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Air Oxygen
monitor pressure delivered with each breath.
A
valve is added and pressurized gas is entering the bag
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Oxygen of
concentration
desired
Flowmeter
CHAPTER 4 Care at Birth
79
Oxygen of
desired
concentration
Flow-inflating bags. Flow-inflating bags contain an
inflatable gas reservoir that must be connected to a
compressed gas source to refill between breaths.
Advantages:
• Ability to deliver 21% to 100% oxygen, depending
on the source
• Ability to maintain a positive end-expiratory pressure
and measure with manometer
• Easy to determine when there is a seal around the
neonate’s face
• Ability to deliver free-flow oxygen at concentrations
up to 100% depending on the source
Disadvantages:
• Requires an external compressed gas source to
inflate
• Requires a tight seal between mask and face to
remain inflated
• Requires use of pressure gauge (manometer) to
Air Oxygen
Self-inflating bags. Self-inflating bags fill with ambient
air and are independent on an external oxygen or
compressed air source.
Advantages:
• Will always refill after being squeezed, even with
no compressed gas source
• Pressure-release valve makes overinflation less
likely
Disadvantages:
• Will inflate even if there is not a seal between the
mask and the neonate’s face
• Requires an oxygen reservoir to provide high
concentration of oxygen
• Cannot be used to deliver free-flow oxygen reliably
through the mask
• Cannot be used to deliver continuous positive
airway pressure (CPAP) and can deliver positive
end-expiratory pressure (PEEP) only when a PEEP
B
FIGURE 4.7 A, Flow-inflating bag. B, Self-inflating bag. C, T-piece resuscitator. (From Weiner GM, ed. Textbook of Neonatal Resuscitation.
7th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2016.)
The facemask should be selected to ensure
that it is the appropriate size to cover the chin,
mouth, and nose but not the eyes. Masks are
commonly available in term and premature sizes
to fit even very low-birth-weight infants. Flexible,
translucent masks with a cushioned rim generally provide the best seal with minimal trauma
and allow monitoring of mouth position and
secretions.
85,86
Perform the following steps:
• Set the flowmeter to deliver 5 to 10 L/min.
Flow rates at the higher end of the range are
necessary to achieve higher pressures and faster
ventilation rates with a flow-inflating bag.
• Test equipment before use. Equipment failure
can cause resuscitation failure!
• Position the infant with the neck slightly
extended, place the mask on the chin, and
roll it over the mouth and nose (but not the
eyes) to make a firm seal.86 Avoid compres-
sion of the soft tissues of the neck by holding
the mask to the face with the thumb and index
finger and providing gentle upward pressure with
the third finger under the chin.
UNIT TWO Support of the Neonate80
Flowmeter
• Risk of prolonged inspiratory time
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Air
Oxygen of
desired
concentration
Maximum
pressure
relief
Circuit
pressure
Gas inlet
Inspiratory
pressure control
T- piece resuscitator.
Advantages:
• Consistent pressure
• Reliable control of peak inspiratory pressure (PIP)
and positive end-expiratory pressure (PEEP)
• Reliable delivery of 100% oxygen
• Operator does not become fatigued from bagging
Disadvantages:
• Requires compressed gas supply
• Requires pressures to be set prior to use
• Changing inflation pressure during resuscitation
is more difficult
FIGURE 4.7, cont’d
• Ventilate at a rate of 40 to 60 breaths/min
with pressures of 15 to 20 cm H2O for
normal lungs or up to 20 to 40 cm H2O
for diseased lungs. Most apneic preterm
infants respond to initial inflation pressures of
20 to 25 cm H2O.81 Pressure as high as 30 to
40 cm H2O may be necessary in term infants
not breathing spontaneously. When surfactant
is administered immediately after birth, rapid
compliance changes may require equally rapid
adjustment of ventilation pressures and oxygen
concentration.
• Place ECG leads and connect to a cardiac
monitor. Check the heart rate after 15 sec-
onds of positive-pressure ventilation. Prompt
improvement in heart rate is the best indicator of adequate ventilation. If the heart rate
is <100 beats/min and chest rise is adequate,
continue ventilation. If the chest is not rising,
perform the corrective steps of MR SOPA:
Gas outlet
(1) reapply the facemask for a better seal,
(2) reposition the head, (3) suction secre-
tions, (4) open the infant’s mouth slightly, (5)
increase pressure, and (6) consider an alter-
native airway.
