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Newborn Resuscitation: The Golden Minute
Delivering a newborn may occur only once in your EMS career, but delivering a new life into the world can be one of the most rewarding and looked-forward-to calls. At the same time, it may cause some anxiety prior to and during the delivery.
Roughly four million babies are born each year,1 the vast majority of whose births go smoothly. Around 10% of newborns will require some assistance following delivery, and less than 1% will require major resuscitation.2 With advances in medicine, most high-risk mothers are followed closely by their obstetricians and may even be admitted early to a hospital or regional medical center that deals with high-risk pregnancies, thus reducing the 10% that may require assistance and resuscitation in the prehospital environment even further. That being said, the need for assistance and resuscitation of newborns in the prehospital environment may still occur. Newborn resuscitation should be considered the Golden Minute.3 That is, if ventilations or chest compressions are required, they are initiated within one minute following delivery; however, do not wait one minute to calculate the APGAR score and then determine that there is a need for resuscitation. The most common cause of bradycardia in the newborn is hypoxia, which is easily reversed with bag-valve mask ventilation.
Time Before Delivery
The time before delivery should be looked at in two periods, the first being the period prior to the call. What classes have you attended or how much review have you done on newborn delivery and resuscitation in the last six months? Do you know what items are in your OB kit for delivery and resuscitation? Due to the low number of newborn deliveries and even fewer major resuscitations that you perform, education, training and review are crucial.2
The second period is the minutes before delivery, when you should be asking the mother key questions and preparing your equipment for a possible or imminent delivery. Some of the questions that will help determine if the delivery is imminent or how much time you have to prepare for it include: Is she having contractions? If so, how far apart are they and how long are they lasting? Have the membranes (water) ruptured? If so, when, and was the fluid clear, bloody or meconium-stained?5 (See Table I for more questions.) The answers will help you determine if you should open the OB delivery kit or just keep it nearby.
If delivery is imminent, open and prepare the OB delivery kit and make sure you have resuscitation equipment ready if needed. This equipment can be kept in an airway, pediatric or first-in bag, or in a newborn resuscitation kit containing bulb suction (there may already be one in the OB delivery kit), a neonate bag-valve mask, suctioning equipment, laryngoscope and neonate-sized Miller blades, epinephrine and intravenous administration equipment (see Table II).
In addition to preparing the equipment, find a flat, firm surface in a warm environment for effective resuscitation, if needed. In the prehospital environment, the patient compartment of the ambulance is ideal and can address both issues. The stretcher can provide an initial assessment area for the newborn and will be adequate for most deliveries. If the newborn is depressed and requires further resuscitation, he/she can be moved to the bench seat for further management prior to transport. It is best to keep the mother and newborn together, if possible, although safety and having adequate room and resources to manage the newborn may require transporting the mother and baby separately to the same hospital, which allows family to gather at one facility.
Maintaining the newborn's body temperature is imperative. Following most deliveries this can be accomplished by drying the newborn, removing wet towels, placing the baby on the mother's chest,5 and covering both with dry, warmed blankets. If resuscitation is required, temperature can best be controlled in the patient compartment of the ambulance, which will avoid exposing the baby to extreme temperatures while moving it from the scene to the vehicle.
Rapid Assessment: Determining the Need for Resuscitation
Following delivery and cutting of the umbilical cord, initial assessment of the newborn should be viewed as a continuum that begins with routine care and may or may not progress to further resuscitation.6 Since the vast majority of deliveries do not require resuscitation, routine care is usually all that is required. The need for routine care or further resuscitation is easily determined by three questions: Is the newborn at full-term gestation, is it crying or breathing, and does it have good muscle tone?6 If the answer to all three is yes, clear the airway as needed (mouth then nose), which typically is only required if there is an obstruction to spontaneous breathing or BVM ventilation is required. Otherwise, routine care is initiated with ongoing evaluation, which includes one- and five-minute APGAR scores (see Figure 1). If the answer to any one of the questions is no, the newborn will require further resuscitative efforts.
