However, free radicals are generated when successful resuscitation results in reperfusion and restoration of oxygen delivery to organs.44 Use of 100 percent oxygen may increase the load of oxygen free radicals, which can potentially lead to end-organ damage. Admission temperature should be routinely recorded. A meta-analysis (very low quality) of 8 animal studies (n=323 animals) that compared air with 100% oxygen during chest compressions showed equivocal results. How soon after administration of intravenous epinephrine should you pause compressions and assess the baby's heart rate?a. Depth is correct. Reduce the inflation pressure if the chest is moving well. Babies who are breathing well and/or crying are cared for skin-to-skin with their mothers and should not need interventions such as routine tactile stimulation or suctioning, even if the amniotic fluid is meconium stained.7,19 Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia as a result of suctioning of the airway. The research community needs to address the paucity of educational studies that provide outcomes with a high level of certainty. Given the evidence for ECG during initial steps of PPV, expert opinion is that ECG should be used when providing chest compressions. While there has been research to study the potential effectiveness of providing longer, sustained inflations, there may be potential harm in providing sustained inflations greater than 10 seconds for preterm newborns. Exothermic mattresses may be effective in preventing hypothermia in preterm babies. After birth, the newborn's heart rate is used to assess the effectiveness of spontaneous respiratory effort, the need for interventions, and the response to interventions. Watch a recording of Innov8te NRP: An Introduction to the NRP 8th Edition: Three webinars hosted by RQI Partners to discuss changes to the 8 th edition NRP and the new RQI for NRP Posted 2/19/21. Current resuscitation guidelines recommend that epinephrine should be used if the newborn remains bradycardic with heart rate <60 bpm after 30 s of what appears to be effective ventilation with chest rise, followed by 30 s of coordinated chest compressions and ventilations (1, 8, 9). The reduced heart rate that occurs in this situation can be reversed with tactile stimulation. In a retrospective study, volume infusion was given more often for slow response of bradycardia to resuscitation than for overt hypovolemia. 0.5 mL Epinephrine is indicated if the heart rate remains below 60 beats per minute despite 60 seconds of chest compressions and adequate ventilation. For infants with a heart rate of 60 to < 100 beats/minute who have apnea, gasping, or ineffective respirations, positive pressure ventilation (PPV) using a mask is indicated. This guideline affirms the previous recommendations. Very low-quality evidence from 2 nonrandomized studies and 1 randomized trial show that auscultation is not as accurate as ECG for heart rate assessment during newborn stabilization immediately after birth. Physicians who provide obstetric care should be aware of maternal-fetal risk factors1 and should assess the risk of respiratory depression with each delivery.19 The obstetric team should inform the neonatal resuscitation team of the risk status for each delivery and continue to focus on obstetric care. Positive-Pressure Ventilation (PPV) (if you are using the 0.1 mg/kg dose.) If the baby is apneic or has a heart rate less than 100 bpm Begin the initial steps Warm, dry and stimulate for 30 seconds Currently, epinephrine is the only vasoactive drug recommended by the International Liaison Committee on Resuscitation (ILCOR) for neonates who remain severely bradycardic (heart rate <. Variables to be considered may include whether the resuscitation was considered optimal, availability of advanced neonatal care (such as therapeutic hypothermia), specific circumstances before delivery, and wishes expressed by the family.3,6, Some babies are so sick or immature at birth that survival is unlikely, even if neonatal resuscitation and intensive care are provided. Unauthorized use prohibited. Resuscitation of an infant with respiratory depression (term and preterm) in the delivery room (Figure 1) focuses on airway, breathing, circulation, and medications. Before giving PPV, the airway should be cleared by gently suctioning the mouth first and then the nose with a bulb syringe. Copyright 2023 American Academy of Family Physicians. Reviews in 2021 and later will address choice of devices and aids, including those required for ventilation (T-piece, self-inflating bag, flow-inflating bag), ventilation interface (face mask, laryngeal mask), suction (bulb syringe, meconium aspirator), monitoring (respiratory function monitors, heart rate monitoring, near infrared spectroscopy), feedback, and documentation. Rapid and effective response and performance are critical to good newborn outcomes. ECG provides the most rapid and accurate measurement of the newborns heart rate at birth and during resuscitation. In babies who appear to have ineffective respiratory effort after birth, tactile stimulation is reasonable. It may be possible to identify conditions in which withholding or discontinuation of resuscitative efforts may be reasonably considered by