81
• Reevaluate respirations, heart rate, and oxy-
gen saturation after 30 seconds of positive-pressure ventilation. If the heart rate is
<100 beats/min, call for additional help and
prepare for intubation or insertion of laryngeal
mask airway.
• Provide CPAP after spontaneous respira-
tions have returned. End-expiratory pressure
decreases lung injury and improves compliance and gas exchange.
45,72
CPAP may have
a role in maintaining lung volumes in premature infants and aiding the absorption of lung
56
fluid.
• Insert an orogastric catheter (8-Fr feeding
tube) after several minutes of bag-and-mask
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81
ventilation or CPAP or if there is evidence of
gastric distention.
• Measure the insertion depth of the catheter
by holding the tip at the bridge of the nose
and measuring to the earlobe and then midway
between the xiphoid and the umbilicus.
81
• Insert the catheter through the mouth, not
the nose, because newborns are obligate nosebreathers.
• Aspirate gastric contents with a 20-mL syringe
and leave the catheter open.
• Tape the catheter to the infant’s cheek.
The adequacy of bag-and-mask ventilation
must be continuously assessed by monitoring
of heart rate, auscultation of breath sounds,
visualization of chest wall movement, and
oxygen saturations. Peak inspiratory pressure
should be limited to that necessary to see
an improvement in heart rate and chest wall
movement and to hear good air exchange on
auscultation of the chest. Inspiratory pressures
cannot be judged clinically; bags fitted with
in-line pressure manometers or T-piece devices
are recommended in the delivery room.81 Devices
that more easily and consistently deliver targeted
volumes during positive-pressure ventilation are
the focus of much recent research.70 Strategies
to avoid intubation, especially CPAP with limited oxygen concentration, offer the promise of
a reduction in the severity of chronic lung disease.21 Further clinical trials will help establish the
optimal method(s) for achieving lung expansion
while minimizing the complications of positive-pressure ventilation.
64,78
Potential complications of bag-and-mask ven-
tilation include trauma to the eyes or face from an
improper size or position of the mask, lung injury
(especially in preterm infants), air leak (pneumothorax, subcutaneous air), gastric distention elevating the diaphragm, and direct lung compression
in the case of a diaphragmatic hernia (Table 4.3) .
Complications can be minimized by using gentle
technique and equipment of the correct size, careful
monitoring of pressures, and insertion of an orogastric tube when indicated.
ENDOTRACHEAL INTUBATION
Endotracheal intubation may be performed at
several points during neonatal resuscitation.81
Intubation is indicated when bag-and-mask
ventilation is ineffective or prolonged positivepressure ventilation is needed and when chest
compressions are necessary. Additional indications for endotracheal intubation include surfactant administration, suspected diaphragmatic
hernia, and direct tracheal suction for obstructive
secretions. Equipment for intubation is listed in the
“Airway” and “Breathing” sections in Box 4.2.
Select an uncuffed, uniform-diameter endotracheal
tube of the correct size (Table 4.4). A variety of sizes
(2.5- to 3.5-mm internal diameter) should be available
because estimated weights may be inaccurate or airway anomalies may exist. Orotracheal intubation is
preferable to nasotracheal intubation during acute
resuscitation because it can be performed rapidly
and without additional equipment.
Perform the following steps:
• Shorten the selected endotracheal tube to 13
cm (or the length appropriate for the fixation
method used), and prepare the laryngoscope,
tape, suction, oxygen, bag, and mask.
• Position the infant with the neck slightly
extended.
• Provide free-flow oxygen as needed to achieve
target saturations.
• Hold the laryngoscope with the left hand;
open the mouth with the right index finger and
gently insert the blade.
• Lift the laryngoscope upward and away so
that the blade is nearly parallel to the surface
beneath the infant.
• Visualize landmarks; identify the epiglottis,
vocal cords, and glottis (Fig. 4.8). If the esophagus
is seen, withdraw the blade until the epiglottis
drops down. If only the tongue is visible, advance
the blade further until it enters the vallecula or
passes under the epiglottis.
• Apply gentle external pressure over the cri-
coid, which may help visualize the vocal
cords. Pressure may be applied with the little
finger of the hand holding the laryngoscope or
by an assistant.
• Insert the endotracheal tube from the right
corner of the mouth to just beyond the vocal
cord guideline at the tip of the tube, or mea-
sure from the tragus of the ear to nasal septum
and add 1 cm to confirm the depth of insertion.
