31.

RESUSCITATION OF THE NEWBORN INFANT

The anaesthesia provider’s prime responsibility is to the safety of the mother. They should not care for
the mother and newborn simultaneously unless the mother is stable and there is another healthcare
provider available who can monitor for changes in the mother’s vital signs/clinical status.

Often the need for newborn resuscitation can be predicted. Certain obstetric situations may warn the
anaesthesia provider that the newborn may need resuscitation including:
Obstetrical: prolonged labour, cephalopelvic disproportion, breech delivery, shoulder dystocia,
difficult forceps delivery, prolapsed umbilical cord.
Maternal: maternal haemorrhage, placenta praevia, maternal infection, maternal diabetes,
preeclampsia, oligo/polyhydramnios
Foetal: foetal distress, prematurity, meconium liquor, multiple pregnancy, serious congenital
abnormality
Drugs: opioids or other respiratory depressant drugs given close to the time of delivery

Evaluating the need to initiate resuscitation begins immediately at birth. Initial assessment is based on
three questions:

 Is the infant at term gestation?

 Is the infant breathing or crying?
 Does the infant have good muscle tone?

If the baby is term, crying and breathing, and has good tone, the newborn may stay with the mother
and engage in skin-to-skin care. During an uncomplicated birth, it may be reasonable to defer cord
clamping for 1 - 2 minutes, as this is associated with higher haematocrit after birth and better iron
levels in infancy. After birth, the baby should be dried and placed directly skin-to-skin with attention
to warm coverings and maintenance of normal temperature. The temperature of newly born babies
should be maintained between 36.5°C and 37.5°C. Preterm infants are at particular risk of
hypothermia. 
A newborn who does not respond to a brief period of stimulation (not more than 20 seconds)  must be
transferred to the resuscitaire for further assessment and management. Position and dry infant,
stimulate if not breathing and suction the mouth and nose if necessary. Tilting the head into a neutral
position and lifting the jaw upwards can clear the newborn airway. The mouth can be cleared of
secretions by gentle suctioning. Aggressive suctioning must be avoided as it may cause laryngospasm
and vagal bradycardia. Intrapartum suctioning (before delivery of the shoulders) makes no difference
to the outcome of babies with meconium stained liquor. If pharyngeal suctioning is required, it should
be performed under direct vision with a suction source of less than 100 mmHg and should not exceed
more than 5 seconds or be inserted more than 5 cm. 

If the infant is not breathing, breathing effectively or the heart rate is less than 100 beats per minute,
then positive pressure ventilation (PPV) is indicated at a rate of 40 to 60 breaths/min. The inspiratory
time should be 0.3 to 0.5 seconds with peak inflation pressures of up to 30 cm H O in term newborns.
2

PPV is initiated in air initially for term infants, and air, or up to 30% oxygen for preterm infants who
are less than 35 weeks gestation. Hyperoxia should be avoided, especially in preterm infants. A rise in
heart rate is the most important indicator of effective ventilation and response to resuscitative
interventions. The infant should be reassessed after 30 seconds of effective positive pressure
ventilation. If the heart rate fails to rise, the adequacy of ventilatory manoeuvres  must be reassessed
and an LMA or intubation considered.
If the heart rate falls below 60 bpm despite 30 seconds of adequate PPV, external chest compressions
(ECC) should be commenced with PPV at a ratio of 3 chest compressions to each ventilation (3:1).
The best method of ECC in the newborn is to place both thumbs over the lower half of the sternum
with the hands encircling the body and the fingers supporting the back. The sternum is compressed 2
to 3 cm. The FiO2 should be increased to 100% and the newborn reassessed after a further 30 seconds
of effective ECC with PPV. If the heart rate is above 60/min, then ECC can be ceased and PPV
continued until the heart rate is above 100/min and the infant is breathing effectively. 
If the heart rate remains below 60/min despite effective ECC and PPV then adrenaline is indicated.
When vascular access is required in the newborn, the umbilical venous route is preferred. When
intravenous access is not feasible, the intraosseous route may be considered. The intravenous dose of
adrenaline is 0.01 to 0.03 mg/kg (repeated every 3 – 5 min in the absence of a response), followed by
a normal saline flush. 
Gestation (weeks) IV Dose 1:10,000 Adrenaline

23-26 0.1ml

27-37 0.25 ml

> 38 0.5 ml

Volume expanders (10ml/kg) should be considered if the infant appears shocked and/or blood loss is
suspected.
Naloxone is an opioid antagonist. If the infant is depressed from maternal morphine or pethidine, give
0.01 mg/kg. Intramuscular injection is usually adequate.

Gestation (weeks) Birth weight (g) Endotracheal tube size Depth of insertion
(from upper lip cm)

< 28  < 1000 2.5 6.5 to 7

28 to 34 1000 to 2000 3.0 7 to 8

34 to 38 2000 to 3000 3.0/3.5 8 to 9

> 38 > 3000 3.5/4.0 >9

Venous Access

Umbilical vein catheterisation is not difficult but there are potential complications. Insertion of an
umbilical vein catheter should occur under sterile conditions. Having cleaned the umbilical stump
with an antiseptic solution, a cord can be lightly tied around it (secure enough to maintain
haemostasis, but not too tight to prevent passage of the catheter). This will be tightened after the
umbilical catheter is inserted.  The cord should be cut leaving at least 2 cm. Immobilize the cord by
grasping the cord edges with two artery forceps at 3 and 9 o'clock, taking care not to include the
vessels. The umbilicus contains 2 arteries and 1 vein. The vein is usually the large thin walled
structure found at 12 o’clock. This should be dilated gently. A sterile 3.5 or 5 French catheter is
inserted 2 to 4 cm beyond the abdominal wall (Long term umbilical catheters must be carefully
positioned using X-ray). It should advance without any resistance and be gently aspirated for blood.
(Sometimes blood cannot be aspirated from a correctly placed catheter because the vein is collapsing.
Flush the catheter with 2 ml of normal saline and aspirate more gently). Tighten the cord around the
base of the umbilical stump and suture the catheter to the base of the cord.