Newborn Care: Initial Assessment & Resuscitation
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
All newborn infants should be cared for by a team of expert physicians and other trained health care providers in the context of a family-centered environment. Individuals trained in neonatal resuscitation may be present in the delivery room and ready to perform timely resuscitation, if needed. Obstetricians are trained to manage key aspects of birth process, including protecting the maternal perineum and fetus from trauma and providing initial support to the newborn. Historically, the initial support for the newborn has included: suctioning the oronasopharynx; immediate clamping of the cord and providing 100% oxygen if resuscitation is necessary. The American Academy of Pediatrics (AAP) recently modified its recommendations on the initial support and alternated several practices, which are discussed in this review (1). At birth, infants are quickly stabilized and assessed to determine the level of care required. All infants undergo an identification process, and copies of maternal and newborn medical records are transferred from the obstetrical to neonatal care teams. Simple recommendations to patients during that transition period may save precious newborn lives. Given the paucity of data in the obstetrical literature, obstetricians and midwives are conceivably less comfortable addressing issues regarding newborn safety.
The purpose of this document is to provide education about current recommendations and guidelines regarding initial assessment and resuscitation of newborns, at or near term. Obstetricians develop relationships with patients over the course of 1 year, with frequent visits, and are in a unique position to provide advice and guidance during this period when patients are highly motivated to learn. The lack of education regarding the newborn state during the antepartum period is a missed opportunity for obstetrical-providers. The Women's Health and Education Center (WHEC) with its partners has launched the series on Newborn Care to disseminate updated literature and guidelines to the health care providers regarding newborn safety. Current guidelines are summarized in this segment. Each child and family are unique; therefore, these Recommendations for Preventive Health Care, in this review, are designed for the care of children who are receiving competent parenting, have no manifestations of any health problems, and are growing and developing in a satisfactory fashion. Developmental, psychological, and chronic disease issues for children and adolescents may require frequent counseling visits separate for preventive care visit. Additional visits also may become necessary if circumstances are different from normal.
Term (37 0/7 to 41 6/7 weeks of gestational age) and late-preterm infants (34 0/7 to 36 6/7 weeks of gestation age) are closely observed during the transition period, the first 4 to 8 hours after birth. Infants who are healthy and stable should remain with their mothers during this period. If possible, an infant should be placed naked on his or her mother's chest and allowed to breastfeed. The infant should be kept warm and assessed by a detailed clinical examination that includes intrauterine growth status, evaluation for gestational age, and a comprehensive risk assessment for neonatal conditions that require additional monitoring or intervention. Neonatal nutrition is ideally provided through breastfeeding. Initiation of breastfeeding should take place after birth, with continued monitoring of the breastfed newborn until discharge and thereafter by the newborn care provider. There are limited contraindications to breastfeeding. In the event breastfeeding is disrupted, breast milk should be collected and stored.
Preventive newborn care includes attention to hygiene; hepatitis immunization; and screening for genetic and metabolic conditions, hearing impairment, critical congenital heart disease, risk of hyperbilirubinemia, and developmental hip dysplasia. Targeted assessment of glucose homeostasis and possible sepsis are implemented on a discretionary basis, depending on individualized risk.
Delivery Room Care
Approximately 10% of term and late-preterm infants require some assistance to begin breathing that includes stimulation at birth; less than 1% will need extensive resuscitative measures. Although the vast majority do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births a sizable number of babies will require some degree of resuscitation. Recognition and immediate resuscitation of a distressed newborn infant requires an organized plan of action that includes the immediate availability of proper equipment and on-site qualified personnel. Anticipated newborn problems should be thoroughly communicated by the obstetric care provider to the responsible lead member of the resuscitation team.
