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200 CHAPTER 9: Emergency Delivery and Newborn Stabilization

addicted to narcotics because the drug mayprecipitate acute narcotic withdrawal andseizures. Assist ventilation with bag-maskand follow the guidelines for care of adepressed newly born.

Assess Heart RateIn the newly born, a low heart rate is usuallydue to hypoxia, not primary cardiac disease.The crying, active baby usually has an ade-quate heart rate. Assess heart rate carefullyin a baby who is not active or who requiresassisted ventilation. This is most easilyaccomplished by palpating a pulse at thebase of the umbilical cord (Figure 9-13).Count the number of beats over 6 secondsand multiply this number by 10. Some-times the umbilical vessels are constrictedso that the pulse is not palpable. Therefore,if a pulse cannot be felt, listen for theheartbeat over the left side of the chestusing a stethoscope.

Treat heart rates of less than 100 beats/min with bag-mask ventilation, even if therespiratory effort appears normal. Bradycar-dia usually responds rapidly to bag-mask

oxygen consumption. Thoroughly dry everyinfant, healthy, or depressed. Remove wettowels or blankets from around the baby afterdrying and replace them with clean, dry ones.This will take no more than 5 to 10 seconds.

Clear the AirwayThe newly borns head is larger than anolder childs or adults compared to its over-all body size, which leads to flexion of theneck in a supine position. This may causeairway occlusion. Extend the head slightlyto place the airway in a neutral position.Repeat nasopharyngeal suctioning to makesure there is a patent airway.

Assess BreathingNext, assess breathing. Most babies will becrying, indicating adequate respiratoryeffort! Breathing effort may be slightly irreg-ular in normal newly borns. Gasping orgrunting are signs of increased work ofbreathing and respiratory distress and indi-cate the need for assisted ventilation.

An apneic baby, with no visible respira-tory effort, requires immediate treatment.Most apneic newly borns will start breathingsimply with tactile stimulation. If the babyis apneic or has gasping respiration afterdrying and suctioning, further stimulation isnot likely to improve respiratory effort.Begin bag-mask ventilation with supplemen-tal (100%) oxygen (see Depressed NewlyBorn Resuscitation).

A special situation occurs when the pre-hospital professional encounters a newlyborn with respiratory depression after deliv-ery by a narcotic-addicted mother. Do notgive naloxone to the baby if the mother is

Assist ventilation in an infant with a heart rateless than 100 beats/min with bag-mask ventila-tion. Bradycardia usually reflects inadequate res-piratory effort.

Do not give naloxone to the newly born if themother is addicted to narcotics.

Figure 9-13 Feel for a pulse at the base of the umbilicalcord.

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ventilation, in which case no further treat-ment is necessary (see Depressed NewlyBorn Resuscitation).

Assess ColorSkin color assessment in newly borns hasseveral unique features. In utero, the fetusdepends on placental delivery of oxygen,and blood oxygen concentrations are verylow compared to conditions after birth.Therefore, prior to the initiation of respira-tion after delivery, the infant will appearcyanotic.

If the cyanotic newly born is apneic,immediately begin bag-mask ventilation. Ifthe baby is breathing, but appears blue,determine if the cyanosis is central (on thetrunk and face) or peripheral (limited to thehands and feet). This difference will helpwith decision making and therapy. If centralcyanosis is present, true hypoxia is present.Administer supplemental oxygen at 15 L/min via a mask held loosely over thebabys face.

Peripheral cyanosis is also termedacrocyanosis. This is a common finding innewly borns through the first 24 to 48 hoursof life and requires no therapy.

Apgar ScoreAll hospitals and some EMS systems use theApgar score for newly born assessment.This score measures the babys overall car-diopulmonary and neurologic function at 1 and 5 minutes of life, then every 5 min-utes thereafter in the unstable baby. TheAPGAR may be helpful in assessing theeffectiveness of resuscitation.

Depressed Newly BornResuscitation

Depressed newly born resuscitation refers tothe series of interventions used to stimulatespontaneous respiratory effort. When the babyremains depressed after drying, warming, andclearing the airway, begin resuscitation. Usethe following sequence:

1. Dry the infant and place in the supineposition in a warm environment.

2. Suction her mouth and nose.3. Position the head in slight extension.4. Assess breathing. If respiratory effort

is absent or irregular, start bag-maskventilation with 100% oxygen at 40 to60 breaths/min.

