Neonatal Resuscitation

When a baby is born, the mother expects to hear the sounds of crying soon after. When the mother hears nothing, it can trigger panic. Many babies need some resuscitation after birth, as many as 1 in 10. Most of the time, warming and rubbing the baby will be enough to get the baby to begin to breathe on its own. Unfortunately, some babies need more treatments and interventions. 

There are standard procedures in childbirth, including looking for children at risk of needing resuscitation, signs of needing resuscitation, and resuscitation protocols. When these practices are not followed it can put the baby at risk of injury, including possible brain damage

What is Neonatal Resuscitation?

When transitioning from life inside the uterus to life outside the uterus, there is a rapid physiological change that the baby goes through. Inside the uterus, the baby receives blood, oxygen, and nutrients from the mother through the umbilical cord. The baby's lungs are filled with amniotic fluid and are not taking in oxygen from the air. Within moments after delivery, the baby must make the transition from getting oxygen from the mother to breathing oxygen from the air. 

During the transition from oxygen supply through the placenta to breathing air, a baby experiences a brief period of asphyxia. When the umbilical cord is clamped, the baby is no longer able to receive oxygen through placental gas exchange. The light, noise, and temperature change outside the womb may help the baby transition. Breathing air will fill the alveolar spaces and replace the amniotic fluid. 

After a baby is born, it is not always able to make the transition to extrauterine life without some level of resuscitation. Resuscitation is the process of reviving someone who is unconscious or correcting a physiological disorder. In most cases, neonatal resuscitation involves helping the baby to begin breathing or provide oxygen until the baby can breathe on its own. 

Neonatal resuscitation is not uncommon. About 5% to 10% of newborns require some degree of resuscitation after birth. Because neonatal resuscitation is so common, an individual who is trained to perform resuscitation should be available at every delivery. If the baby needs resuscitation, immediate action and appropriate care can help reduce the risk of long-term damage or death. 

Simple resuscitation can be accomplished through warming and stimulating the baby to help them breathe. If the baby is still not breathing, oxygen can be provided through bag-and-mask ventilation. In severe cases, the baby may require intubation, oxygen, chest compressions, and drugs to restore breathing function. 

Neonatal Resuscitation vs. Perinatal Resuscitation

The terms neonatal resuscitation and perinatal resuscitation may be used to refer to the same thing.  Perinatal is the term for the period around the birth, which may include before, during, and immediately after. Neonatal is the period after the child is born. Neonatal resuscitation is generally performed immediately after delivery. 

Risk Factors for Neonatal Resuscitation?

There are risk factors that may increase the likelihood that the baby will need neonatal resuscitation after birth. These risk factors can put the mother and medical personnel on notice that the baby may need resuscitation and to be prepared to take action to give the baby the best chance for survival. Some of the risk factors for possible birth complications include: 

  • Gestational diabetes
  • Pre-eclampsia
  • HELLP syndrome
  • High blood pressure
  • Alcohol or drug use
  • Smoking
  • Maternal age over 40
  • Prior birth complications
  • Prior preterm birth
  • Multiple births
  • Trauma
  • Anemia
  • Infection
  • Gestational age over 30 weeks
  • Intrauterine growth restriction
  • Excessive or reduced amniotic fluid
  • Meconium stained amniotic fluid
  • Prolonged labor
  • Maternal sedation

When is it Necessary to Perform Neonatal Resuscitation?

Proper preparation, evaluation, and immediate support may reduce the risk of injury, brain damage, or death if the baby is not breathing after delivery. Primary evaluations begin with determining:

  1. Is the child full-term?
  2. Is the baby breathing or crying?
  3. Does the baby have good muscle tone?

If a baby is preterm, they are more likely to require resuscitation. Preterm babies may not have full lung development and may be more at risk of cold stress. Preterm babies may also have a higher risk of infection. If the baby is not breathing or crying, they are not getting oxygen through the lungs. Poor muscle tone may also be a sign of hypoxia, or lower oxygen levels. 

The first step is generally thermal protection. Babies may be dried rapidly to reduce evaporation cooling. Keeping the baby warm may include covering the baby's head with a cap, wrapping in a blanket or plastic, and using a warming device. However, improper thermal protection with warming devices, heating pads, or hot water bottles can cause burn injuries to the baby's sensitive skin and tissue.

