Newborn Resuscitation: Case and Viva Q&A

Clinical Case of Newborn Resuscitation

Case Presentation

A 28-year-old G1P0 woman at 39 weeks gestation presents to the labor and delivery unit with spontaneous rupture of membranes and regular contractions. Her pregnancy has been uncomplicated, with normal prenatal care. After 8 hours of labor, she delivers a term male infant.

Initial Assessment

At birth, the infant is noted to be cyanotic, limp, and not breathing. The cord is clamped and cut, and the infant is quickly moved to the warmer.

Resuscitation Steps

1. Initial steps (warming, positioning, suctioning) are performed.
2. Positive pressure ventilation (PPV) is initiated with 21% oxygen.
3. Heart rate is assessed and found to be 40 bpm.
4. Chest compressions are started along with continued PPV.
5. Oxygen is increased to 100%.
6. After 60 seconds of coordinated compressions and ventilations, heart rate remains 50 bpm.
7. Epinephrine 0.1 mL/kg of 1:10,000 solution is administered via umbilical vein catheter.
8. After 3 minutes of continued resuscitation, heart rate improves to 120 bpm.
9. Spontaneous respirations begin at 5 minutes of life.

Outcome

The infant is stabilized and transferred to the NICU for post-resuscitation care and further evaluation. Apgar scores were 1 at 1 minute, 3 at 5 minutes, and 7 at 10 minutes.

Clinical Presentations of Newborn Resuscitation

1. Respiratory Distress Syndrome (RDS)

Premature infant presents with tachypnea, grunting, nasal flaring, and intercostal retractions immediately after birth due to surfactant deficiency.

2. Meconium Aspiration Syndrome (MAS)

Term or post-term infant born through meconium-stained amniotic fluid, presenting with respiratory distress, cyanosis, and poor muscle tone.

3. Persistent Pulmonary Hypertension of the Newborn (PPHN)

Full-term infant with severe hypoxemia, differential cyanosis (upper body pink, lower body blue), and respiratory distress unresponsive to 100% oxygen.

4. Congenital Diaphragmatic Hernia (CDH)

Newborn presents with severe respiratory distress, scaphoid abdomen, barrel-shaped chest, and bowel sounds audible in the chest.

5. Perinatal Asphyxia

Infant born with low Apgar scores, poor muscle tone, absent reflexes, and metabolic acidosis due to compromised gas exchange before or during birth.

6. Congenital Pneumonia

Newborn presents with tachypnea, grunting, and cyanosis shortly after birth, often with a history of maternal chorioamnionitis.

7. Neonatal Sepsis

Infant may present with temperature instability, respiratory distress, poor perfusion, and lethargy, requiring immediate resuscitation and antibiotic treatment.

8. Congenital Heart Disease

Newborn with cyanosis, tachypnea, and poor perfusion, potentially presenting with a murmur or signs of shock in cases of critical congenital heart defects.

Viva Questions and Answers on Newborn Resuscitation

1. Q: What are the initial steps in newborn resuscitation?

   A: The initial steps include:

   • Provide warmth (dry the infant and place under a radiant warmer)
   • Position the head in a slightly extended "sniffing" position
   • Clear the airway if necessary (suction mouth, then nose)
   • Stimulate by rubbing the back or flicking the soles of the feet

2. Q: What is the correct compression to ventilation ratio during neonatal CPR?

   A: The correct ratio is 3:1, with 90 compressions and 30 breaths per minute.

3. Q: What is the initial concentration of oxygen recommended for preterm infants during resuscitation?

   A: For preterm infants less than 35 weeks gestation, resuscitation should be initiated with 21-30% oxygen, titrated based on oxygen saturation targets.

4. Q: How do you assess the effectiveness of positive pressure ventilation (PPV)?

   A: Effectiveness of PPV is assessed by:

   • Observing chest rise with each breath
   • Improvement in heart rate
   • Improvement in color and tone
   • Auscultation of breath sounds

5. Q: What is the preferred route of epinephrine administration during neonatal resuscitation?

   A: The preferred route is intravenous via an umbilical venous catheter. If IV access is not available, epinephrine can be given via the endotracheal tube, but at a higher dose.

6. Q: What is the dose of epinephrine used in neonatal resuscitation?

   A: The recommended dose is 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) given intravenously. If given endotracheally, a higher dose of 0.05-0.1 mg/kg may be used.

7. Q: What are the indications for starting chest compressions in a newborn?

   A: Chest compressions are indicated when the heart rate remains below 60 beats per minute despite 30 seconds of effective positive pressure ventilation with 100% oxygen.

8. Q: How do you perform chest compressions in a newborn?

   A: Chest compressions in a newborn are performed by:

   • Using the two-thumb encircling hands technique
   • Compressing the lower third of the sternum
   • Compressing to a depth of approximately one-third of the anterior-posterior diameter of the chest
   • Allowing full recoil between compressions
   • Delivering at a rate of 90 compressions per minute, coordinated with 30 ventilations (3:1 ratio)

9. Q: What are the target oxygen saturation levels for a newborn in the first 10 minutes of life?

   A: Target oxygen saturation levels are:

   • 1 minute: 60-65%
   • 2 minutes: 65-70%
   • 3 minutes: 70-75%
   • 4 minutes: 75-80%
   • 5 minutes: 80-85%
   • 10 minutes: 85-95%

10. Q: What is the role of pulse oximetry in neonatal resuscitation?

    A: Pulse oximetry is used to monitor oxygen saturation and guide oxygen therapy. It should be applied to the right hand or wrist (pre-ductal) as soon as possible after birth, ideally within the first 1-2 minutes of life.

11. Q: What are the indications for endotracheal intubation during neonatal resuscitation?

    A: Indications for intubation include:

    • Ineffective bag-mask ventilation
    • Need for prolonged positive pressure ventilation
    • When performing chest compressions
    • For administration of surfactant
    • Suspected congenital diaphragmatic hernia

12. Q: How do you confirm correct endotracheal tube placement?

    A: Correct ET tube placement is confirmed by:

    • Observing symmetrical chest rise
    • Auscultation of breath sounds in both axillae and absence over the stomach
    • Improvement in heart rate, color, and oxygen saturation
    • Presence of exhaled CO2 (using a colorimetric detector or capnography)

13. Q: What is the current recommendation regarding suctioning of meconium-stained amniotic fluid?

    A: Current guidelines do not recommend routine intrapartum suctioning of the oropharynx and nasopharynx for meconium-stained amniotic fluid. If a newborn is non-vigorous, begin resuscitation steps immediately without suctioning first.

14. Q: What is the appropriate laryngoscope blade size for a term newborn?

    A: For a term newborn, a size 1 laryngoscope blade is typically appropriate.

15. Q: What are the indications for volume expansion during neonatal resuscitation?

    A: Volume expansion is indicated when there are signs of shock or poor perfusion (pallor, poor pulses, persistent bradycardia) and a history suggestive of blood loss (e.g., placental abruption, cord accidents).

16. Q: What fluid is used for volume expansion and at what dose?

    A: Normal saline (0.9% NaCl) is typically used for volume expansion. The recommended dose is 10 mL/kg given over 5-10 minutes.

17. Q: What is the role of naloxone in neonatal resuscitation?

    A: Naloxone is no longer recommended as part of the initial resuscitation of newborns with respiratory depression. The focus should be on effective ventilatory support.

18. Q: What are the components of the Apgar score and when is it assessed?

    A: The Apgar score assesses:

    • Appearance (color)
    • Pulse (heart rate)
    • Grimace (reflex irritability)
    • Activity (muscle tone)
    • Respiration
    It is typically assessed at 1 and 5 minutes after birth, and may be repeated at 10, 15, and 20 minutes if the score remains low.

19. Q: What is the significance of persistent bradycardia during resuscitation despite adequate ventilation?

    A: Persistent bradycardia (heart rate <60 bpm) despite adequate ventilation may indicate:

    • Severe hypoxia or acidosis
    • Hypovolemia
    • Pneumothorax
    • Congenital heart defect
    • Medication effect (e.g., maternal anesthesia)
    It requires continuation of CPR and consideration of these underlying causes.

20. Q: What is the role of temperature management in neonatal resuscitation?

    A: Maintaining normothermia is crucial. Hypothermia increases oxygen consumption and metabolic demands. Steps include:

    • Use of radiant warmers
    • Pre-warming linens
    • Drying the infant immediately after birth
    • Using plastic wrap or bags for very preterm infants
    • Maintaining room temperature at 23-25°C

21. Q: What are the indications for discontinuing resuscitation efforts in a newborn?

    A: Consider discontinuing resuscitation if:

    • There is no detectable heart rate after 10 minutes of continuous, adequate resuscitative efforts
    • All possible interventions have been performed
    • Excluding cases where hypothermia is present or reversible causes are suspected
    The decision should be individualized and consider factors such as gestational age and the presumed etiology of the arrest.

22. Q: What is the role of delayed cord clamping in neonatal resuscitation?

    A: Current guidelines recommend delayed cord clamping for at least 30-60 seconds in vigorous term and preterm infants. For non-vigorous infants requiring resuscitation, immediate cord clamping may be necessary to begin resuscitative measures.

23. Q: How do you assess the need for ongoing respiratory support after initial resuscitation?

    A: Assess the need for ongoing support by evaluating:

    • Respiratory effort (rate, work of breathing)
    • Heart rate
    • Oxygen saturation levels
    • Blood gas results
    • Overall clinical status
    Consider CPAP or ongoing mechanical ventilation if respiratory distress persists or if the infant is extremely preterm.