Gestational age can also be used to predict inser-
tion depth (see Table 4.4).
• Limit each intubation attempt to 30 seconds
to avoid hypoxia.
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TABLE
4.3
PROBLEM CAUSE DIAGNOSIS REMEDIES
Persistent cyanosis Inadequate oxygenation
Bradycardia Same as for persistent
Hypothermia Evaporative heat loss;
Hyperthermia Excessive warming
Hypoglycemia Glucose stores used before
Hemorrhage Inadequately secured umbili-
COMPLICATIONS DURING RESUSCITATION AND STABILIZATION
• Inadequate Fio
• Disconnected O2 line Check all connections Reconnect line
• Empty O2 cylinder Check O2 source Replace O2 cylinder
Inadequate ventilation
• Inadequate face mask
seal
• Compression of airway Diminished breath sounds; little chest wall
• Insufficient insufflation
pressure
• Compression of lungs by
distended stomach
• Malpositioned ET tube Check tube position with laryngoscope
Pneumothorax Check breath sounds
cyanosis
Vagal stimulation
Perinatal myocardial
ischemia
conductive heat loss
Maternal fever
birth or during resuscitation
cal arterial or venous line
Liver laceration Perform chest compressions with correct position/
2
Check pulse oximetry saturation and
blender setting
Diminished breath sounds; little chest wall
movement; air leak around mask
movement
Diminished breath sounds; little chest wall
movement
Diminished breath sounds; little chest wall
movement; visibly distended stomach
Check breath sounds
Check for chest asymmetry
Transillumination
Chest x-ray examination
Auscultation of precordium or palpation
of umbilical cord base; pulse oximeter or
cardiac monitor
Lack of response to oxygenation, ventilation, and chest compressions
Specific signs overlap those of asphyxia
and shock
Low core temperature
Apnea
High core temperature
Specific symptoms overlap those of
asphyxia and shock
Low blood sugar
Pallor
Poor capillary refilling
Leakage of blood
Always have available blended O
Readjust facemask; seal tightly against skin
Apply upward force to mandible to counteract
downward force holding facemask in place; extend
neck slightly
Increase insufflation pressure until breath sounds
are audible and chest movement seen
Place orogastric tube
Reinsert into trachea
Withdraw until breath sounds are bilaterally equal
Tape ET tube in place
Decompress tension pneumothorax
Same as for persistent cyanosis
External cardiac compression if heart rate less than
60 beats/min after 30 sec of effective ventilation
Stop oropharyngeal suctioning
Emergency epinephrine/volume expander
administration
Dry infant; remove wet linen
Use polyethylene bags/warming mattress
Cover wet hair
Keep under radiant warmer
Servocontrol of warming devices
Removal of warming mattress
Bolus 2 mL/kg of D10W
Maintenance infusion of D10W
Keep all intravascular tubing connection sites in
plain view
Tape UAC/UVC in place in addition to suturing lines
depth
2
ET, Endotracheal; UAC, umbilical artery catheter; UVC, umbilical venous catheter.
TABLE
ocal cords
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4.4
ENDOTRACHEAL TUBE SIZE AND DEPTH OF INSERTION
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83
WEIGHT (G) GESTATIONAL AGE (wk) TUBE SIZE (mm) (INSIDE
DIAMETER)
<1000 <28 2.5 <7
1000-2000 28-34 3.0 7
2000-3000 >34 3.5 8
>3000 >40 3.5 9
Adapted from Weiner GM, ed. Textbook of Neonatal Resuscitation. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2016.
Tongue
Vallecula
Epiglottis
FIGURE 4.8 Anatomic landmarks that relate to intubation. (From Weiner GM, ed. Textbook of Neonatal Resuscitation. 7th ed. Elk Grove
Village, IL: American Academy of Pediatrics and American Heart Association; 2016.)
• Confirm endotracheal tube position by
exhaled CO2 detector and by auscultation for
bilaterally equal breath sounds in the axillae
and absence of breath sounds over the stom-
as during bradycardia. To prevent complications,
provide free-flow oxygen during intubation, use
gentle technique, and limit each intubation attempt
to 30 seconds.
DEPTH OF INSERTION (cm
FROM UPPER LIP)
Vallecula
Epiglottis
Glottis
V
Esophagus
ach. Observe chest wall movement. Note the
centimeter marking at the lip (see Table 4.4).
