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INTRODUCTION AND EPIDEMIOLOGY

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Resuscitation of the newborn is required to some extent in nearly 10% of all births. Extensive resuscitation is required in about 1%. Delivery room resuscitation is required for >50% of the high-risk population of very-low-birth-weight (<1500 grams) newborns. Worldwide, nearly 25% of neonatal deaths result from birth asphyxia.1 With proper antenatal and intrapartum surveillance, the potential need for active resuscitation at birth can often be identified before birth. Unfortunately, the arrival of a newborn to the ED is never planned. This chapter reviews the principles of emergency resuscitation of neonates.

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PATHOPHYSIOLOGY

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The transition from intrauterine to extrauterine life is a treacherous time. Even the normal laboring process places significant stress on the placental-fetal unit. Blood flow and, therefore, oxygen delivery are transiently impaired during uterine contractions. Compression of the umbilical cord, when it occurs, further impairs circulatory flow. Although antenatal/intrapartum US imaging and fetal heart tone monitoring have permitted better surveillance of fetal well-being, prediction of fetal status at birth remains inexact. Maternal complications of pregnancy can predispose newborns to complications and include infections, chronic or gestational disease (e.g., diabetes, lupus), and illicit or prescribed medication use. Complications of labor, such as preterm delivery and/or prolonged rupture of membranes, maternal fever, breech or transverse fetal position, placental abruption, and umbilical cord problems such as a nuchal cord (cord wrapped around the neck) or true knots in the cord, can significantly heighten the risk to the fetus.

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Once delivery occurs, the newborn still faces a variety of risks as the transition to extrauterine life unfolds. Requirements of this transition include the onset of respiration, absorption of lung fluid, reduction of pulmonary vasculature resistance to allow flow to the pulmonary vascular circuit, and closure of the ductus arteriosus and foramen ovale. Premature infants and infants who are small for gestational age are at risk for additional challenges in transitioning from fetal to infant physiology including insufficient pulmonary surfactant, fragile germinal matrices within the cerebral ventricles, and thin skin that impairs thermoregulation. The transition from the sterile intrauterine environment to the extrauterine world teeming with bacteria places yet another burden on the newborn.

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CLINICAL FEATURES

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HISTORY

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Obtain a brief history from the mother, including the date of last menstrual period/estimation of gestational age, number of fetuses, number of previous pregnancies and living children, history of diabetes, hypertension or pregnancy-related problems, prenatal care (including known congenital anomalies), prolonged rupture of membranes, fever, and meconium-stained amniotic fluid.

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PHYSICAL EXAMINATION

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The need for resuscitation or routine newborn care (see "Treatment" below) is determined by the initial physical examination. For the term infant who is crying or breathing and who has good muscle tone at delivery, provide routine newborn care with the infant skin-to-skin on the mother. A slightly more detailed examination using the Apgar scoring system has been used for generations to assist medical personnel in assessing ...

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