5. Assess heart rate. If less than 100 beats/min, start bag-maskventilation (Figure 9-14).

6. Assess heart rate after 30 seconds ofventilation. If less than 60 beats/min,proceed with chest compressions.Compressions should be delivered a depthof one third of the anterior-posteriordiameter of the chest. The two thumbencircling hand technique is recommended(compressions with two thumbs withfingers encircling the chest and supportingthe back). Deliver 90 compressions and 30 ventilations (120 events per minute).Continue bag-mask ventilation.

7. Continue positive-pressure ventilationuntil heart rate is above 100 beats/minand spontaneous breathing is present.

Depressed Newly Born Resuscitation 201

Figure 9-14 Using a bag-mask device on a newly born.

Good ventilation will usually reverse bradycardia.

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202 CHAPTER 9: Emergency Delivery and Newborn Stabilization

Advanced Life Support

Assess babys risk for requiring resuscitation Provide warmth

Position, clear airwayDry, stimulate to breathe

Give supplemental oxygen, as necessary

Assist ventilationwith positive pressure

Intubate the trachea

Provide chest compressions

Administermedications

Always neededby newborns

Needed lessfrequently

Rarely needed by newborns

Figure 9-15 The relationship between resuscitationprocedures and the number of newly born babies who needthem. Source: Kattwinkel J, ed. Textbook of NeonatalResuscitation. 5th ed. Elk Grove, IL: American Academy ofPediatrics and American Heart Association; 2006:12.

meconium staining who is not vigorousdespite suctioning on the perineum needsfurther aggressive suctioning of the mouthand nose. However, suctioning of meconiumshould not distract from the need for emergentoxygenation and ventilation of the newly born.In the patient with meconium aspirationand respiratory failure or apnea, quicklyperform endotracheal suctioning of meco-nium. Then provide ventilation with a cleanendotracheal tube or by bag-mask device.

A meconium aspirator device may facili-tate endotracheal suctioning in an intubatednewly born with absent or ineffective respi-ratory effort. However, the use of this devicehas not been studied in the prehospital set-ting and its impact on clinical outcome isunknown.

Endotracheal Intubation andEpinephrine AdministrationCheck the heart rate after 30 seconds. If lessthan 60 beats/min, prepare for endotrachealintubation and administration of epineph-rine (0.010.03 mg/kg = 0.10.3 mL/kg of1:10,000 solution). The endotracheal routemay be associated with lower blood levels ofthe drug. IV access should be obtained assoon as possible. The recommended dose is(0.010.03 mg/kg 1:10,000). The same asthe endotracheal intubation dose.

Continue chest compressions and give repeated doses of epinephrine every 3 to 5 minutes until heart rate is above 60 beats/min.

The Inverted PyramidThe inverted pyramid (Figure 9-15) illus-trates the relative need for interventions indepressed newly borns.

Basic life support (BLS) is usually allthat is required during deliveries and there-fore comprises the largest area at the top ofthe inverted pyramid. In contrast, advancedlife support (ALS) interventions such aschest compressions, intubation, and medica-tion administration are rarely required, andcomprise the smallest area at the bottom ofthe inverted pyramid.

Meconium AspirationA child born with thin meconium stainingwho appears active and without respiratorydistress needs only routine oral and nasalsuctioning and standard newly born care.On the other hand, a child born with thick

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Advanced Life Support

Advanced Life Support

been associated with intraventricular hemor-rhage. The only medication likely to be usedin newly born resuscitation is epinephrine,which may be administered via the endotra-cheal tube or through an IV or IO line.

Summary of DepressedNewly Born Resuscitation

The typical newly born response to hypoxiais apnea and bradycardia. The primary treat-ment of the depressed newly born thereforeinvolves reversal of hypoxia with immediatebag-mask ventilation with supplemental(100%) oxygen. If the child does notimprove, begin chest compressions and perform endotracheal intubation on thescene before transport. Shock is rare, and ismost commonly the result of asphyxia.Hypovolemia is an uncommon cause ofshock in the newly born. If hypovolemicshock is suspected, transport immediatelyand initiate volume resuscitation via IV orIO line on the way to the hospital.

Vascular AccessVascular access is rarely needed in newlyborns in the field because resuscitation islargely focused on airway management andbreathing.

In reality, establishing vascular access ischallenging in the newly born and its bene-fits must be carefully weighed against prolonged on scene time and potential com-plications. IV access may be attempted inthe antecubital fossae or the saphenousvein at the ankle. Intraosseous infusion isan alternative.

Summary of Depressed Newly Born Resuscitation 203

ShockShock at birth is most commonly due toasphyxia (severe hypoxia in the womb orduring delivery) and acidosis. Blood lossduring delivery due to umbilical cord avul-sion or fetal-placental transfusion is anuncommon cause of shock in the newlyborn. Signs and symptoms of shock, what-ever the cause, include abnormal appear-ance (lethargy, hypotonia), abnormal color(pallor, mottling), tachycardia, and pro-longed capillary refill time. Hypothermiamay also mimic these findings.