Steps in Resuscitation
If the newborn requires further resuscitation, move him/her immediately to a firm, flat surface and turn the temperature to the warmest setting possible. Place the baby's neck in a neutral or slightly extended position, which can be accomplished with a rolled washcloth or folded towel under the shoulders, clear the airway further if necessary, and continue to dry and stimulate the newborn. Suctioning and drying is often adequate stimulation to get the newborn to breathe effectively. If it does not, flick the feet with a finger or rub the trunk, back or extremities.4 Rapidly reassess respirations, heart rate and color. If the newborn is breathing adequately or crying, has a heart rate greater than 100 (which is easily assessed by palpating the base of the umbilical cord), and skin color is pink, observation is all that is required and the baby can be moved to the mother's chest, as discussed earlier.2
If the heart rate is greater than 100 with labored breathing or persistent cyanosis, clearing the airway further may be required. Assessment of oxygen saturation (SaO2 percentage) should be performed by placing a neonatal probe on the upper right extremity with the goal of maintaining saturation within the interquartile range of targeted preductal saturations (see Table III)2; give further post-resuscitation care as needed. The use of pulse oximetry is now preferred, since assessment of color is subjective and research has established ranges and trends of postductal SaO2 percentage. If the SaO2 percentage remains outside the norms of predicted postductal ranges or the heart rate is less than 100 beats per minute, positive pressure ventilations with a bag-valve mask should be initiated with a ventilatory rate of 40–60 per minute. At this point, reassess the infant. If the heart rate remains less than 100 but greater than 60, continue bag-valve mask ventilation and reassess every 30 seconds. Once the heart rate is 100 or greater, post-resuscitation care can be initiated as discussed earlier.
If the heart rate is less than 60 beats per minute despite resuscitative efforts, initiate chest compressions using one of two techniques. First is the two-thumbs encircling the chest technique, which has been shown to generate higher peak systolic and coronary perfusion pressures than the two-finger technique (see Figure 2).2 The two-thumb technique also provides a firm surface on which to perform compressions; both are acceptable methods according to the American Heart Association. Regardless of which technique is used, the goal is a compression-to-ventilation ratio of 3:1, with 90 compressions and 30 ventilations per minute, or 120 events per minute. If continued bradycardia is suspected to be cardiac in origin and not hypoxia-related—that is, unresponsive to adequate ventilations and airway management—a ratio of 15:2 or even 30:2 may be more effective.2
Following 30 seconds of ventilations and chest compressions, reassess the heart rate. If it is now greater than 60, discontinue compressions and continue with ventilations, reassessing pulse every 30 seconds thereafter and continuing with post-resuscitation care as required and described above. If the newborn's heart rate remains under 60 beats per minute, endotracheal (ET) intubation, vascular access, epinephrine and volume replacement must be considered.
Resuscitation Tools
Intubation
ET intubation is an infrequently performed intervention by EMS providers on a newborn; however, the rare possibility of ET intubation being required in the prehospital environment still exists. Three indicators for intubation are: initial suctioning of the meconium-stained newborn if it is non-vigorous; if bag-valve mask ventilation is ineffective or prolonged; and when chest compressions are performed. ET intubation also allows a route for administration of epinephrine when vascular access is unavailable or being attempted.7 Tube size is best selected by referring to neonatal resuscitation reference cards, but typically, preterm newborns will require smaller ET tubes than full-term. Having a selection of ET tubes sized down to 2.5 mm will address all possible resuscitation scenarios. An emerging alternative to ET intubation is the laryngeal mask airway (LMA) and other supraglottic airways, which EMS services are beginning to use as a secondary and, in some cases, a primary airway for adult patients,8 and it is being explored for the pediatric population.9 It has been demonstrated to be effective in ventilating newborns when caregivers are unable to intubate them,10 but its use during chest compressions and for administration of medications has not been researched.2
Vascular Access
Medications and fluid administration are rarely needed in newborn resuscitations outside of the delivery room. Umbilical vein catherization (UVC) is commonly used in initial resuscitation in the hospital setting, but is seldom used in the prehospital environment. EMS providers are more familiar with intraosseous (IO) insertion, commonly used on both adult and pediatric patients, and are able to achieve it more rapidly than a UVC line, making it the route of choice for vascular access in the newborn requiring resuscitation in the prehospital environment.11-13
Epinephrine
Typically, epinephrine is not needed in resuscitation of the newborn, since most bradycardia and cardiac arrests are due to hypoxia and not a cardiac cause.6 If epinephrine is required, IV or IO is the route of choice, with the recommended IV/IO dose of 0.01 to 0.03 mg/kg 1:10,000. Higher doses have been shown to negatively impact cardiac function when administered IV/IO. If there is a delay or vascular access is not obtainable, epinephrine may be administered through an ET tube, with suggested doses in the range of 0.05 to 0.1 mg/kg 1:10,000, but its safety and effectiveness at those doses has not been evaluated.2,14
Volume Replacement
Volume expanders should be considered when blood loss is evident or there are signs of hypovolemia or suspected hypovolemia, which include weak pulses greater than 100, persistent paleness despite adequate oxygenation, or the newborn responding poorly or not at all to resuscitative efforts.2,4 The prehospital solution of choice is an isotonic solution like normal saline (NS) or lactated Ringer's (LR), with an initial dose of 10 ml/kg over 5 to 10 minutes, repeated if needed. If administering fluids through an IO line, the line should be manually held or firmly secured so it does not inadvertently become dislodged. Remember, these fluids are being administered under pressure into a small marrow cavity. Unlike an adult IO, only a small portion of the needle may be in the bone and marrow cavity.
Meconium-Stained Amniotic Fluid
Meconium is the first stool of a newborn, which consists of amniotic fluid, fine hair, blood, bile and other substances. It is typically greenish to black with varying degrees of thickness and stickiness. The presence of meconium in the amniotic fluid indicates possible fetal distress and hypoxia during labor. Past practices of managing newborns with meconium-stained amniotic fluid included attempting to suction the mouth and nose prior to delivery of the shoulders and ET intubation with tracheal suctioning until clear of meconium prior to other interventions, neither of which was able to demonstrate a clear benefit to the newborn.15,16 In 2000, an international multicenter trial found no difference in post-delivery respiratory disorders in vigorous meconium-stained newborns who were intubated and tracheal-suctioned versus those who were not.17 Current research continues to show that even in non-vigorous, meconium-stained newborns who are intubated and tracheal-suctioned, death rates continue to climb. Until conclusive evidence is presented, the practice of intubating and tracheal-suctioning the non-vigorous, meconium-stained newborn should be continued2,17 using a meconium aspirator (see Figure 3).
Utilizing and Scoring the APGAR During Resuscitation
EMS providers are all familiar with the APGAR score and calculating it at one and five minutes following delivery of a newborn. What is often misunderstood is that it was not designed to guide resuscitation; that is, the provider should not wait until one minute, calculate the APGAR, and then decide that resuscitation is needed.18 An APGAR score calculated during resuscitation is not equivalent to an APGAR score calculated on a spontaneously breathing full-term newborn. There is currently no accepted standard for calculating an APGAR during resuscitation, due to the many variables contributing to the score that are influenced by the resuscitation itself.18 That said, the best practice is to have the provider recording the resuscitation also record an APGAR at one and five minutes. This will allow the medical facility to see what the estimated APGAR score was at those points in relation to what was occurring with the resuscitation. In the prehospital environment, once the newborn is resuscitated, the next APGAR score calculation should be done when it is due. Typically, following a normal full-term delivery that does not require resuscitation, the APGAR is scored at one and five minutes. If the APGAR is less than 7 at five minutes, it should be rescored every five minutes for 20 minutes.18
Summary
Delivering a new life into the world is truly a unique and proud moment, not just for the EMS providers who may do only one in their careers, but also for the parents, who probably did not think their new baby would be born outside the hospital. Due to the infrequency of delivering a baby in the prehospital environment, and even more rarely having to perform a major resuscitation on a newborn, perseverance in reviewing and preparing for delivering the newborn who requires ventilation cannot be overlooked, downplayed or pushed to the back of the training calendar. All EMS providers, services and systems need to allocate time for review and improvement in the knowledge, skills and attitudes required to conduct a major resuscitation of a distressed newborn.
Table 1: Key Questions Before Delivery
The first three questions suggest that delivery may be imminent:
1. Does the patient feel the need to push or have a bowel movement, or pressure in the vaginal area?
This is often a symptom of the baby's head moving into the birth canal.
2. Has the patient had any vaginal bleeding or discharge?
This is often an indication that labor has started.
3. Has the patient's water broken?
If the patient's water has broken, the amniotic sac has ruptured and delivery may be imminent. You will need to ask about the color of water (if broken). A watery to thick, particulate, greenish-yellow to blackish color of the amniotic fluid that may come from the vaginal opening or cover the baby's head suggests meconium is present and the baby may have stressed in utero. A yellowish color suggest the meconium is old and a greenish color suggests a more recent event.
Additional questions that may indicate a newborn that may require resuscitation:
4. When is your baby due?
Three weeks before the due date is considered preterm and the newborn is premature. Anticipate that the newborn may require resuscitation.
