Case Answers and Summary
1. What are the initial steps of newborn resuscitation?
Following delivery of a newborn, a series of initial resuscitative steps are provided in order to facilitate the transition to extrauterine life. The extent of these initial steps depends on the findings of the postpartum evaluation (Table 1), which is rapidly performed immediately following birth.
Table 1 Ongoing Assessment
| Level of Activity | Conscious, good muscle tone |
| Airway and Breathing | Intubated (confirmed with capnometry); breath sounds, clear and equal bilaterally; ventilations provided as needed to maintain a heart rate of greater than 100 beats/min |
| Heart Rate | 130 beats/min, strong and regular |
| Color | Peripheral cyanosis, centrally pink |
| Blood Glucose | 90 mg/dL |
If the answer to any of the questions in Table 3-4 is “no,” then the newborn should be assumed to have respiratory depression, cardiovascular depression, or both, and in need of aggressive initial resuscitative steps (Table 2). Otherwise, the initial steps are mainly supportive and focus on providing warmth, maintaining a clear airway, and drying the newborn.
Table 2 Postpartum Evaluation of the Newborn
| Is the amniotic fluid clear of meconium?1 |
| Is the newborn breathing or crying? |
| Does the newborn have good muscle tone? |
| Is the infant’s color pink?2 |
Is this a term gestation?3 1 Meconium, which has the consistency of tar, is the baby’s first bowel movement, and should occur within the first 24 hours following birth. If meconium is present in the amniotic fluid, there is a chance that the newborn could have aspirated it. Treatment for meconium depends on the newborn’s clinical presentation. |
A useful mnemonic to assist you in remembering the initial steps of newborn resuscitation is to “Do What Probably Seems Simple” (Dry, Warm, Position, Suction, Stimulate). Following the initial steps of newborn resuscitation, a cardiopulmonary assessment is performed to determine the need for and extent of further resuscitation.
According to the American Academy of Pediatrics, nearly 90% of newborns are vigorous term babies that have clear amniotic fluid and effective breathing immediately following birth. Following clamping and cutting of the umbilical cord, they usually do not need to be separated from their mothers to provide further care.
2. When is management indicated for this newborn?
Following the initial steps of newborn resuscitation, a rapid cardiopulmonary assessment is performed, which focuses on three parameters: respiratory effort, heart rate, and color.
This infant is in need of positive-pressure ventilations (PPV), as evidenced by the following clinical findings:
• Heart rate of 90 beats/min
- Newborn bradycardia exists when the heart rate is less than 100 beats/min and is treated with PPV.
- Provide PPV at a rate of 40 to 60 breaths/min for 30 seconds and then reassess the newborn’s heart rate.
Other indications for PPV in the newborn include gasping respirations or apnea, cardiopulmonary arrest, and persistent central cyanosis despite the administration of blow-by oxygen.
Bradycardia in infants and children (including newborns) is almost always the result of hypoxia, not a cardiac event. Because they are very sensitive to oxygen, their heart rate usually responds quickly to PPV and 100% supplemental oxygen. To assess the newborn’s heart rate, auscultate the heartbeat with a stethoscope (apical pulse), palpate the brachial pulse, or palpate the pulse at the base of the umbilical cord.
A useful method for calculating the newborn’s heart rate is to count the number of pulsations in a 6-second time frame and multiply that number by 10. For example: 11 pulsations in 6 seconds 3 10 5 110 beats/min
Irregular respirations are a normal finding in the newborn and, unless associated with reduced tidal volume (shallow breathing), bradypnea, or gasping, are not treated with PPV.
The presence of central cyanosis alone (eg, normal heart rate and respirations) is treated initially with supplemental (blow-by) oxygen at 5 L/min via oxygen tubing or facemask. However, in the presence of bradycardia, central cyanosis is likely the result of significant hypoxemia and reinforces the need for PPV.
3. How will you manage this newborn now?
This newborn’s condition is clearly deteriorating despite PPV with 100% oxygen. At this point, after ensuring effective bag-valve-mask ventilations (eg, adequate mask-to-face seal, good chest rise), the delivery of 100% oxygen, and a clear airway, you must now perform the following treatment interventions:
• Chest compressions
- Chest compressions are indicated if the newborn’s heart rate falls below 60 beats/min despite 30 seconds of effective PPV with 100% oxygen.