families and care providers. Several animal studies found that ventilation with high volumes caused lung injury, impaired gas exchange, and reduced lung compliance in immature animals. The heart rate should be re- checked after 1 minute of giving compressions and ventilations. A multicenter randomized trial showed that intrapartum suctioning of meconium does not reduce the risk of meconium aspiration syndrome. Breathing is stimulated by gently rubbing the infant's back. Epinephrine should be administered intravenously at 0.01 to 0.03 mg per kg or by endotracheal tube at 0.05 to 0.1 mg per kg. If a baby does not begin breathing . There is a history of acute blood loss around the time of delivery. Epinephrine use in the delivery room for resuscitation of the newborn is associated with significant morbidity and mortality. The effect of briefing and debriefing on longer-term and critical outcomes remains uncertain. Naloxone and sodium bicarbonate are rarely needed and are not recommended during neonatal resuscitation. Administration of epinephrine via a low-lying umbilical venous catheter provides the most rapid and reliable medication delivery. Therefore, identifying a rapid and reliable method to measure the newborn's heart rate is critically important during neonatal resuscitation. Epinephrine can cause increase in heart rate and blood pressure. If the infant's heart rate is less than 60 beats per minute after adequate positive pressure ventilation and chest compressions, intravenous epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) is recommended. Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute. Most babies will respond to this intervention. Premature animals exposed to brief high tidal volume ventilation (from high PIP) develop lung injury, impaired gas exchange, and decreased lung compliance. While the science and practices surrounding monitoring and other aspects of neonatal resuscitation continue to evolve, the development of skills and practice surrounding PPV should be emphasized. Please contact the American Heart Association at [email protected] or 1-214-706-1886 to request a long description of . The frequency and format of booster training or refresher training that best supports retention of neonatal resuscitation knowledge, technical skills, and behavioral skills, The effects of briefing and debriefing on team performance, Optimal cord management strategies for various populations, including nonvigorous infants and those with congenital heart or lung disease, Optimal management of nonvigorous infants with MSAF, The most effective device(s) and interface(s) for providing PPV, Impact of routine use of the ECG during neonatal resuscitation on resuscitation, Feasibility and effectiveness of new technologies for rapid heart rate measurement (such as electric, ultrasonic, or optical devices), Optimal oxygen management during and after resuscitation, Novel techniques for effective delivery of CPR, such as chest compressions accompanied by sustained inflation, Optimal timing, dosing, dose interval, and delivery routes for epinephrine or other vasoactive drugs, including earlier use in very depressed newly born infants, Indications for volume expansion, as well as optimal dosing, timing, and type of volume, The management of pulseless electric activity, Management of the preterm newborn during and after resuscitation, Management of congenital anomalies of the heart and lungs during and after resuscitation, Resuscitation of newborns in the neonatal unit after the newly born period, Resuscitation of newborns in other settings up to 28 days of age, Optimal dose, route, and timing of surfactant in at-risk newborns, including less-invasive administration techniques, Indications for therapeutic hypothermia in babies with mild HIE and in those born at less than 36 weeks' gestational age, Adjunctive therapies to therapeutic hypothermia, Optimal rewarming strategy for newly born infants with unintentional hypothermia. In animal studies (very low quality), the use of alterative compression-to-inflation ratios to 3:1 (eg, 2:1, 4:1, 5:1, 9:3, 15:2, and continuous chest compressions with asynchronous PPV) are associated with similar times to ROSC and mortality rates. Early skin-to-skin contact benefits healthy newborns who do not require resuscitation by promoting breastfeeding and temperature stability. 1-800-AHA-USA-1 The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth. Alternative compression-to-ventilation ratios to 3:1, as well as asynchronous PPV (administration of inflations to a patient that are not coordinated with chest compressions), are routinely utilized outside the newborn period, but the preferred method in the newly born is 3:1 in synchrony. Multiple clinical and simulation studies examining briefings or debriefings of resuscitation team performance have shown improved knowledge or skills.812. Delayed cord clamping is associated with higher hematocrit after birth and better iron levels in infancy.921 While developmental outcomes have not been adequately assessed, iron deficiency is associated with impaired motor and cognitive development.2426 It is reasonable to delay cord clamping (longer than 30 seconds) in preterm babies because it reduces need for blood pressure support