• Secure the endotracheal tube and obtain a
chest radiograph.
• Shorten the endotracheal tube to 4 cm beyond
the lips, if necessary.
Complications of intubation include hypoxia
caused by prolonged intubation attempts or lack
of supplemental oxygen; tube malposition; apnea
or bradycardia caused by hypoxia or vagal stimulation; and trauma to the oropharynx, trachea, vocal
cords, or esophagus (see Table 4.3). Exhaled CO2
detection devices may be helpful even in newborn
infants weighing less than 2 kg.89 Color change
in detection devices may be delayed in extremely
preterm infants, especially if cardiac output is low,
CHEST COMPRESSIONS
Indications for chest compressions include a
heart rate of less than 60 beats/min despite
effective positive-pressure ventilation for 30
seconds. Follow the sequence of (A) airway, (B)
breathing, and (C) circulation in providing resuscitative support. Even if the heart rate is less than
60 beats/min shortly after delivery, the airway
should be cleared, and positive-pressure ventilation should be given for 30 seconds before
beginning chest compressions. Often, adequate
ventilation alone will result in a rapid increase
in heart rate.62 Beginning chest compressions
too early may interfere with the effectiveness of
positive-pressure ventilation and actually delay an
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infant’s response to resuscitation.
Perform the following steps:
• Attach ECG leads and intubate if not already
done.
• Position the infant with the neck slightly
extended.
• Provide firm support for the back.
• Increase oxygen concentration to 100%
• Perform compressions from the head of the
bed using the two-thumb technique (Fig. 4.9) .
The person providing ventilation moves to the
side of the warmer once the intubation is complete and the tube is secured.
• Position: Lower third of sternum
88
• Rate: 90 times/min
• Depth: One third of the anterior-posterior
diameter of the chest
• Support: Encircling fingers
• Provide 90 compressions/min and interpose
30 breaths/min with a 3:1 ratio of compressions to breaths (120 events/min).
88
• Evaluate the heart rate after 60 seconds by ECG
monitoring.
• Continue chest compressions until the heart
rate is greater than 60 beats/min.
• Administer epinephrine if the heart rate remains
less than 60 beats/min after 60 seconds of
coordinated and effective chest compressions
with 100% oxygen.
When the response to positive-pressure
ventilation and chest compressions is poor,
reevaluate for technical problems and conditions interfering with ventilation. Confirm that
oxygen is connected properly and that oxygen has
been increased to 100% (see Table 4.3). Ventilate
with pressures to expand the chest and breaths
interposed between compressions. Evaluate the
infant for pneumothorax, diaphragmatic hernia, or
hypovolemia (see Delivery Room Emergencies
later in this chapter).
Complications of chest compressions include
liver laceration, rib fractures, and pneumothorax. To
prevent complications, check the position of compressions, maintain contact with the chest during
the release portion of the compression cycle, and
avoid excessive force during compressions.
MEDICATIONS
The indications for drug administration during
newborn resuscitation include the following:
• Epinephrine: Heart rate less than 60 beats/min
despite 60 seconds of coordinated ventilation via
endotracheal tube and chest compressions
• Volume expanders: Evidence of acute bleeding
or signs of hypovolemia; poor response to other
resuscitative measures
Perform the following steps:
• Calculate the correct dosage of each drug
based on the newborn’s (estimated) weight.
• Prepare each drug for administration, draw up
the appropriate concentration and volume, and
label the syringe.
• Administer each drug by the correct route
and at the proper rate.
• Reevaluate for desired effect and take follow-up action.
Epinephrine increases the rate and strength
of cardiac contractions. Perhaps more important
during resuscitation is its action as a peripheral
vasoconstrictor, directing cardiac output to the central circulation and increasing coronary perfusion
pressure.82 Epinephrine is most effective when
administered by umbilical venous catheter in
a dose of 0.1 to 0.3 mL/kg (0.01 to 0.03 mg/
kg). Endotracheal administration in a one-time
dose of 0.5 to 1 mL/kg (0.05 to 0.1 mg/kg) can
be considered while obtaining venous access.
Expansion of plasma and blood volume may also be
necessary to maintain cardiac output, blood pressure,
and peripheral perfusion.
Volume expansion should be considered when
there is evidence of acute blood loss (e.g., placental
abruption, bleeding from placenta previa, fetal-maternal hemorrhage, umbilical cord tear, acute neonatal hemorrhage) or poor response to resuscitation
(e.g., pallor, bradycardia, exaggerated tachycardia).
