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 The care of a newborn or neonate must be tailored to meet the unique needs of this
population. The rate of complications increases as birth weight and gestational age
decrease. Approximately 10% of newborns need additional assistance to survive.
 Initial steps of neonatal resuscitation include positioning and clearing the airway,
stimulating the newborn to breathe, and assessing heart rate and oxygenation. In a
newborn, resuscitation efforts are focused on establishing the airway and ensuring
adequate ventilation.
 Both short- and long-term outcomes have been linked to initial stabilization efforts,
which include warming the newborn; positioning; clearing the airway if necessary;
drying the newborn’s head, face, and body; and stimulating the newborn. Additional
steps that may be required include providing supplemental oxygen, assisting ventilation
by providing positive pressure, intubating, providing chest compressions, and
administering medications as needed.
 At birth, a fetus must transition from receiving oxygen from the placenta to receiving
oxygen via breathing. A rapid series of events must occur to enable the newborn to
breathe. Anything that delays this decline in pulmonary pressure can lead to delayed
transition, hypoxia, brain damage, and, ultimately, death.
 While a delivery is occurring, use any time available to obtain a patient history and
prepare the environment and equipment that may be necessary for neonatal resuscitation.
 Your initial rapid assessment of the newborn may be done simultaneously with any
treatment interventions. Note the patency of the airway, respiratory rate, respiratory
effort, pulse rate, color, and capillary refill.
 The Apgar score is used to determine the need for and the effectiveness of resuscitation.
It includes a score for appearance, pulse rate, grimace or irritability, muscle activity, and
respiratory effort. This score is obtained at 1 and 5 minutes after birth.
 It is important to follow the neonatal resuscitation algorithm developed by the American
Academy of Pediatrics and the American Heart Association.
 Thermoregulation is limited in the newborn; therefore, you must take an active role in
keeping the newborn’s body temperature in the normal range. Place the newborn directly
on the mother’s chest. Dry the head and the body with towels. Cover the newborn with a
dry towel; cover the head with a cap. Position the newborn to ensure a patent airway.
 If the newborn does not respond by 30 seconds after initial stabilization efforts (bulb
suctioning mouth and nose, drying and stimulating), further intervention is indicated.
 If the newborn has a normal breathing pattern and a pulse rate of greater than 100
beats/min but maintains central cyanosis of the trunk or of the mucous membranes,
provide supplemental free-flow oxygen.
 If the newborn remains apneic or has a pulse rate of less than 100 beats/min, begin
positive-pressure ventilation by bag-mask device.
 If the newborn’s pulse rate is less than 60 beats/min after 30 seconds of adequate
ventilation by positive-pressure ventilation with 100% oxygen via a bag-mask device,
begin chest compressions.
 Airway management in the newborn follows these steps. If a newborn is cyanotic or pale,
administer warmed, humidified free-flow oxygen. If the newborn has an airway
obstruction, for example from a congenital malformation, insert an oral airway. If these
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measures are not effective and the newborn is apneic, has inadequate respiratory effort, or
is bradycardic, perform bag-mask ventilation. If this is not effective, endotracheal
intubation is required.
Gastric decompression using an orogastric tube is indicated for prolonged bag-mask
ventilation (more than 5 to 10 minutes), if abdominal distention is impeding ventilation,
and in the presence of diaphragmatic hernia or a gastrointestinal congenital anomaly like
a tracheoesophageal fistula.
Chest compressions are indicated if the pulse rate remains less than 60 beats/min despite
positioning, clearing the airway, drying and stimulation, and 30 seconds of effective
positive-pressure ventilation.
Emergent vascular access becomes necessary when fluid administration is needed to
support circulation, when resuscitation medications must be administered IV, and when
therapeutic drugs must be given IV. Vascular access in a newborn occurs via the
umbilical vein.
Most newborns can be resuscitated with effective ventilator support. Medications may be
needed in patients with bradycardia, low blood volume, acidosis, respiratory depression
secondary to narcotics, and hypoglycemia. Remember that neonatal medication doses are
based on weight.
Once the newborn is stabilized as much as possible in the field, you should provide
transport to the nearest facility that can provide the next level of care.
Ongoing communication with the family is a must. Do not be specific about survival
statistics. If you do not have an answer, put the family in touch with the people who do.
Bradycardia in a newborn is usually caused by hypoxia, which is readily reversed by
effective positive-pressure ventilation. Another cause is a tension pneumothorax that
requires needle decompression. If ventilation and chest compressions do not improve the
bradycardia, administer epinephrine via an IV line or ET tube.
When a newborn is delivered through meconium-stained amniotic fluid, there is a high
risk of morbidity. If the newborn is depressed, do not dry or stimulate the newborn. Clear
the airway of meconium, intubate the trachea, attach a meconium aspirator and suction
catheter to the end of the endotracheal tube, and suction the ET tube while withdrawing
the tube from the trachea.
Diaphragmatic hernia is an abnormal opening in the diaphragm. If positive-pressure
ventilation is needed in a newborn with this condition, endotracheal intubation will be
necessary, along with an orogastric tube to minimize intestinal distention. Surgical
correction is required for this condition.
Newborns born before 37 weeks of gestation are considered premature. You should
provide cardiorespiratory support and a thermoneutral environment to optimize their
survival and long-term outcome.
Seizures are a very distinctive sign of neurologic disease in the newborn. Quickly
evaluate prenatal and birth history, and perform a careful physical exam. Consult with
medical control if you are considering administering anticonvulsant medication.
Non-bilious vomiting is common in newborns. Keep the newborn’s face turned to one
side to prevent further aspiration. Suction or clear the vomitus from the airway with the
help of a suction catheter or suction bulb. Ensure adequate oxygenation. Consider fluid
resuscitation. Transport the newborn on his or her side.
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In an infant with diarrhea, estimate the number and volume of loose stools, decreased
urinary output, and degree of dehydration. Ensure adequate oxygenation and ventilation.
Perform chest compressions in addition to positive-pressure ventilation in a newborn if
the pulse rate is less than 60 beats/ min. Administer fluid therapy.
If fever is suspected, observe the newborn for the presence of rashes. Obtain a careful
history and vital signs. Ensure adequate oxygenation and ventilation. Remove additional
layers of clothing and improve ventilation in the environment. Perform chest
compressions, if indicated. Do not administer antipyretic agents.
Birth trauma includes both avoidable and unavoidable injuries to the newborn resulting
from mechanical forces during the delivery process. A difficult birth or injury to the
newborn can occur because of the newborn’s size or position during labor or delivery.
Various congenital heart diseases or malformations of the heart may cause cardiac
emergencies in newborns.