and transfusion and may improve survival.18, There are insufficient studies in babies requiring PPV before cord clamping to make a recommendation.22 Early cord clamping should be considered for cases when placental transfusion is unlikely to occur, such as maternal hemorrhage or hemodynamic instability, placental abruption, or placenta previa.27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping.1012,2834 Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks gestational age, because it is associated with brain injury.23, Temperature should be measured and recorded after birth and monitored as a measure of quality.1 The temperature of newly born babies should be maintained between 36.5C and 37.5C.2 Hypothermia (less than 36C) should be prevented as it is associated with increased neonatal mortality and morbidity, especially in very preterm (less than 33 weeks) and very low-birthweight babies (less than 1500 g), who are at increased risk for hypothermia.35,7 It is also reasonable to prevent hyperthermia as it may be associated with harm.4,6, Healthy babies should be skin-to-skin after birth.8 For preterm and low-birth-weight babies or babies requiring resuscitation, warming adjuncts (increased ambient temperature [greater than 23C], skin-to-skin care, radiant warmers, plastic wraps or bags, hats, blankets, exothermic mattresses, and warmed humidified inspired gases)10,11,14 individually or in combination may reduce the risk of hypothermia. Tactile stimulation should be limited to drying an infant and rubbing the back and soles of the feet.21,22 There may be some benefit from repeated tactile stimulation in preterm babies during or after providing PPV, but this requires further study.23 If, at initial assessment, there is visible fluid obstructing the airway or a concern about obstructed breathing, the mouth and nose may be suctioned. Most RCTs in well-resourced settings would routinely manage at-risk babies under a radiant warmer. 5 minutec. All Rights Reserved. Birth Antenatal counseling Team briefing and equipment check Neonatal Resuscitation Algorithm. If heart rate after birth remains at less than 60/min despite adequate ventilation for at least 30 s, initiating chest compressions is reasonable. An important point is that ventilation has been shown to be the most effective measure in neonatal resuscitation If the infant's heart rate is less than 100 bpm, PPV via face mask (not mask continuous positive airway pressure) is initiated at a rate of 40 to 60 breaths per minute to achieve and maintain a heart rate of more than 100 bpm.1,2,57 PPV can be administered via flow-inflating bag, self-inflating bag, or T-piece device.1,6 There is no major advantage of using one ventilatory device over another.23 Thus, each institution should standardize its equipment and train the neonatal resuscitation team appropriately. Hypothermia (temperature less than 36C) should be prevented due to an increased risk of adverse outcomes. The dose of epinephrine can be re-peated after 3-5 minutes if the initial dose is ineffective or can be repeated immediately if initial dose is given by endo-tracheal tube in the absence of an . For babies requiring vascular access at the time of delivery, the umbilical vein is the recommended route. The intravenous dose of epinephrine is 0.01 to 0.03 mg/kg, followed by a normal saline flush.4 If umbilical venous access has not yet been obtained, epinephrine may be given by the endotracheal route in a dose of 0.05 to 0.1 mg/kg. A 3:1 ratio of compressions to ventilation provided more ventilations than higher ratios in manikin studies. Many current recommendations are based on weak evidence with a lack of well-designed human studies. Routine oral, nasal, oropharyngeal, or endotracheal suctioning of newly born babies is not recommended. Newly born infants who receive prolonged PPV or advanced resuscitation (eg, intubation, chest compressions epinephrine) should be closely monitored after stabilization in a neonatal intensive care unit or a monitored triage area because these infants are at risk for further deterioration. Suctioning may be considered if PPV is required and the airway appears obstructed. When should I check heart rate after epinephrine? In preterm newly born infants, the routine use of sustained inflations to initiate resuscitation is potentially harmful and should not be performed. You have administered epinephrine intravenously. Hypoglycemia is common in infants who have received advanced resuscitation and is associated with poorer outcomes.8 These infants should be monitored for hypoglycemia and treated appropriately. The chest compression technique of using two thumbs, with the fingers encircling the chest and supporting the back, achieved better results in swine models compared with the technique of using two fingers, with a second hand supporting the back. It is reasonable to provide PPV at a rate of 40 to 60 inflations per minute. During an uncomplicated delivery, the newborn transitions from the low oxygen environment of the womb to room air (21% oxygen) and blood oxygen levels rise over several minutes. 