24. Q: What is the importance of team communication during neonatal resuscitation?

    A: Effective team communication is crucial for successful resuscitation. It involves:

    • Clear role assignment
    • Use of closed-loop communication
    • Regular updates on the infant's status
    • Clear and concise orders
    • Debriefing after the event
    Good communication reduces errors, improves efficiency, and leads to better outcomes.

25. Q: What are the components of post-resuscitation care?

    A: Post-resuscitation care includes:

    • Continuous monitoring of vital signs
    • Maintaining normothermia
    • Blood glucose monitoring and management
    • Assessing and treating any underlying conditions
    • Neurological evaluation
    • Consideration of therapeutic hypothermia for eligible infants with hypoxic-ischemic encephalopathy
    • Family support and communication

26. Q: How do you determine the appropriate endotracheal tube size for a preterm infant?

    A: For preterm infants, the appropriate ET tube size can be estimated based on gestational age:

    • <28 weeks: 2.5 mm internal diameter
    • 28-34 weeks: 3.0 mm internal diameter
    • 34-38 weeks: 3.5 mm internal diameter
    • >38 weeks: 3.5-4.0 mm internal diameter

27. Q: What is the role of capnography in neonatal resuscitation?

    A: Capnography or colorimetric CO2 detectors are used to:

    • Confirm endotracheal tube placement
    • Monitor the effectiveness of chest compressions (ETCO2 should be >10-15 mmHg with effective CPR)
    • Detect return of spontaneous circulation (abrupt increase in ETCO2)

28. Q: What are the potential complications of positive pressure ventilation in newborns?

    A: Potential complications include:

    • Pneumothorax
    • Gastric distension
    • Bruising or laceration of the lips or gums
    • Subconjunctival hemorrhage
    • Volutrauma or barotrauma to the lungs
    • Increased intracranial pressure

29. Q: How do you manage a pneumothorax during neonatal resuscitation?

    A: Management of a pneumothorax includes:

    • Rapid recognition (sudden deterioration, asymmetric chest movement, shifted heart sounds)
    • Immediate needle decompression in case of tension pneumothorax
    • Placement of a chest tube for ongoing air leak
    • Adjustment of ventilatory settings (lower pressures if possible)
    • Consideration of unilateral intubation past the carina on the unaffected side in severe cases

30. Q: What is the significance of the "golden hour" in neonatal care?

    A: The "golden hour" refers to the first hour of life, especially important for preterm infants. Key elements include:

    • Optimizing temperature management
    • Establishing adequate ventilation and oxygenation
    • Initiating early feeding or parenteral nutrition
    • Minimizing separation of infant and mother
    • Preventing complications like hypoglycemia and infection
    Proper management during this time can significantly impact short and long-term outcomes.

31. Q: What are the indications for therapeutic hypothermia in newborns?

    A: Therapeutic hypothermia is indicated for term or near-term infants (>36 weeks) with moderate to severe hypoxic-ischemic encephalopathy. Criteria typically include:

    • Evidence of fetal distress or neonatal depression (e.g., low Apgar scores, need for resuscitation)
    • Metabolic acidosis (pH <7.0 or base deficit ≥16 mmol/L)
    • Clinical signs of moderate to severe encephalopathy
    • Treatment should be initiated within 6 hours of birth

32. Q: How do you assess and manage hypoglycemia in a newborn after resuscitation?

    A: Assessment and management include:

    • Regular blood glucose monitoring, especially in at-risk infants
    • Defining hypoglycemia (typically <45 mg/dL or 2.5 mmol/L in the first 24 hours)
    • Early feeding if possible
    • IV glucose for symptomatic hypoglycemia or if levels remain low despite feeding
    • Consider glucagon for severe, refractory hypoglycemia
    • Investigating underlying causes (e.g., hyperinsulinism, metabolic disorders) if hypoglycemia persists

33. Q: What is the role of surfactant therapy in neonatal resuscitation?

    A: Surfactant therapy:

    • Is not part of initial resuscitation measures
    • Is considered for preterm infants with Respiratory Distress Syndrome (RDS)
    • Can be given prophylactically in extremely preterm infants or as early rescue therapy
    • Is administered via the endotracheal tube
    • Can significantly improve oxygenation and reduce the need for mechanical ventilation

34. Q: How do you manage persistent pulmonary hypertension of the newborn (PPHN) during resuscitation?

    A: Management of PPHN includes:

    • Optimizing oxygenation (may require 100% oxygen initially)
    • Ensuring adequate ventilation and avoiding respiratory acidosis
    • Maintaining systemic blood pressure (may require volume expansion or inotropes)
    • Correcting metabolic acidosis
    • Consideration of inhaled nitric oxide therapy
    • Minimizing stimulation and maintaining sedation if necessary
    • Preparing for possible ECMO in severe cases