide to ETT size and distances based on infant weight. ETT 2.5 can beused for infants up to 1.4kg; ETT 3.0 1.0 -2.0kg; ETT 3.5 1.9 3.7kg; ETT 4.0 - 3.7kg+.

As a rough guide, use a 2.5 ETT for most babies 28/40 or less, a 3.0 would suit most 29 – 31/40 and a 3.5 for32 weeks and above.Tube placement should always be checked clinically as detailed below.Once stabilised a chest x-ray should be done to check placement as well as for condition of the lungs, air leaksetc.

Checking position of the ETT:

Ensure you see the ETT going through the cords; insert to 2cm (slightly less in infants <750g) which is the endblack mark (2cm).A PediCap or respiratory function monitor can be used to assist in assessing ETT placement.

An observation study reported both methods correctly identified successful ETT placement in 21/35 (60%)intubations, in 3 (9%) both indicated the ETT was not in the trachea, in the remaining 11 (31%) thePediCap failed to change colour despite the flow wave indicating correct ETT placement. Colorimetric CO2detectors may fail to change colour in spite of correct tube placement in up to one third of the cases.

Listen for air entry in each side of the chest; if the tube is too far down (usually it would be down the right mainbronchus) there will be decreased breath sounds on the unventilated side (usually the left) withdraw the ETT untilbreath sounds are equal. No single technique is without limitations and clinicians should utilize a combination.46

If there is doubt as to whether it is in the trachea despite the measures above, look again with a laryngoscope tosee if the tube is through the cords.

f. Combined external cardiac compression and assisted ventilation:

Check for pulse: either by auscultation,4 palpating umbilical arteries or apex beat.Perform cardiac massage: if initial heart rate after initiation of ventilation is < 60-bpm4 or remains 60-80 bpmafter initiation of adequate ventilation.

Chest compression:

Compressing the lower half of sternum either by:Encircle the chest with both hands and use 2 thumbs (higher blood pressure and better coronary perfusionin pigs47) preferred method;4 or by:

Using 2 fingers over the lower sternum. The 2-finger technique may be preferable when access to theumbilicus is required during insertion of an umbilical catheter.4Avoid the chest margins and xiphisternum and do not restrict chest re-expansion.

Compress the chest 1/3rd of its depth4

Provide chest compression in combination with ventilation:

There should be at least 90 compressions and 30 breaths per minute, with a ratio of 3 compressions with 1breath (ie 3:1 ratio: c-c-c-v-c-c-c-v-c-c-c-v).4

g. Assess the response:

Reassess the response to ventilation every 30-60 secondsContinue to ventilate until there is an adequate response crying or adequate sustained spontaneous breathingand heart rate > 100 bpmWith infants receiving coordinated chest compressions and ventilations, Respirations, heart rate, and oxygenationshould be reassessed periodically, and coordinated chest compressions and ventilations should continue until thespontaneous heart rate is ³ 60 per minute.Frequent interruptions of compressions should be avoided, as they will compromise artificial maintenance ofsystemic perfusion and maintenance of coronary blood flow.4

h. Failure to respond to resuscitation:

If there is an initial heart beat this is usually due to inadequate ventilationIf bag and mask ventilation: ensure an adequate airway (chin lift and slight head tilt)Failure to respond to bag and mask ventilation is an indication for intubation.If endotracheal tube: usually a misplaced endotracheal tube (ie oesophageal). See Checking position ofthe ETT.If the above have been checked and optimised and there is inadequate response, then there may beblocked endotracheal tube, blocked airway or severe lung disease. Change tube under suction.Preterm infants with surfactant deficiency may respond to surfactant treatment.Deterioration after initial response to resuscitation may indicate a misplaced endotracheal tube or air leak.Consider the possibility of anatomical anomalies or pleural effusions (suggested by antenatal findings).

If none of the above then increase ventilatory effort and follow Newborn Resuscitation AlgorithmCall for assistance

i. Vascular access:

Use umbilical vein where possible,Alternative routes include: peripheral vein (eg scalp vein), femoral vein, or endotracheal (ETT) routes foradrenaline.The umbilical artery and subclavian veins should be avoided where possible due to the potential complications ofthese routes.

6. Drugs in resuscitation:

Summary:

Adrenaline is the most commonly used drug in newborn resuscitation and is included in the ILCOR resuscitationalgorithm. However, its reported use is for <1 per 1000 deliveries.Hypovolaemia is difficult to diagnose but must be considered in specific situations and when there is a failure ofresponse to resuscitation measures despite adequate ventilation. Volume expansion (normal saline or blood) is reported

in 1 per 12 000 deliveries.The other agents are rarely indicated for newborn resuscitation but may have a roll in post-resuscitation care.

a. Adrenaline:

The recommended IV dose is 0.01 to 0.03 mg/kg per dose.4 Higher IV doses are not recommended because animaland paediatric studies show exaggerated hypertension, decreased myocardial function, and worse neurological functionafter administration of IV doses in the range of 0.1 mg/kg.