Normal saline is the preferred solution for
volume expansion in a dose of 10 mL/kg by
umbilical venous catheter.
Complications of drug administration include
extravasation with intravascular administration,
hepatic injury with low umbilical venous catheters,
and unpredictable absorption with endotracheal
administration. The use of resuscitation drugs also
may result in complications from their adverse
pharmacologic effects. Epinephrine, administered
in high doses, increases the risk for significant
hypertension and a hyperadrenergic state, which
may result in germinal matrix hemorrhage or myocardial damage. Absorption of epinephrine after
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85
A
FIGURE 4.9 Two-thumb method of chest compression. Two thumbs placed one over the other or side by side (depending on the size of
the baby) compress the sternum; the fingers support the spine. Providing chest compressions from the head of the bed facilitates emergency
UVC placement. (From Weiner GM, ed. Textbook of Neonatal Resuscitation. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics
and American Heart Association; 2016.)
B
endotracheal administration is erratic.82 Volume
overload may result from administration of repeated
doses of volume expanders. Rapid volume expansion, resulting in acute elevation of systolic blood
pressure, has been associated with intraventricular
hemorrhage.
33
Distressed newborns have impaired auto-
regulation of cerebral blood flow, with
blood flow directly related to the systolic
blood pressure. Increased cerebral blood flow
and elevated systolic pressures may be responsible for intraventricular hemorrhage in the
presence of a capillary bed insulted by acidosis
and hypoxia.53 Autopsy studies also suggest that
increased cerebral venous capillary pressure can
initiate intraventricular hemorrhage. Volume
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expansion should be performed cautiously in
preterm or asphyxiated infants, infusing 10
mL/kg aliquots of fluid over a 5- to 10-minute period and evaluating the response before
administering repeated aliquots of fluid. The
exception to this rule is the infant who has
experienced acute perinatal hemorrhage with
hypovolemia. These infants should have the circulatory fluid volume restored as rapidly as possible. Complications of medication administration
can be prevented by choosing the correct dose,
rate, and route of administration and positioning
umbilical lines carefully. The infant should be
evaluated for adverse effects and response to fluid
volume after each medication/volume dose.
Sodium bicarbonate is no longer recom-
mended for use during resuscitation immediately after birth. Although acidosis frequently
persists after a prolonged resuscitation, many
infants correct an acidosis spontaneously once
the asphyxiating circumstances are relieved and
adequate ventilation is established. Metabolic correction of pH is a slow process that takes several
hours, and treatment with sodium bicarbonate
is not necessary. Sodium bicarbonate results in
worsened acidosis in the setting of impaired ventilation; bicarbonate also may worsen intracellular
acidosis. Furthermore, bicarbonate adds a high
sodium load, which may directly depress myocardial performance.
Naloxone hydrochloride is indicated during
acute resuscitation only in the very specific
circumstance of severe neonatal respiratory
depression and narcotic administration to
the mother in the last 4 hours. Naloxone is
not part of the routine resuscitation of an
apneic infant.81 Establishment of gas exchange
with positive-pressure ventilation is the first
priority for any infant who does not have
adequate spontaneous respirations after birth.
Furthermore, naloxone hydrochloride is contraindicated in infants of narcotic-addicted
mothers because administration can result
in severe abstinence syndrome, including
seizures.
Calcium and atropine have little role in
delivery room settings. Calcium is indicated for
hypocalcemia or hyperkalemia, both of which are
infrequent problems in the delivery room. Atropine
may mask hypoxia-related bradycardia.
7
DELIVERY ROOM
EMERGENCIES
Certain conditions can present as emergencies in
the delivery room (Table 4.5). These conditions may
require extensive resuscitation or result in a poor
response to resuscitation. Some situations require
special intervention immediately; most merit the
involvement of a neonatal nurse practitioner,
pediatrician, and/or neonatologist for management. Coordinated teamwork, with techniques and
communication skills acquired through simulation
training, can help ensure rapid and effective stabilization.
complete the treatment of diaphragmatic hernia,
abdominal wall defects, and neural tube defects. See
Box 4.3 for an outline of emergency procedures in
the delivery room setting.
37,83
Surgical intervention is necessary to
CARE DURING THE
TRANSITION FROM THE
DELIVERY ROOM TO THE
NURSERY
After the infant is stabilized and vigorous, perform
elective procedures, such as clamping and shortening the umbilical cord, footprinting, and identification. A head covering prevents heat loss from
the large surface area of the head and wet hair. A
vigorous, stable infant may remain in skin-toskin contact with the mother and breastfeed
immediately. The stable infant may complete
the transition period with the parents under
appropriate observation.
The infant who has required more extensive
resuscitation in the delivery room should be
transferred to a special care or intensive care
nursery when the infant has been dried and
protected from excessive heat loss, adequate
spontaneous or controlled ventilation has been
established, and the heart rate is greater than 100
beats/min. Note the time of the infant’s first respi-
ratory effort and when sustained, regular respirations
occur. Transfer the infant in a warmed transport
incubator with necessary support measures, such
as supplemental oxygen or positive-pressure
ventilation and pulse oximetry monitoring of
heart rate and oxygen saturations.42 Delay elective procedures until the infant is physiologically
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TABLE
4.5
CONDITION SIGNS AND SYMPTOMS ONGOING PROBLEMS INITIAL RESPONSES
Pneumothorax Cyanosis, respiratory distress,
Choanal atresia; oral/
pharyngeal airway
anomalies
Extreme prematurity Respiratory distress Continuing hypoxemia,
Sepsis Respiratory distress, hypotonia,
Severe asphyxia Prolonged apnea, bradycardia,
Hydrops fetalis Body wall edema, ascites, pallor,
Pulmonary hypoplasia and
oligohydramnios
Congenital diaphragmatic
hernia
Abdominal wall defect Midline abdominal wall defect at
Neural tube defects Open spinal defect (myelome-
DELIVERY ROOM EMERGENCIES
unequal breath sounds, bradycardia, displaced heart sounds
Noisy respirations, pink when crying
but cyanotic when quiet, cannot
pass suction catheter per nares
poor perfusion, foul odor
poor perfusion, pallor, hypotonia,
seizures
poor perfusion, respiratory distress,
possibly unequal breath sounds
(pneumothorax), distant heart
sounds (pericardial effusion)
Respiratory distress; flattened,
deviated nose; infraorbital creases;
low-set, crumpled ears; small chin;
deformities of the extremities
Respiratory distress with asymmetric breath sounds, barrel chest
and scaphoid abdomen, point of
maximal cardiac intensity shifted to
side opposite hernia
base of umbilical cord (omphalocele) or lateral to cord insertion
(gastroschisis) with externalization
of abdominal contents
ningocele), cranial defect with
outpouching brain tissue (occipital
or frontal encephalocele), failure
of formation of skull and brain
(anencephaly)
Continuing asphyxia, shock
(poor venous return)
Respiratory distress, intermittent
hypoxemia and bradycardia
hypothermia, possible sepsis,
hypovolemia
Continuing hypoxemia, shock Intubate, place umbilical lines, administer
Hypoxemia, shock, multiorgan
system injury
Hypoxemia, anemia, shock,
potential for multiorgan system
injury
Hypoxemia, pneumothorax,
pulmonary hypoplasia
Hypoxemia, pulmonary hypertension, contralateral pneumothorax
Hypovolemia, respiratory
distress, hypothermia, ischemic
injury to externalized abdominal
contents, infection
Prolonged apnea, infection,
hypothermia
Transilluminate chest, perform needle thoracentesis, evaluate chest tube placement
Supplemental oxygen, oral airway, and prone
positioning; or intubation (lower airway anomalies may require emergency tracheostomy)
Intubate, place umbilical lines, evaluate for
artificial surfactant, begin antibiotics, consider
transport to neonatal center
antibiotics
Intubate, place umbilical lines, give volume
expander and vasopressors for shock, consider
transport to neonatal center
Intubate, perform posterolateral needle
thoracentesis bilaterally if unable to ventilate;
consider paracentesis if ascites compromises
ventilation; place chest tube for pneumothorax,
place umbilical lines, evaluate need for partial
exchange transfusion, consider transport to
neonatal center
Intubate, place umbilical lines, monitor closely
for pulmonary air leak, consider transport to
neonatal center
Intubate, decompress bowel with orogastric tube
to low intermittent suction, place umbilical lines,
arrange transport to neonatal center
Protect exposed tissue with evaporative barrier;
begin parenteral fluids at 1.5 times maintenance; place an orogastric tube to low intermittent suction, position infant side-lying with
support of exposed organs, monitor temperature
and urine output, arrange transport to a neonatal
center with pediatric surgery
Provide supportive care unless prenatal diagnosis
of lethal anomaly has allowed formation of a
plan for limited support; protect exposed tissue
with gauze soaked in warmed saline and evaporative barrier; arrange transport to a neonatal
center with specialists in spinal defects
87
Exchange volume = Estimated dry wt × Blood volume/kg
(desired Hct − current Hct) ÷ Hct of PRBCs
BOX
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4.3
UNIT TWO Support of the Neonate88
EMERGENCY PROCEDURES IN THE DELIVERY ROOM
A. Umbilical vessel catheterization (see Chapter 7)
B. Thoracentesis and chest tube placement (see Chapter 23)
C. Partial exchange transfusion for anemia (see Chapter 20)
1. Indications: Profound chronic anemia (hematocrit [Hct] <25%), as in the
setting of hydrops. Distinct from situations of acute loss of blood volume,
chronic anemia results in normal blood volume per kilogram, necessitating
partial exchange transfusion to rapidly raise the hematocrit.
