Neonatal Resuscitation: A Review
Since 2015, the guidelines updates are made on an ongoing basis. But the traditional major updates which goes at a five-year interval continues nonetheless. The guidelines are expected to receive major updates next year, 2020. Let’s look back and review how things prevailed over the last decade.
In-depth understanding of neonatal resuscitation practices should be obtained by every health care provider. An estimated 10% of newborns need to be assisted in order to start breathing upon delivery while approximately less than 1% require extensive resuscitation. While majority of neonates are able to make the transition from intrauterine to extra-uterine life, the increasing number of births worldwide means that there is always a possibility that many infants would require some assistance to achieve cardio-respiratory stability. Healthcare providers should bear in mind that neonates require highly specific needs that could be poles apart to those of adult patients.
The 2015 American Heart Association Emergency Cardiovascular Care Updates for Neonatal Resuscitation guidelines are applicable to neonates in transition from intrauterine to extra-uterine life as well as neonates who have completed newborn transition but require resuscitation during the first weeks after birth.
The 2010 neonatal resuscitation algorithm of the American Heart Association begins in evaluating if there is a need for resuscitation by checking on three parameters namely- age of gestation (term or preterm), whether the newborn crying or breathing, and if the new born has good muscle tone. The 2015 algorithm on the other hand begins with antenatal counseling, team briefing and equipment check. The new guidelines recognize that successful neonatal resuscitation may be realized through preparedness, thus perinatal evaluation must be done. By carrying out a perinatal risk evaluation, possible outcomes are foreseen, thus healthcare providers can launch a team of personnel and at the same time prepare the necessary equipment and supplies prior to the delivery. neonatal resuscitation
In both 2010 and 2015 algorithms, if the neonate is term, with good cry, breathing, and muscle tone, the neonate stays with the mother, undergoes routine newborn care, kept warm and dry with cleared airway, and is continuously monitored. Otherwise, the neonate is stimulated in addition to the steps mentioned.
The temperature of non-asphyxiated neonates is a strong predictor of mortality at all gestational ages. The 2015 AHA algorithm for neonate resuscitation states that temperature should be maintained between 36.5°C and 37.5°C, not to exceed 38.0°C (hyperthermia) as it is associated with risks. In keeping hypothermic neonates warm, previous recommendation favored slow rewarming at less than 0.5°C/h over fast rewarming at 0.5°C/h. However, both are actually applicable. Should there be lack of resources to rewarm the neonate, it is permitted to place the neonate in a clean food-grade plastic bag up to the neck level and wrap them after drying. neonatal resuscitation
The newborn’s heart rate is an effective means of evaluating the effectiveness of respiratory effort. It also reflects the neonate’s response to the interventions given. The 2010 guidelines applied clinical assessment through auscultation of the pre-cordial area and pulse oximetry in the counting of heart rate. However, these are prone to inaccuracy thus the 2015 algorithm recommended utilization of ECG in order to obtain a more accurate value for the patient’s heart rate.
In the 2010 algorithm, if the neonate is apneic, gasping, with heart rate below 100 beats per minute, it is suggested to apply Positive-Pressure Ventilation and monitor the oxygen saturation. In the 2015 algorithm, the same recommendations are applied, however as mentioned above, ECG monitoring should be done instead. If the above steps has been undertaken yet the heart rate remains below 100 beats per minute, the 2015 algorithm recommends that chest movement should be checked, and ETT or laryngeal mask be used if needed in addition to ventilation correction which was the recommendation back in 2010. If the above recommendation has been performed yet the neonate’s heart rate is still below 100 beats per minute, the 2015 algorithm recommends intubation if not yet performed, chest compression, coordination with PPV, 100% oxygen, ECG monitoring, and emergency umbilical vein catheterization. Should bradycardia persist, IV epinephrine should be administered. However, if heart rate is persistently low, hypovolemia and pneumothorax should be considered. neonatal resuscitation