Neonatal Resuscitation

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Approximately 6 percent of all newborns require life support in the delivery room or nursery, and in those neonates whose birth weights are less than 1500 g, the need for resuscitation rises to 60 percent. Personnel skilled in neonatal resuscitation should be available at every delivery. It is important to anticipate the delivery of high-risk neonates so that delivery room personnel may be alerted to the possible need for resuscitation.

There are no guidelines available to assist in making the decision to resuscitate extremely premature infants in the emergency department. When in doubt, resuscitate. At the present time, survival at 22 weeks of gestation or less is rare. However, a 20 to 30 percent survival rate is reported at 24 weeks' gestation, although often with severe resultant morbidity.

The following factors are associated with an increased risk for neonatal resuscitation:

Maternal factors

Inadequate prenatal care Age <16 and >35 years

History of previous perinatal morbidity or mortality

Toxemia, hypertension

Diabetes

Chronic renal disease Anemia

Drug therapy (e.g., reserpine, lithium, carbonate, magnesium, adrenergic-blocking agents) Substance abuse

Blood type or group isoimmunization Oligohydramnios Intrapartum factors Abnormal presentation Caesarean section

Prolonged labor or precipitous delivery Prolonged rupture of membranes, chorioamnionitis Cephalopelvic disproportion

Forceps delivery other than outlet or vacuum extraction Prolapsed cord Cord compression Maternal hypotension, shock

Analgesic or sedative drugs given within 2 h of delivery Fetal factors Prematurity Postmaturity

Intrauterine growth failure Multiple gestation

Acidosis per fetal scalp capillary monitoring Abnormal fetal heart rate per monitor Thick meconium in amniotic fluid Congenital infection

Fetal malformation or edema diagnosed by ultrasound

The following conditions should alert nursery personnel to the possibility of apnea: previous need for resuscitation, prematurity, sepsis and/or meningitis, congenital abnormalities, respiratory distress, or seizures.

Normal newborns are equipped with physiologic, pharmacologic, and metabolic responses to enable them to survive the hypoxia that develops as a consequence of asphyxia. Generally, brain injury occurs only when the asphyxia is severe enough to impair cerebral blood flow. Initially the injury is reversible, and only longer periods of ischemia lead to permanent damage. The pattern of injury is strongly influenced by the distribution of blood flow. During asphyxia, blood flow is redirected to the heart, brain, and adrenals at the expense of other organs, such as the kidneys and the gastrointestinal tract. Within the brain, flow is directed to the brainstem at the expense of the high cerebral structures, such as the cortex. In the preterm neonate, the periventricular white matter is susceptible to injury. In the full-term or postterm neonate, the gray-matter regions, such as the overlying parasagittal "watershed" cortex, are more vulnerable to ischemic injury. When the asphyxial insult is severe or prolonged, hypoxic multiorgan dysfunction occurs because of the redistribution of organ blood flow and results in cardiopulmonary distress, renal failure, impaired hepatic function, seizures and encephalopathy, gastrotintestinal dysfunction, and coagulopathies.

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