Resuscitation and Immediate Stabilization
The Neonatal Resuscitation Program (NRP), sponsored by the American Academy of Pediatrics (AAP), is the standard in the United States for stabilization of infants in the delivery room. Helping Babies Breathe is another evidence-based resource. In this section, we outline the NRP guidelines.
Basics of Neonatal Resuscitation
Standardization of neonatal care in the delivery room through the NRP improves morbidity and mortality in all term and preterm infants. The NRP guidelines are updated as new research becomes available. Current NRP guidelines recommend the following:
Begin any interaction with antenatal counseling, a team briefing, and equipment check.
Maintain body temperature between 36.5°C and 37.5°C throughout resuscitation and stabilization.
If positive pressure ventilation (PPV) is needed, oxygen should be set at 21% for infants ≥35 weeks’ gestation and 21%–30% for infants <35 weeks’ gestation.
Electrocardiogram (ECG) leads are the standard of care during PPV and chest compressions to ensure accurate heart-rate readings (rather than using the oxygen saturation monitor alone).
If an infant requires chest compressions, the infant should be intubated prior to beginning compressions to ensure adequate ventilation.
Routine intubation is no longer recommended for infants born through meconium-stained amniotic fluid. However, infants with meconium-stained amniotic fluid should be intubated if spontaneous respiration does not occur during initial resuscitation attempts. (Previously, nonvigorous infants with meconium-stained amniotic fluid were routinely intubated to suction meconium from the trachea and airway. However, studies have shown that this practice does not reduce morbidity associated with meconium aspiration.)
Providing Ventilation Support
In contrast with resuscitation in adults, neonatal resuscitation relies heavily on the infant’s ability to have adequate ventilation. Appropriate PPV in neonatal resuscitation generally will improve circulation and overall outcome. When ventilation of the infant is difficult, the following mnemonic can help you remember the steps to achieve effective ventilation.
Mnemonic for Effective VentilationMR. SOPA
Mask should be readjusted (ensure correct mask size to provide adequate seal over the infant’s mouth and nose).
Reposition airway by adjusting head into the “sniffing” position (without hyperextending the neck).
Suction mouth prior to the nose.
Pressure: increase to ensure adequate chest rise (starting peak inspiratory pressure [PIP] of 20 cm H2O and positive end-expiratory pressure [PEEP] of 5 cm H2O).
Alternative airway can be considered (including laryngeal mask airway or endotracheal tube) if bag-mask ventilation is not providing adequate ventilation.
(Source: Reprinted with permission 2010 & 2015 American Heart Association Guidelines for CPR & ECC. Part 12: Pediatric Advanced Life Support ©2015 American Heart Association, Inc.)
Virginia Apgar developed the Apgar (appearance, pulse, grimace, activity, respiration) score in 1953 to standardize assessment of infants after birth. Scores are assigned at 1 minute, 5 minutes, and every 5 minutes thereafter until the Apgar score is >7. Apgar scores reflect the effectiveness of resuscitation but do not predict long-term prognosis of an infant in the NICU or well-baby nursery.
ulse (heart rate)
Abbreviation: BPM, beats per minuteAn infant can receive a score of 0, 1, or 2 for each component (score range, 0 to 10).(Source: The Newborn Scoring System: Reflections and Advice. Pediatric Clin North Am 1966.)
Delayed Cord Clamping
Studies have shown that delayed cord clamping reduces the need for transfusion and the risk of intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC), and increases neurodevelopmental scores later in life. The effectiveness of this intervention is more apparent in preterm infants than in term infants. However, the benefit for term infants is a later nadir of blood counts (physiologic anemia). Therefore, cord clamping should be delayed for 30–60 seconds in most vigorous term and preterm infants without contraindications. During this period, the infant is either placed skin-to-skin with the mother and covered with warm towels after a vaginal delivery or on the maternal abdomen and covered with warm sterile towels after a cesarean section. The delivery attendant should evaluate and report the infant’s tone and breathing effort to the neonatal resuscitation team.
Extremely Low Birth Weight Infants
ELBW infants are at increased risk for hypothermia and insensible water loss. A plastic bag and thermal mattress are used to maintain adequate body temperature and reduce water loss during the first minutes after delivery. The operating room temperature should be set at 72°F (22°C). When administering PPV to ELBW infants, oxygen should be set at 30% for initial resuscitation.