Resuscitation and Immediate Stabilization

The Neonatal Resuscitation Program (NRP), sponsored by the American Academy of Pediatrics (AAP), is the standard in the United States for stabilization of infants in the delivery room. Helping Babies Breathe is another evidence-based program that is used in many other international settings. In this section, we outline the NRP guidelines.

Basics of Neonatal Resuscitation

Standardization of neonatal care in the delivery room based on the NRP guidelines is aimed at reducing morbidity and mortality in all term and preterm infants. The NRP guidelines are updated as new research becomes available. NRP guidelines (2021, 8^th edition) recommend the following:

• Begin any interaction with antenatal counseling, a team briefing, and equipment check.

• Maintain body temperature between 36.5°C and 37.5°C throughout resuscitation and stabilization.

• If positive pressure ventilation (PPV) is needed, oxygen should be set at 21% for infants ≥35 weeks’ gestation and 21%-30% for infants <35 weeks’ gestation.

• Electrocardiogram (ECG) leads are the standard of care during PPV and chest compressions to ensure accurate heart-rate readings (rather than using the oxygen saturation monitor alone).

• If an infant requires chest compressions, the infant should ideally be intubated before compressions are begun, to ensure adequate ventilation.

• Routine intubation is no longer recommended for infants born through meconium-stained amniotic fluid. However, infants with meconium-stained amniotic fluid should be intubated if spontaneous respiration does not occur during initial resuscitation attempts. (Previously, nonvigorous infants with meconium-stained amniotic fluid were routinely intubated to suction meconium from the trachea and airway. However, studies have shown that this practice does not reduce morbidity associated with meconium aspiration.)

Providing Ventilation Support

In contrast with resuscitation in adults, which is focused on circulatory support, the primary focus of neonatal resuscitation is adequate ventilation. Appropriate positive-pressure ventilation (PPV) in neonatal resuscitation generally improves circulation and overall outcome. See the NRP guidelines (2021, 8^th edition) for the NRP algorithm.

During resuscitation, if ventilation is inadequate, the following mnemonic can be used to remember the steps to achieve effective ventilation.

Apgar Score

Virginia Apgar developed the Apgar score in 1953 to standardize assessment of neonates after birth. The score is based on assessment of the infant in 5 domains (appearance, pulse, grimace, activity, respiration) and determined at 1 minute, 5 minutes, and every 5 minutes thereafter until the score is >7. Apgar scores reflect the effectiveness of resuscitation and can indicate the need for further intervention at that moment, but do not predict long-term prognosis of an infant in the NICU or well-baby nursery.

Delayed Cord Clamping

Studies have shown that delayed umbilical cord clamping reduces the need for transfusion and the risk of intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC), resulting in improved neurodevelopmental scores later in life. The impact of this intervention is more apparent in preterm infants than in term infants. However, the benefit for term infants is a later nadir of blood counts (physiologic anemia). Therefore, cord clamping should be delayed for 30-60 seconds in most vigorous term and preterm infants without contraindications. During this period, the infant is either placed skin-to-skin with the mother and covered with warm towels after a vaginal delivery or on the maternal abdomen and covered with warm sterile towels after a cesarean section. The delivery attendant should evaluate and report the infant’s tone and breathing effort to the neonatal resuscitation team. If resuscitation is warranted, the infant is moved to a warming table for evaluation and intervention as indicated.

Extremely Low Birth Weight Infants

ELBW infants are at increased risk for hypothermia and insensible water loss. A plastic bag and thermal mattress are used to maintain adequate body temperature and reduce water loss during the first minutes after delivery. The ambient room temperature should be set at 72°F (22°C). When administering PPV to ELBW infants, oxygen should be set at 30% for initial resuscitation.

Use of Point-of-Care Ultrasound (POCUS)

Ultrasound is increasingly being used in the NICU as a bedside diagnostic tool for conditions such as pericardial effusions, pneumothorax, pleural effusions, and others in which prompt assessment is critical. It can also be used as an adjunct to improve efficacy and precision of procedures such as UVC/UAC placement, lumbar punctures, and peripheral arterial lines. Formal training and certification are required for those who use ultrasound in their clinical practice.