5. How many babies are you expecting?
If the patient is expecting more than one baby, additional EMS units may be needed. Anticipate that each baby after the first may require more resuscitative efforts.
6. Is this your first pregnancy?
With successive pregnancies, labor and delivery often are more rapid. If this is a second or third pregnancy, you may have less time to prepare than you would for a first pregnancy.
7. Are you having contractions?
As the delivery gets closer, the contractions will come closer together.
8. If yes, how far apart are your contractions
As the delivery becomes more imminent, the contractions will progressively be closer together
Table II: Newborn Resuscitation Equipement
1. OB Kit
2. Suction equipment
a. Bulb syringe
b. 8F feeding tube (gastric decompression)
c. 20 ml syringe (gastric decompression)
d. Meconium aspriator
e. Suction catheters (5,8,10F)
3. Bag-mask equipment
a. Neonate bag-valve mask
b. Various sized masks
4. ET intubation equipment
a. Pediatric (small) laryngoscope
b. Cuffed ET tubes, various sizes from 2.5 to 4.00mm
c. Small stylets
d. Securing device
e. 5F feeding tube to administer ET medications
f. Neonate stethoscope
5. Medications
a. Epinephrine 1:10,000
b. Normal saline
Table III: Targeted Preductal SpO2 After Birth2
1 min 60%-65%
2 min 65%–70%
3 min 70%–75%
4 min 75%–80%
5 min 80%–85%
10 min 85%–95%
References
1. CNN. U.S. birth rate falls for second year in midst of recession. https://articles.cnn.com/2010-08-28/us/birth.rate.decline_1_statistics-center-birth-rate-great-recession?_s=PM:US.
2. American Academy of Pediatrics. Special report. Neonatal resuscitation: 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. https://pediatrics.aappublications.org/cgi/reprint/peds.2010-2972Ev1.
3. Helping babies breathe: The golden minute. www.helpingbabiesbreathe.org/index.html.
4. Aehlert B. Paramedic Practice Today: Above and Beyond. St. Louis, MO: Mosby, 2010.
5. Kangaroo mother care. www.kangaroomothercare.com/birth.htm.
6. Caroline N. Emergency Care in the Streets, 6th ed. Sudbury, MA: Jones and Bartlett, 2008.
7. American Heart Association. Highlights of the 2010 American Heart Association guideline for CPR and ECC. https://guidelines.ecc.org/pdf/90-1043_ECC_2010_Guidelines_Highlights_noRecycle.pdf.
8. Frascone RJ, Wewerka SS, Griffith KR, Salzman JG. Use of the King LTS-D during medication-assisted airway management. Prehosp Care 13(4):541–545, 2009.
9. DeBoer S, Seaver M, McNeil M, et al. Prehospital pediatric airway management: It's time to reconsider how we maintain pediatric airways. EMS Mag 38(1):2009.
10. Stone BJ, Chantler PJ, Baskett PJ. The incidence of regurgitation during cardiopulmonary resuscitation: A comparision between the bag valve mask and laryngeal mask airway. Resuscitation V38 (1): 3–6, May 1998.
11. Abe KK, Blum GT, et al. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. Am J Emerg Med 18(2):126–129, 2000.
12. DeBoer S, Seaver M, Vardi A. Infant intraosseous infusion. Neonatal Network 27(1):25–32, 2008.
13. Ellemunter H, Simma B, et al. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed 80(1):F74–75, 1999.
14. Barbra C, Wyckoff M. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 118(3):1028–1034, Sep 2006.
15. Ting P, Brady JP. Tracheal suction in meconium aspiration. Am J Obstet Gynecol 122:767–771, 1975.
16. American Heart Association (2009). Worksheet for evidence-based review of science for neonatal resuscitation. www.americanheart.org/downloadable/heart/1265039640057NRP-012A%2031-Jan-2010.pdf.
17. Wiswell T, Gannon C, Jacob J, et al. Delivery room management of the apparently vigorous meconium-stained neonate: Results of the multicenter, international collaborative trial. Pediatrics 105:1–7, 2000.
18. American Academy of Pediatrics. The APGAR score. Pediatrics 17(4):1444–1447, 2009.
Scott Tomek, MA, EMT-P, has been a paramedic for 25 years, 23 with Lakeview Hospital EMS in Stillwater, MN. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.