1 Exhaled carbon dioxide detection is the recommended method of confirming endotracheal intubation. In newly born infants who require PPV, it is reasonable to use peak inflation pressure to inflate the lung and achieve a rise in heart rate. Flush the UVC with normal saline. Teams and individuals who provide neonatal resuscitation are faced with many challenges with respect to the knowledge, skills, and behaviors needed to perform effectively. If intravenous access is not feasible, it may be reasonable to use the intraosseous route. Hypothermia after birth is common worldwide, with a higher incidence in babies of lower gestational age and birth weight. The goal should be to achieve oxygen saturation targets shown in Figure 1.5,6, When chest compressions are indicated, it is recommended to use a 3:1 ratio of compressions to ventilation.57, Chest compressions in infants should be delivered by using two thumbs, with the fingers encircling the chest and supporting the back, and should be centered over the lower one-third of the sternum.5,6, If the infant's heart rate is less than 60 bpm after adequate ventilation and chest compressions, epinephrine at 0.01 to 0.03 mg per kg (1:10,000 solution) should be given intravenously. For every 30 seconds that ventilation is delayed, the risk of prolonged admission or death increases by 16%. The baby could attempt to breathe and then endure primary apnea. If the heart rate is less than 60 bpm, begin chest compressions. Identification of risk factors for resuscitation may indicate the need for additional personnel and equipment. A multicenter quality improvement study demonstrated high staff compliance with the use of a neonatal resuscitation bundle that included briefing and an equipment checklist. If it is possible to identify such conditions at or before birth, it is reasonable not to initiate resuscitative efforts. Before every birth, a standardized equipment checklist should be used to ensure the presence and function of supplies and equipment necessary for a complete resuscitation. The benefit of 100% oxygen compared with 21% oxygen (air) or any other oxygen concentration for ventilation during chest compressions is uncertain. When blood loss is suspected in a newly born infant who responds poorly to resuscitation (ventilation, chest compressions, and/or epinephrine), it may be reasonable to administer a volume expander without delay. A large observational study showed that most nonvigorous newly born infants respond to stimulation and PPV. Compared with preterm infants receiving early cord clamping, those receiving delayed cord clamping were less likely to receive medications for hypotension in a meta-analysis of 6 RCTs. In preterm newborns (less than 35 wk of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen with subsequent oxygen titration based on pulse oximetry. Most changes are related to program administration and course facilitation. 2020;142(suppl 2):S524S550. Other recommendations include confirming endotracheal tube placement using an exhaled carbon dioxide detector; using less than 100 percent oxygen and adequate thermal support to resuscitate preterm infants; and using therapeutic hypothermia for infants born at 36 weeks' gestation or later with moderate to severe hypoxic-ischemic encephalopathy. In newborns born before 35 weeks' gestation, oxygen concentrations above 50% are no more effective than lower concentrations. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. If there is a heart rate response: Continue uninterrupted ventilation until the infant begins to breathe adequately and the heart rate is above 100 min-1. Neonatal resuscitation science has advanced significantly over the past 3 decades, with contributions by many researchers in laboratories, in the delivery room, and in other clinical settings. diabetes. In a prospective interventional clinical study, video-based debriefing of neonatal resuscitations was associated with improved preparation and adherence to the initial steps of the Neonatal Resuscitation Algorithm, improved quality of PPV, and improved team function and communication. A team or persons trained in neonatal resuscitation should be promptly available to provide resuscitation. During chest compressions, an ECG should be used for the rapid and accurate assessment of heart rate. In newly born infants who are gasping or apneic within 60 s after birth or who are persistently bradycardic (heart rate less than 100/min) despite appropriate initial actions (including tactile stimulation), PPV should be provided without delay. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Level of Evidence (LOE; ie, quality) and Class of Recommendation (COR; ie, strength) (Table(link opens in new window)).11. When chest compressions are initiated, an ECG should be used to confirm heart rate. 1-800-242-8721 Rate is 40 - 60/min. CPAP, a form of respiratory support, helps newly born infants keep their lungs open. Early cord clamping (within 30 seconds) may interfere with healthy transition because it leaves fetal blood in the placenta rather than filling the newborns circulating volume. When providing chest compressions to a newborn, it may be reasonable to choose the 2 thumbencircling hands technique over the 2-finger technique, as the 2 thumbencircling hands technique is associated with improved blood pressure and less provider fatigue. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts.