The term ‘newborn’ refers to a baby in the first few hours following the birth; the neonatal period on the other hand is defined as the first four weeks (28 days) of life. ‘Resuscitation’ is the preservation of life by establishing and maintaining the airway, breathing, and circulation. The neonatal resuscitation guidelines and the Newborn Life Support algorithm reflect the differences in the anatomy, physiology and root causes of cardiorespiratory arrest in adults, children, and young children (1).

High Risk Births Requiring Neonatal Resuscitation

Up until the moment a newborn baby has managed to successfully breathe independently with his or her own lungs, the baby is still dependant on the placenta and umbilical cord for respiration. However it is possible that the normal function of the placenta or umbilical cord can be disturbed as a result of pathological events, either before or during the birth. These occurrences increase the chance of hypoxia – a reduction in the supply of oxygen to the brain or tissues (1).

The birth itself is a fairly hypoxic event for the foetus, as during the mother’s contractions respiratory exchange by the placenta is disturbed. Although most newborns will manage to tolerate this disturbance, some resuscitation support is likely to be required by babies who fall into the following categories (1):

• Babies who are delivered prematurely before 35 weeks of gestation
• Breech babies who have been delivered vaginally
• Babies who were a result of multiple pregnancies
• Caesarean deliveries in babies who are delivered before 39 weeks of gestation

Although in many cases neonatal resuscitation can be foreseen, there is still a 1% chance of resuscitation requirements in low risk births. This is why specialist equipment and medical professionals should be available at all times in delivery wards.

Related CPD training: Advanced Life Support 1 – Developed by LearnEM

Newborn Life Support Algorithm

The newborn life support algorithm is intended to provide guidance and support when a young baby is being resuscitated. It compromises of the following steps (2):

• Enabling placental transfusion via delayed cord clamping
• Keeping the newborn dry and covered, and taking additional steps to maintain a healthy temperature when required
• Assessing the condition and tone of the newborn and judging the requirement of any interventions
• Obtaining and maintaining an open airway
• Ventilating the baby’s lungs with inflation breaths if the baby is not breathing on his or her own
• Continue aerating the baby’s lungs until independent respiration is established
• If the baby’s heartbeat is less than sixty beats per minute after five inflation breaths, carry out chest compressions
• Considering the administration of drugs and fluids if the heartbeat is still low
• Update the parents and medical team immediately after completing the above steps
• Complete any documentation and note down any discussions and decisions that have been made also

What Do The Neonatal Resuscitation Guidelines Suggest?

Neonatal resuscitation guidelines outlined by the Australian Resuscitation Council, suggest that if a high risk birth is pre-anticipated, then more than one experienced neonatal resuscitation professional should be in the delivery room at the time of birth. Such personnel should be trained in basic measures which can maintain and open an airway, ventilation through the use of masks, chest compressions, vascular cannulation and the knowledge and use of relevant drugs and fluids (2).

Communication between the medical staff responsible for the mother and the baby is also essential. Any maternal conditions, antenatal diagnoses and foetal wellbeing assessments should be shared as these could affect the resuscitation procedure (2).

Any young infant is at a higher risk of hyperthermia or hypothermia, therefore maintaining a healthy balanced body temperature is essential for survival. As babies are usually born wet, it is recommended that the baby is immediately dried and head is covered with a warm cap. Newborn skin to skin contact with the mother is highly recommended, in such a position that the airway is open and both are covered with a warm blanket to preserve heat. If resuscitation is required then it is suggested the infant is placed under an alternative preheated source (2).

The guidelines also suggest prior preparation of standardised kits which have the equipment for neonatal resuscitation can save a considerable amount of time in emergencies. The recommended equipment and drugs include (1):

• General equipment and a safe working area
• Airway management equipment
• Breathing support equipment
• Circulation support equipment
• Drugs and fluids
• Documentation

Delayed cord clamping is associated with increased placental transfusion, increased cardiac output and also a stable, healthier neonatal blood pressure. There is still some controversy surrounding the subject of delayed cord clamping, however some studies suggest that by waiting as long as it takes for the cord to stop pulsating, is linked with higher neonatal haemoglobin levels.

On the other hand, it is known that immediately after birth, the uterine arteries will constrict; therefore we cannot be entirely sure whether the placenta is able to provide compensatory gas exchange in a newborn who does not breathe independently right after birth (2).


References:

1. https://www.resus.org.uk/resuscitation-guidelines/resuscitation-and-support-of-transition-of-babies-at-birth/
2. http://www.nzrc.org.nz/assets/Uploads/Guidelines/Neonatal-Resus/All-Neonatal-guidelines-Jan-2016.pdf