Treatment of ShockBecause intrauterine or perinatal asphyxia isthe most common cause of depression in thenewly born, initial resuscitative efforts shouldensure adequate oxygenation and ventilation.Volume resuscitation is rarely needed. Inexceptional circumstances where hypov-olemic shock is suspected, consider placingan IO line. Isotonic crystalloid is recom-mended at a dose of 10 mL/kg. Fluid resusci-tation should be limited in premature infants,as giving volume expanders too rapidly has

A meconium aspirator device may facilitate tra-cheal suctioning in an intubated newly bornwith absent or ineffective respiratory effort.However, the use of this device has not beenstudied in the prehospital setting and its impacton clinical outcome is unknown.

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When there is no IV or IO access, giveresuscitation medications such as epineph-rine through the endotracheal tube. Do notgive other solutions such as sodium bicar-bonate or dextrose through the endotrachealtube, as these are damaging to the lungs.

Umbilical catheterization in the fieldis a controversial procedure. While thisroute of vascular access is widely used inthe neonatal intensive care unit, there willbe very few opportunities for the prehospi-tal professional to practice and maintainthis skill, and serious complications canoccur. Intraosseous infusion may be prefer-able if vascular access is clearly necessary forresuscitation, and a peripheral IV cannot beplaced.

Stabilization for Transport

The active term infant requires no inter-vention or electronic monitoring duringtransport. Be sure the child is restrained asper local EMS system policy. In some sys-tems it is acceptable to restrain the motherappropriately and allow her to hold thebaby during transport. Encourage her tobreastfeed the active infant if possible.This may prevent hypoglycemia and pro-mote maternal-infant bonding, uterinecontractions, and decreased uterine bleed-ing. Provide a warm environment in theambulance.

204 CHAPTER 9: Emergency Delivery and Newborn Stabilization

Transport of the CompromisedNewly BornOxygen TherapyGive supplemental oxygen if the newly born ishypoxic (pulse oximetry < 95% on room air).

MonitoringAfter resuscitation, reassess the status of theinfant throughout transport. Place cardiacleads in the same position as in an adult. Aheart rate between 120 and 160 beats/min isnormal in a newly born. If heart rate decreases,follow the procedures for depressed newlyborn management.

Attach an infant pulse oximetry probe ona finger or toe. If unable to get an accuratereading, the probe may have to be placedaround the hand or the foot. Saturationsbetween 90% and 100% are normal.Although there are negative effects of hyper-oxia (high oxygen saturation) in the newlyborn, if the baby is distressed, the goal in thefield should be to ensure adequate oxygena-tion through administration of supplementaloxygen and assisted ventilation when needed.

HypothermiaHypothermia develops quickly in newlyborns. Oxygen demand triples when skintemperature drops by 1 degree. Signs ofhypothermia are similar to those of shock.Keep the baby warm during transport. Have

If commercial warm packs are used to preventor treat hypothermia in the newly born, place atowel between the infants skin and the device.The combination of thin skin, little subcuta-neous fat, and an inability to communicate dis-comfort puts them at high risk for burns.

Treat a hypovolemic newly born like an acutetrauma patient with life-threatening blood loss.

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Stabilization for Transport 205

a small knit cap available to cover theinfants head. Turn the heat on in the ambu-lance even at the risk of discomfort to themother and crew. Place the baby on themothers bare chest (skin-to-skin contact)and cover both of them to maintain theinfants temperature.

Transport of the CompromisedNewly Born: HypoglycemiaThe depressed newly born or prematurelydelivered baby is at risk for hypoglycemia,but this complication is unlikely to develop

Upon arriving at the home of a family who had called 9-1-1 for labor, you find a woman has just delivered anapparently term female infant that is still attached to the umbilical cord and is not crying or moving.

1. Discuss the scene management of the baby.2. What is the role of vascular access?

in the first 30 minutes of life. If transporttimes are longer, measure a bedside glucoselevel at approximately 30 minutes afterbirth, or immediately in any baby who has adrastic change in responsiveness or perfu-sion. If a serum glucose of less than 40 mg/dLis documented in a depressed newly born,and an IV or IO line can be established intransport, give 10% dextrose in a 2 mL/kgpush. Re-check serum glucose every 30 min-utes during long transports. If the infant hasdocumented hypoglycemia but is active, inno respiratory distress, and has a suckreflex, allow her to breastfeed or offer her 20to 30 mL of 5% dextrose by bottle.

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