Neonatal Resuscitation: Management Plan
Assessment and resuscitation of the newborn at delivery should be provided in accordance with the principles of guidelines for neonatal resuscitation. Most of the principles are applicable throughout the neonatal period and early infancy. Each hospital should have policies and procedures addressing the care and resuscitation of the newborn infant, including the qualifications of physicians and other health care practitioners who provide this care. The provision of services and equipment for resuscitation should be planned jointly by the medical and nursing directors of the departments involved in resuscitation of the newborn, usually the departments of obstetrics, pediatrics, and anesthesia. A physician, usually a pediatrician, should be designated to assume primary responsibility for initiating, supervising, and reviewing the plan for management of infants requiring resuscitation in the delivery room. The following issues should be considered in this plan (2):
Accurately defining and reporting perinatal deaths (i.e., fetal and infant deaths) is a critical first step in understanding the magnitude and causes of these important events. In addition to obstetrical health care providers, neonatologists and pediatricians should have easy access to current and updated resources that clearly provide nationally and internationally approved definitions and reporting requirements for live births, fetal deaths, and infant deaths. Correct identification of these vital events will improve local, state, and national data so that these deaths can be better addressed and prevented (3).
Delivery Room Assessment and Management
With careful consideration of risk factors, most infants who will need resuscitation can be identified before birth, although some infants without any apparent risk factors will require resuscitation. If the need for resuscitation is anticipated, additional skilled personnel should be recruited, and the necessary equipment prepared for immediate use.
All infants should have rapid assessment immediately after birth. Infants who are at risk of requiring interventions should have the initial steps of newborn care performed at a radiant warmer. These infants can be identified by asking three questions (4):
If the answers to these questions are "yes", the infant should remain with the mother for the initial steps of newborn care. Observation of breathing, activity, and color should be ongoing. If the answer to any of these questions is "no", the infant should receive one or more of the following categories of action in sequence:
Approximately 60 seconds are allotted for a rapid assessment, completing the initial steps of newborn care, evaluating the baby's heart rate, and beginning positive pressure ventilation if required. The decision to progress beyond the initial steps is determined by simultaneous assessment of two vital characteristics:
Initial assessment of the heart rate should be performed using a stethoscope. Auscultation along the left side of the chest is the most accurate physical examination method of determining a newborn's heart rate. Although pulsations may be felt at the umbilical cord base, palpation is less accurate and may underestimate the true heart rate. If the heart rate cannot be determined by physical examination and the infant is not vigorous, another team member should quickly connect a pulse oximetry sensor or electrogram leads to the baby in order to evaluate the heart rate. If positive pressure evaluation is needed, assessment should consist of simultaneous evaluation of three vital characteristics:
The most sensitive indicator of a successful response to each step is an increase in heart rate.
Targeted preductal blood oxygen saturation (SpO2) after birth (5)
Initial Steps of Newborn Care
Maintenance of Body Temperature
Infants born preterm, those without good muscle tone, and those who are not breathing, or crying should be placed under a preheated radiant warmer. The radiant warmer will reduce heat loss and allow easy access to the infant during resuscitation procedures. Preterm infants less than 32 weeks of gestation are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss. For this reason, additional warming techniques are recommended (e.g. pre-warming the delivery room to 26oC (78.8oF), covering the infant in plastic wrapping (food or medical grade, heat-resistant plastic), placing the infant on an exothermic mattress). The infant's temperature must be monitored closely because overheating has been described when plastic wrap is used in combination with an exothermic mattress. The goal should be an axillary temperature of approximately 36.5oC (97.7oF).
Clearing the Airway
For a healthy newborn suctioning appears to do more harm than good because it can cause cardiorespiratory complications. Given the lack of evidence of benefit, and evidence of potential harm, reserve suctioning for newborns who have obvious respiratory difficulty caused by secretions. If you determine that suctioning is required, perform gentle bulb suctioning of the mouth and nares with minimal stimulation of the posterior pharynx, which can cause a vagal response and bradycardia.
When meconium is present in amniotic fluid, evidence does not support routine intrapartum oropharyngeal or nasopharyngeal suctioning, as these interventions do not prevent or alter the course of meconium aspiration syndrome. Vigorous newborns who have been birthed through meconium-stained amniotic fluid do not need airway suctioning (7). If an infant is born through meconium-stained amniotic fluid and has depressed respirations or poor muscle tone, the infant should be placed under the radiant warmer and the initial steps of newborn care as aforementioned performed. If the baby is not breathing or the heart rate is less than 100 beats per minute (bpm) after the initial steps are completed, positive pressure ventilation should be initiated.