If the endotracheal route is used, doses of 0.01 or 0.03 mg/kg will likely be ineffective. Therefore, IV administration of0.01 to 0.03 mg/kg per dose is the preferred route. While access is being obtained, administration of a higher dose (0.05to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this practice have notbeen evaluated.4

Dosage regimen used at RPA:

1. Adrenaline 0.03 mg/kg intravenously via UVC = 0.3 ml/kg of 1:10000 adrenaline, or2. If unable to obtain rapid venous access give: adrenaline 0.1 mg/kg via ETT = 1 ml/kg of 1:10000 adrenaline.

Repeat dose once if no response after 60 seconds.

b. Naloxone:

This should only be considered in infants who are depressed by opiates once an infant has first been stabilised withventilatory support, and has good heart rate and colour.4

DO NOT give Naloxone to infants of narcotic dependent mothers. It can precipitate acute withdrawal.

Opiates given to the mother in labour (within 4 hours of delivery), can affect the infants drive to breathe at the time ofdelivery, and possibly in the first few hours of life. If a mother has received Pethidine, the infant needs close observationfor at least the first 4 hours of life (see Observation And Management Of Newborn Infants With RespiratoryMaladaptation To Birth, Including Infants Exposed To Intrapartum Opioids Administered To The Mother DuringLabour Policy). It is yet to be demonstrated that use of Naloxone in opiate exposed newborns can reduce the need foradmission to NICU or mechanical ventilation.48 The half life of Naloxone is shorter than pethidine, so close observationis particularly important in infants who have received this to ensure apnoea does not occur as the effect of Naloxonewears off.

Dose: Naloxone 100 µg/kg via intravenous or intramuscular injection (preferred)49. For term or near term infants, ifweight is not known, then give 0.5ml of Naloxone 400µg/ml (ie 200µg).

Naloxone is quick acting and should work within a couple of minutes of giving it. Effect after giving this IM is only slightlydelayed compared with IV.

c. Bicarbonate:

A single trial of intravenous infusion of sodium bicarbonate to newborn babies during resuscitation in the delivery room atbirth did not show any benefit of the use of this drug immediately after birth, nor any adverse effects.50

Bicarbonate should be restricted to post-resuscitation correction of acidosis. See acidosis guideline.Obtain an early blood gas after resuscitation.If there is a significant metabolic acidosis the dose is: 4.2% NaHCO3 ml = 0.3 x weight kg x BE given over 30-60minutes.

d. Dextrose:

Glucose has not been shown in animal models or adult humans to change the outcomes of cardiopulmonaryresuscitation.51, 52 No trial of glucose versus no glucose for resuscitation exists for neonates.

Neonates requiring CPR should have an early blood sugar estimate after resuscitation and correction of hypoglycaemiaif BSL < 2.0 mmol/L (see hypoglycaemia guideline).

e. Calcium and Atropine:

There is no evidence to support the use of these agents during neonatal resuscitation.

7. Volume replacement in resuscitation:

Hypovolaemia is difficult to diagnose in the neonate. Volume expansion should be considered when blood loss is known orsuspected (pale skin, poor perfusion and weak pulse) and the babys heart rate has not responded adequately to otherresuscitative measures.4 An isotonic crystalloid solution or blood is recommended for volume expansion in the delivery room.4

Significant hypovolaemia should be strongly considered in the following situations:

Pale infant with tachycardia, especially if preceded byVasa praevia53 orFeto-placental haemorrhage54 (when there is cutting of a nuchal cord on delivery of the head and the cord is cutbefore placenta-fetal transfusion can occur after delivery), orFeto-maternal haemorrhage55. Suspect if sinusoid CTG trace and/or raised middle cerebral artery peak systolicvelocity on fetal ultrasound.56 Order maternal QFMH.Placental trauma (accidents and at caesarean when cutting through an anterior placenta with subsequent delayeddelivery)Acute twin-twin transfusion with uterine contractions57, 58

Note - Uterine rupture, antepartum haemorrhage and placental abruption is usually associated with fetal hypoxia59 andblood loss is commonly maternal.

Treatment:

Early and adequate blood volume replacement may improve outcome in fetal haemorrhagic shock. Give whole blood orpacked red cells in 20 ml/kg aliquots titrated against response. Serial haematocrit may be used to determine adequacyof red cell replacement. Note initial haematocrit may be normal with acute blood loss.If hypovolaemia / poor output is suspected but blood is not immediately available: give Normal Saline 10-20 ml/kg over10-30 minutes and titrate against response. There are no data to suggest that albumen or other volume expanders aresuperior to normal saline in hypotensive infants.60

Arrhythmias in neonates: these are rarely a primary problem at neonatal resuscitation. See arrhythmia and hyperkalaemiaguidelines.

