Neonatal Resuscitation

Apgar Scores and Resuscitation Guidance


Apgar > 8: suction, warm

Apgar 5-7: O2 by mask (mechanically vent if needed), external stimulation

Apgar 3-6: mechanical ventilation by mask, intubation if spontaneous ventilation absent, ABG from double-clamped cord

Apgar < 2: intubation, chest compression if HR < 60

For neonates with an Apgar or 0-4, have a extremely low threshold for intubation (proper positioning is a neutral head with a slightly extended neck). Ventilate at ~ 40/min and consider 3-5 mm Hg of PEEP. Keep airway pressures < 30 cm H2O (or even lower if possible). Send an umbilical ABG as soon as possible

6% of neonates will require resuscitation, usually due to 1) acidosis 2) trauma from the birth and 3) maternal drugs. Normal maternal/fetal gradient is 5 mm Hg of CO2 and 0.05 for pH

Cardiopulmonary Resuscitation


HR < 80 epinephrine (10-30 ucg/kg IV into trachea or through umbilical artery) HR < 60 CPR (isoproterenol if repeated doses needed)

Unlike in adults, chest compressions are initiated for bradycardia (in this case, HR < 60) [Davis PG et al. Lancet 364: 1329, 2004], 120/minute with PPV at 40-60/min. Epinephrine is indicated for HR < 80 after 30 seconds of ventilation. Consider isoproterenol if repeated doses are necessary to keep HR > 100


Can theoretically reverse acidosis, heart failure, and pulmonary vasoconstriction associated with asphyxia (acidosis causes pulmonary hypertension), however a small, randomized controlled trial of bicarbonate versus dextrose for asphyxiated neonates showed no difference in any outcomes [Lokesh L et al. Resuscitation 60: 219, 2004]. A Cochrane Database Systemic Review echoed these sentiments, saying that “There is insufficient evidence from randomised controlled trials to determine whether the infusion of sodium bicarbonate reduces mortality and morbidity in infants receiving resuscitation in the delivery room at birth” [Beveridge CJ and Wilkinson AR. Cochrane Database Syst Rev: CD004864, 2006]. Additionally, it is not recommended by Barash [Barash, PG. Clinical Anesthesia, 5th ed. (Philadelphia), p. 1174, 2006]

Volume and Vascular Access

Suspect hypovolemia in the presence of cord compression, abruptio placentae, or placenta previa. Establish access with umbilical venous catheterization, then consider umbilical arterial catheterization (which is more difficult to achieve, but which allows one to analyze ABG and an accurate SBP)


Contraindicated in opiate-addicted mothers. Give 0.1 mg/kg IV. Note that neonates born in the presence of opiates will often be vigorous at birth but subsequently become lethargic


Suspect hypoglycemia in any infant with IUGR, asphyxia, or with a diabetic mother

Meconium Aspiration

Intubate and THEN use the endotracheal tube as a suction catheter


Note that infants who asphyxiate do not take up as much placental blood as their healthy counterparts, and are thus hypovolemic at birth. They may need volume resuscitation or even PRBCs (O negative, crossed matched with the mother’s blood).