- Perform chest compressions at a rate of 120 compressions/min at a depth that is approximately one-third of the anterior-posterior diameter of the newborn’s chest.
You must avoid giving a compression and a ventilation simultaneously, as one will decrease the effectiveness of the other. Ventilations and compressions are therefore performed synchronously, with one ventilation given after every third compression. At this rate, a total of 30 breaths and 90 compressions will be performed each minute.
Profound newborn bradycardia (heart rate < 60 beats/min) indicates severely low blood-oxygen levels. This results in decreased myocardial contractility and a decreased amount of blood pumped to the lungs to pick up oxygen.
Chest compressions in the newborn are usually required only for a short period of time (30 to 60 seconds), until the myocardium recovers and resumes its ability to function adequately.
• Endotracheal intubation
- During prolonged PPV with a bag-valve-mask device, the risk of gastric distention is very high; therefore, you should consider intubating the newborn. Intubation will also increase the effectiveness of delivered ventilations.
- If intubation is not possible, consider inserting an orogastric tube to decompress the stomach.
There are many benefits to endotracheal intubation. It allows for the instillation of 100% oxygen directly into the lungs; it provides a route for certain resuscitative medications; and it virtually eliminates the risk of gastric distention.
During the course of a newborn resuscitation, endotracheal intubation can be considered at any point — especially if prolonged PPV is anticipated, chest compressions are being performed, or if certain medications need to be administered.
To avoid exacerbating newborn bradycardia and hypoxia, you must limit your intubation attempts to 20 seconds. Once you obtain a laryngoscopic view of the glottis, determine if the vocal cords are open or closed. If the cords are together (closed), do not touch them with the laryngoscope blade, as this may result in laryngospasm. If the cords do not open within 20 seconds, provide PPV for 30 to 60 seconds prior to reattempting intubation.
The appropriate-sized ET tube is determined by estimating the newborn’s weight in grams. However, you may also use the diameter of the newborn’s little fingernail to estimate ET tube size. Only uncuffed ET tubes are used in newborns.
For premature newborns (less than 37 weeks or 5.5 lbs [2.5 kg]), use a size 0 blade; a size 1 blade should be used for term babies. Most clinicians advocate the use of a straight blade rather than a curved blade. Curved blades can be difficult to use in infants because their epiglottis is proportionately larger and much floppier. Additionally, curved blades are associated with a higher incidence of vagal-induced bradycardia.
4. What is the appropriate dose and route for epinephrine in this newborn?
IV administration of epinephrine is preferred over endotracheal administration. Since vascular access has been obtained, the following dose of epinephrine should be administered to the newborn:
• 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg) of a 1:10,000 solution via rapid administration
- Repeat this dose every 3 to 5 minutes as needed.
Epinephrine increases the rate (chronotropy) and force (inotropy) of cardiac contractions, as well as vasoconstriction, which will enhance cardiac and cerebral perfusion pressure.
Epinephrine is available in both 1:1,000 and 1:10,000 concentrations; however, only the 1:10,000 concentration should be used in newborns. Epinephrine 1:1,000 is too concentrated and thus too strong for use in newborns. Because newborns have a relatively fragile network of cerebral vasculature, strong doses of epinephrine may cause excessive vasoconstriction, resulting in a spontaneous intracranial hemorrhage. Additionally, using the 1:10,000 concentration will avoid the need to dilute the 1:1,000 concentration.
Atropine sulfate is rarely indicated in the newborn. Newborn bradycardia is most often the result of hypoxia, not parasympathetic nervous system stimulation. Therefore, atropine would be of no benefit. Additionally, if atropine is given in a dose of less than 0.1 mg, or if it is given too slowly, a paradoxical (reflex) bradycardia may occur.
Epinephrine is the preferred drug to treat severe newborn bradycardia because of its direct effect on the myocardium, which may need an adrenergic “boost” to help overcome the decreased contractility caused by hypoxia.
Back to Pediatric Case Study for Paramedics: Premature Newborn with Cardio-pulmonary Depression