Clamping of Umbilical Cord
Autotransfusion significantly increases hemoglobin concentration in a newborn, it is notable that newborn obtains benefit from delayed clamping whether it has been placed on its mother's abdomen or held below the vaginal introitus – suggesting that gravity alone is not responsible for cord-to-newborn transfusion. Note: if you are concerned about waiting 1 to 5 minutes to clamp the cord because it might delay resuscitation of an infant, milking the cord four times appears to provide significant cord-to-fetus transfusion (9).
In a healthy term infant who has access to good prenatal nutrition, the benefits of delayed cord clamping are likely limited to a modest increase in hemoglobulin concentration. The problem with delayed cord is an increased risk of jaundice and need for phototherapy (11).
Delayed clamping of the cord is likely to provide the greatest benefit to preterm newborns. In some studies, delayed clamping in very preterm infants (<32 weeks' gestation) reduced the incidence of intraventricular hemorrhage and late-onset sepsis. For example, in this study, 72 mother-infant were randomized to delayed cord clamping or immediate cord clamping, intraventricular hemorrhage occurred in 14% of infants in the delayed group and in 36% of the immediate-clamping group (12).
In some centers, umbilical cord blood is collected and stored in a public cord blood bank for use in a bone marrow transplantation program. Autotransfusion of blood from the cord to the newborn reduces the success rate of cord blood collection for public banking because fewer stem cells are obtained from a depleted cord.
Administration of Supplemental Oxygen
Reduce the use of 100% oxygen (O2) during resuscitation (13). Use of 100% O2 may be associated with more harm than benefit when a newborn requires resuscitation. It may increase the level of free oxygen radicals, thereby damaging tissue. In fact, some studies report that use of 100% O2 is associated with an increased risk of neonatal mortality (13). When a newborn requires resuscitation, the recommendations are (1),(14):
Endotracheal intubation may be performed at various points during resuscitation, depending on clinical circumstances. Indications for intubation include the following (16):
Exhaled carbon dioxide detection is recommended method to confirm endotracheal tube placement; however, critically ill infants with poor cardiac output and poor or absent pulmonary blood flow may not exhale sufficient carbon dioxide to be detected reliably, and thus may give false-negative test results. As with bag and mask ventilation, effective assisted ventilation with an endotracheal tube should result in an increased heart rate. If the heart rate does not improve, esophageal intubation should be suspected.
The Apgar score is useful for conveying information about the infant's over all status and response to resuscitation. However, resuscitation must be initiated before the 1-minute score is assigned. Therefore, the Apgar score is not used to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to use them. The score is reported at 1-minute and 5-minutes after birth for all infants, and at 5-minute intervals thereafter until 20 minutes for infants with a score less than 7. When an infant has an Apgar score of 5 or less at 5 minutes, umbilical artery blood gas from a clamped section of umbilical cord should be assessed, if possible.
The details about the Apgar score are reviewed and discussed in the next chapter.
Newborn in the Delivery Room
Immediately after delivery, the newborn infant must be assessed for individual needs to determine the best location for care. An infant with known or anticipated medical needs may be admitted to the special care nursery or neonatal intensive care unit (NICU) in the birth hospital or transferred to a hospital that provides the appropriate level of care (20).
A healthy-appearing newborn infant should remain with the mother. If the infant's condition is stable and the infant does not require further intervention, immediate and sustained skin-to-skin contact between the mother and her infant should be provided. Early, sustained skin-to-skin contact improves neonatal temperature stability and increases neonatal glucose levels. For mothers who have chosen to breastfeed, evidence from randomized controlled trial shows that skin-to-skin contact increases duration of breastfeeding by approximately 42 days (21). The nursing staff in labor, delivery, recovery, and postpartum areas should be trained in assessing and recognizing problems in the newborn and in assessing and assisting with breastfeeding. In most circumstances, the baby can be transported safely with the mother from the delivery to postpartum area.