The ABC principles of resuscitation remain the same for all ages, from neonates to adults. These are: 

  • Airway
  • Breathing 
  • Circulation

Airway

Some of the possible difficulties in maintaining an open airway in neonates involve trauma to the mouth or upper respiratory area, airway secretions, or malformations that restrict the airflow through the mouth, nose, and throat. Another factor in resuscitating a neonate involves airway position. Adequate head and neck position can maintain the optimal opening for intubation and oxygenation. 

Another possible cause of airway obstruction may include meconium aspiration. Meconium is a dark, greenish-black stool that can appear like tar. Stool is produced in the baby's intestines before birth and is generally released after birth. However, in some cases, meconium can be released while the baby is still in the womb. 

When meconium is released early, it can mix with the amniotic fluid and be aspirated, or breathed in, by the baby. Meconium-stained amniotic fluid can lead to a condition known as meconium aspiration syndrome (MAS). While MAS is not uncommon, it is still a serious condition which can cause respiratory distress. The particles in the meconium may block the baby's airway or lung function, causing oxygen deprivation. 

Getting a clear airway begins with positioning of the baby, which is generally on the back or side with the head extended slightly. If there are secretions blocking the airway, they can be cleared with a suction device or cloth. Suction should be done gently and not too deep. 

Breathing

Drying the baby and stimulation is often enough to get the baby breathing on its own. Gentle stimulation like rubbing the back or flicking the bottom of the feet may also help stimulate the baby. However, inappropriate stimulation like clapping on the back, shaking, or squeezing the chest too hard can cause injury. 

If the baby is not breathing, positive pressure ventilation may be used. Bag-and-mask ventilation uses a mask over the baby's mouth and nose and a self-inflating bag that can be squeezed to provide pressurized air into the lungs. Supplemental oxygen may be used to make sure the baby has enough oxygen. 

If the baby is breathing, it may still not be enough to provide adequate levels of oxygen. Slow or shallow respiration, poor respiratory effort, or gasping may require additional resuscitation procedures, including ventilation and supplemental oxygen. A positive reaction to ventilation may show improvements in the heart rate, skin color, muscle tone, breathing sounds, and chest movement. 

Circulation

If the baby's heart rate falls below 60 beats per minute after a minute of positive-pressure ventilation, chest compressions may be initiated. Chest compressions are a way to physically squeeze the heart, to pump oxygenated blood through the body and carbon dioxide out through the lungs. 

Medications may also be used to address poor circulation. If the baby's heart rate remains too low after compressions, epinephrine may be administered. 

After a baby has gone through neonatal resuscitation and is able to breathe on their own, the baby should continue to be monitored and evaluated.  

Endotracheal Intubation and Resuscitation

Intubation is a medical procedure used to maintain an open airway and access to the lungs. Endotracheal intubation may be required as part of neonatal resuscitation where ventilation is ineffective. Intubation can be more complicated with a neonate because of the smaller size of the mouth, throat, and tracheal opening. 

A laryngoscope is inserted into the mouth to show a clear pathway to the vocal cords and down the trachea. After the tube is inserted to the correct depth, the position of the tube should be confirmed by watching the chest motion, listening for equal breath sounds, and making sure there is not stomach inflation. 

During neonatal intubation, the anesthesiologist may administer drugs to minimize the effects of intubation. However, these sedatives and analgesics may cause side effects or an allergic reaction. This can compromise the infant's functions, including lowered blood pressure, depressed nervous system, or lowered breathing rate. 

Neonatal Resuscitation Malpractice Lawyer

Neonatal resuscitation requires fast action and appropriate interventions to give the baby the best chance at recovery. Delayed diagnosis, improper diagnosis, improper treatment, negligent intubation, or other errors may put the baby at risk of serious injury or death. 

If a child suffers a brain injury as the result of a medical mistake, the parents may never know that the injury was caused by negligence. The doctors or hospitals may not admit to any wrongdoing. If you suspect something went wrong during the delivery or after the child was born, you may need an advocate to find out what happened. 

By calling an experienced birth injury attorney, you will have someone on your side to investigate what happened, identify any wrongdoing, and help you recover damages to pay for your child's care.

If you have questions about possible medical mistakes during delivery, talk to an experienced birth injury malpractice attorney about your options. Do not hesitate to contact Gilman & Bedigian today for a free consultation.

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