2. Procedure
a. Obtain O-negative packed red blood cells (PRBCs) by emergency
release if necessary. PRBCs should be as fresh as possible to
minimize risk for hyperkalemia.
b. Insert a low umbilical vein catheter, and attach a four-way stop-
cock (exchange set).
c. Perform an isovolumetric exchange by alternating withdrawal
and infusion of 5- to 10-mL aliquots of patient blood and PRBCs
to a total exchange volume of approximately 20 mL/kg. The
formula is as follows:
This equation can be used to estimate the rise in hematocrit for a
given exchange volume and a given hematocrit of exchange blood.
d. Alternatively, place both a low umbilical vein catheter (UVC)
and an umbilical artery catheter (UAC). Withdraw from the UAC
while infusing PRBCs per the UVC at the same rate to the total
exchange volume.
3. Risks
a. Thrombotic, embolic events
b. Infection
c. Bleeding (from mechanical complications or depletion of clotting
factors)
d. Hyperkalemia (consider use of washed PRBCs for nonemergent
partial volume exchanges)
D. Prophylactic administration of exogenous surfactant (see Chapter 23)
1. Indications
a. Prematurity
b. Respiratory distress
c. Presumed surfactant deficiency
2. Procedure
a. Calculate the appropriate dose of surfactant based on birth
weight.
b. Confirm correct endotracheal tube position by centimeter mark-
ings at the lip (see Table 4.4) and careful auscultation. Chest
x-ray film confirmation is ideal if surfactant is administered during
stabilization in the nursery.
c. Suction the endotracheal tube to clear secretions.
d. Monitor heart rate and oxygen saturation with pulse oximetry.
e. Administer surfactant according to manufacturer’s directions.
Administration options include rapid bolus and gradual infusion
combined with positioning of the infant and hand or mechanical
ventilation.
f. Refrain from suctioning for at least 4 hours after surfactant
administration.
g. Monitor chest wall rise, saturations, and arterial blood gases, and
adjust ventilator support accordingly.
3. Complications
a. Hypoxemia
b. Air leak
c. Pulmonary hemorrhage
stable.48 Depending on the level of care required
by the infant and the level of care available in the
institution, the infant may need to be transported
from the birth setting to receive appropriate care
after resuscitation (see Chapter 3).
In the intensive care nursery, place the infant
on a preheated open warmer with servocontrol.
Avoid overwarming because hyperthermia may
be associated with respiratory depression and worsened neurologic outcome after asphyxial insults.
Continue adequate cardiopulmonary monitoring, including electrocardiogram, respiratory
rate and pattern, and monitoring of oxygen
saturation with pulse oximetry (see Chapter 7).
Obtain serum glucose by heelstick and blood
51,61
pressure by a Doppler device and blood pressure cuff. If a UVC was inserted during the initial
resuscitation for medication administration, place a
peripheral intravenous line and remove the low-lying UVC or replace it with a central umbilical line
for maintenance fluid administration. If blood glu-
cose is low or volume expansion is indicated,
begin a glucose infusion or volume expansion
via either route. Evaluate for placement of an
arterial line for blood sampling and continuous
arterial pressure monitoring. Confirm endotracheal
tube and umbilical line placement with an x-ray
examination.
Debriefing after resuscitation and stabili-
zation of the infant in the NICU gives those
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