8. Cord Blood Sampling:

A cord gas should be taken for every baby who requires resuscitation. Take blood from an umbilical artery. There are twoumbilical arteries that are smaller, muscular and blue (compared with one larger purple coloured umbilical vein). Sample fromthe placental surface if necessary (arteries go over the veins). An umbilical venous-arterial pH difference of 0.15 is an effectivecutoff value in differentiating cord prolapse from abruptio placentae (accuracy 92%).61

Normal values for cord gases:62

Umbilical artery: Umbilical Vein:

pH: 7.24 ± 0.07 [range7.37 7.10]

pH: 7.32 ± 0.06 [range7.43 7.20]

BE: -5.6 ± 3.0 mmHg[range +0.3 to -11.5]

BE: -4.5 ± 2.4 mmHg[range +0.2 to -9.2]

Measures of hypoxia - pH <7.0 (important for diagnosis of HIE) - pH <7.10 (2SD below normal)

Sample before 30 minutes from a clamped cord63

A blood gas is stable in syringe for 30 minutesWith delayed sampling placental pH values fall at twice the rate as umbilical pH values.63

9. Management after resuscitation (see asphyxia):

Seek the cause of the arrest and treat specifically.Complications of the resuscitation procedure should be sought, including air leaks (pneumothorax, pneumomediastinumor pneumopericardium), oesophageal injury and blood loss from organ damage (eg liver).Obtain cord arterial and venous blood gas analysis (may be obtained from placental vessels - arteries cross veins).Perform Apgars at 1 and 5 and every 5 until Apgar > 7.Document time to sustained spontaneous respiration.Obtain early arterial blood gas and BGL. Correct persisting acidosis and hypoglycaemia.Respiratory support: continue ventilation till adequate sustained spontaneous respiration and without severe respiratorydistress. Ventilate to ensure adequate oxygenation and normocarbia.Monitor vital organ function: cardiac dysfunction as determined by hypotension or poor cardiac output (ECHO); renaldysfunction (oliguria < 0.5 ml/kg/hour or creatinine 120mmol/L); hepatic dysfunction (abnormal LFTs); and cerebraldysfunction (hypoxic ischaemic encephalopathy and seizure).Avoid running high fluid rates in asphyxiated infants, as fluid retention may occur resulting in hyponatraemia.Monitor electrolytes.

10. Cessation of cardiopulmonary resuscitation:

The decision to cease cardiopulmonary resuscitation should be based on cause of arrest, response to resuscitation, andremediable factors.

Death or severe neurological abnormality is predicted by a failure to obtain a heart rate by 10 minutes (Apgar score 0 at 10)despite adequate resuscitation and failure to respond to adrenaline.

A search of the literature has failed to reveal a single infant with Apgar score of 0 at 10 minutes who was normal at follow upwith the majority not able to be resuscitated or becoming a neonatal death.6

11. Key Points

Key Point Rating

Newborn infants who do not require resuscitation can generally be identified by a rapid assessmentof the following 3 characteristics: Term gestation; Crying or breathing; Good muscle tone.If the answer to all 3 is yes, the baby does not need resuscitation and should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature.

LOE 5

If the infant is not term, crying or breathing or is floppy, the infant should be placed on a resuscitairewith radiant heater, dried and stimulated and assessed. LOE 5

Normothermia is the goal.a. Hypothermia is associated with worse outcome in premature babiesb. Hyperthermia exacerbates ischaemic cerebral injury.c. Use polyethylene wrap for premature babies under 28 weeks gestation

LOE 1aLOE 2LOE 1a

A person who is able to initiate basic life support should be present at every delivery. A person capable of advanced resuscitation should be present if there are risk factors for the infant LOE 5

to be compromised.

Suctioning the oropharynx/nasopharynx is not routinely needed, including when liquor is meconiumstained.However, suction if there is obstruction of the airway.

LOE 1bGOR A

Do not suction below the cords when meconium is present if the baby is vigorous and breathingspontaneously.

If the infant is born through thick meconium and is floppy and not breathing, consider suctioning thetrachea. However, if attempted intubation is prolonged and unsuccessful, bag-mask ventilation shouldbe instituted, particularly if there is persistent bradycardia,

LOE 1a GOR A

LOE 5

Ventilation is the most important part of advanced resuscitation, and the majority of babies willrespond to this alone. LOE 5

If intermittent positive pressure ventilation is required:

In term and near term infants (³32 weeks gestation) start in air (21% oxygen) and titrate tophysiological preductal SpO2 (see algorithm)In very preterm infants (<32 weeks) start in 30% oxygen and titrate to physiological preductalSpO2 (see algorithm). Do not give supplementary oxygen if SpO2 >95%.

LOE 1aLOE 2b

If the heart rate is <60 bpm, correct ventilation and commence 3:1 cardiac compressions : breathusing encircling method. Rate 120 events per minute. Reassess every 30 seconds and stop compressions when heart rate >60 bpm or infant has return oftone, breathing or circulation.

LOE 5

Adrenaline 0.03 mg/kg intravenously via UVC = 0.3 ml/kg of 1:10000 adrenaline, or If unable to obtain rapid venous access give: adrenaline 0.1 mg/kg via ETT = 1 ml/kg of 1:10000adrenaline

LOE 5

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Revised: January, 2012Main author: David Osborn