Infants who require intervention in the delivery room are at risk of developing subsequent complications. Such infants, and infants at risk of developing neonatal abstinence syndrome, and should be evaluated frequently during the immediate neonatal period (22). These infants should be managed in an area where frequent vital signs can be obtained, and the nursing staff is familiar with the signs and symptoms of an infant who is in distress. Some of these infants may require transport to another hospital for a higher level of care.
Immediate plans for the newborn infant should be discussed with the parents or other support person(s), preferably before leaving the delivery room. Whenever possible, the parents should have the opportunity to see, touch, and hold the infant before transfer to another facility. The physician or other health care provider delivering the infant also should be advised to the status and plans for the infant, including potential transfer or admission to a special care nursery or NICU.
Parents should be active participants in the decision-making process concerning the treatment of severely ill infants. This approach requires honest and open communication. Ongoing evaluation of the condition and prognosis of the high-risk infant is essential, and the physician, as the spokesperson for the health care team, must convey this information accurately and openly to the parents of the infant.
Newborn Care Training and Perinatal Mortality in Developing Countries
Of the 3.7 million neonatal deaths and 3.3 million stillbirths each year, 98% occur in developing countries (23). An evaluation of community-based interventions designed to reduce the number of these deaths is needed. Without a major reduction in neonatal deaths in the first 7 days after birth, achievement of the United Nations' Sustainable Development Goal 4 - a reduction in mortality by two-thirds among children younger than 5 years of age – is unlikely to be realized. In areas of the world with high rates of home delivery, stillbirths are prevalent, but they are difficult to distinguish from early neonatal deaths (24). Therefore, examining both stillbirths and early neonatal deaths is important in an evaluation of perinatal programs that are designed to reduce mortality. Major global causes of perinatal mortality are asphyxia at birth, low-birth weight, and prematurity. Low-cost interventions, including training in neonatal resuscitation and "kangaroo" (skin-to-skin) care, may effectively reduce deaths from these causes. It has been estimated that introducing these interventions as a package might decrease perinatal deaths by 50% or more (25). A recent study that used a "before-and-after" implementation design showed that training in the World Health Organization (WHO) Essential Newborn Care Course improved midwives' skill and knowledge and reduced neonatal deaths in the first 7 days after birth among low-risk women who delivered in first-level clinics in Zambia (26). This systematic review of the literature suggests that perinatal mortality may be decreased by training birth attendants. Thus, wide-scale implementation and evaluation of evidence-based interventions are needed to improve perinatal outcomes, particularly in rural settings, where more than 50% of neonatal deaths occur.
This large, multicenter study conduced in rural communities in developing countries showed that training in and implementation of the Essential Newborn Care program were not associated with a decrease in the primary outcome of neonatal death (27). In this study, training birth attendants in Essential Newborn Care was not associated with a reduction in neonatal mortality but was associated with reduced rates of stillbirth; further training in neonatal resuscitation did not have significant effect on outcomes. These data suggest that training in basic neonatal care may have a role in improving perinatal outcomes in the developing world, although more work is needed to further reduce perinatal mortality.
A detailed clinical examination and assessment of the infant is performed by the clinical care team soon after birth and includes the following: evaluation of airway patency and skin color; auscultation of the heart and lungs; ascertainment of anal patency; assessment of muscle tone, level of consciousness, response to handling; measurement of vital signs (i.e. body temperature, heart rate, and respiratory rate); and measurement of head circumference, body length, and body weight. Each newborn infant must be kept warm during weighing. The scale pan should be covered with clean paper before each newborn is weighed. Additional targeted evaluations may include assessment of capillary refill, blood pressure, oxygen saturation, and need for supplemental oxygen. Obstetrical and neonatal medicine practices are evolving in ways that might surprise you. Obstetrical providers have a unique relationship with pediatric colleagues regarding the care of mother and her newborn. Simple recommendations to patients during the transition period may save precious newborn lives.
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