17 Apr 2020

Neonatal Resuscitation

Anesthesia providers who specialize in acute care are involved in trauma, critical care and emergency care anesthesiology.1 In these cases, clinicians must be prepared for patients in shock, with severe injuries or with significant blood loss.1 Emergencies, such as when a patient’s vital signs suddenly change or the patient requires oxygen, can be high-risk and stressful for anesthesia providers.2 This includes neonatal resuscitation, which anesthesia providers may need to perform despite lacking a fellowship in obstetric anesthesia or formal neonatal resuscitation training.3 To ensure their patients are in safe hands, anesthesia providers must be familiar with neonatal resuscitation, situations that may require it and their role in performing it. 

Practitioners who resuscitate infants at birth or at any time during the initial hospital admission should be aware of neonatal resuscitation guidelines.4 Approximately 10 percent of newborns require some assistance to begin breathing at birth.4 Though less than 1 percent require extensive resuscitation measures, the large total number of births translates to many newborns who need resuscitation.4 In neonatology, the term “resuscitation” is used to describe two different clinical situations.5 The first is an emergency in which the neonate’s respiratory or cardiac system unexpectedly arrests, and clinicians must take measures to restore life.5 The second situation usually occurs in the delivery room, and it involves assisting the newborn with the transition from the uterus to the outside world.5 Many complex changes occur in the fetus during this transition, and many neonates may require assistance to breathe on their own.5 The main goals of resuscitation are to deliver oxygen to the body, optimize oxygen uptake in the tissues and control the use of oxygen in the body.6 In neonatal resuscitation, this means stabilization, such as warming, regulating temperature, repositioning, clearing secretions that obstruct the airway, drying and stimulating; ventilation and oxygenation; chest compressions; and epinephrine administration or volume expansion to affect blood pressure.7 Approximately one minute is allotted for completing the initial steps and beginning ventilation if required.7 Once ventilation begins, the clinician must continuously assess heart rate, respirations and oxygen saturation.7 

Some circumstances put a neonate at higher risk for needing resuscitation.8 In fact, the majority of newborns who will require resuscitation can be identified before birth.8 For example, preterm delivery (before 37 weeks’ gestation) requires special preparations.8 These babies have immature lungs that are more difficult to ventilate and more vulnerable to injury by mechanical ventilation; immature brain blood vessels that are prone to hemorrhage; thin skin and a large surface area, leading to hypothermia; increased susceptibility to infection; and increased risk of hypovolemic shock related to small blood volume.8 However, it should be noted that—according to scientific evidence—Cesarean section performed under regional anesthesia at 37 to 39 weeks, versus similar vaginal delivery at term, does not increase risk of the neonate requiring intubation.8 Thus, the need for resuscitation is likely due to the baby’s gestational age and birth weight rather than the mode of delivery. 

The anesthesia provider’s role in neonatal resuscitation remains controversial.9 Guidelines from national professional organizations state that during Cesarean section, the anesthesiologist responsible for the care of the pregnant woman is not responsible for the care of the newborn, including resuscitation.10 However, anesthesia providers may be asked to assist with endotracheal intubation or medication administration to the neonate, depending on the expertise or number of other practitioners in the delivery room.2 Gaiser et al. found that the majority of graduates from the University of Pennsylvania anesthesia residency program who worked in obstetric anesthesia did, indeed, help with resuscitation of the newborn.11 Given their extensive knowledge of masks and ventilation,12 anesthesia providers would in theory be able to effectively assist in neonatal resuscitation. However, this creates a significant liability for anesthesiology practitioners,2 as their primary duty is to the parturient10 and they should not be held responsible for the health of the neonate.2 Additionally, most anesthesia providers do not have adequate training in neonatal resuscitation,3 despite their interest in learning those skills.11 

Anesthesia providers are often faced with urgent situations requiring quick and effective reactions. This applies to neonatal resuscitation, which may be necessary during respiratory or cardiac arrest or immediately after birth. However, many anesthesia providers are not trained in neonatal resuscitation, and national policy obligates the anesthesiologist to caring for the parturient. Future policy should aim to standardize the role of the anesthesiology practitioner in the delivery room and provide neonatal resuscitation training to clinicians who want or need it. 

1.McCunn M, Dutton RP, Dagal A, et al. Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the “Acute Care” Anesthesiologist? Anesthesia & Analgesia. 2015;121(6):1668–1673. 

2.Domino KB, Davies JM. Neonatal Injury and Resuscitation: A Liability for Anesthesiologists? An Update From the Anesthesia Closed Claims Project. ASA Newsletter. 2017;81(2):16–17. 

3.Gao W, Moss D, Schumann R, Drzymalski DM. Knowledge and comfort with neonatal resuscitation among practising anesthesiologists. International Journal of Obstetric Anesthesia. 2019;39:148–149. 

4.Kattwinkel J, Perlman JM, Aziz K, et al. Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2010;126(5):e1400–e1413. 

5.Karlowicz MG, Karotkin EH, Goldsmith JP. Resuscitation. In: Goldsmith JP, Karotkin EH, eds. Assisted Ventilation of the Neonate (Fifth Edition). Philadelphia: W.B. Saunders; 2011:71–93. 

6.Tam CW, Kumar SR, Ivascu NS. Cardiopulmonary Resuscitation. In: Hemmings HC, Egan TD, eds. Pharmacology and Physiology for Anesthesia (Second Edition). Philadelphia: Elsevier; 2019:575–584. 

7.Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13: Neonatal Resuscitation. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Reprint). 2015;136(Supplement 2):S196–S218. 

8.Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: Neonatal Resuscitation. Circulation. 2010;122(18 Supplement 3):S909–S919. 

9.Chadha I. Neonatal resuscitation: Current issues. Indian Journal of Anaesthesia. 2010;54(5):428–438. 

10.Wissler RN. Anesthesiology: Resuscitation of the Newborn. Decision Support in Medicine 2017; https://www.clinicalpainadvisor.com/home/decision-support-in-medicine/anesthesiology/resuscitation-of-the-newborn/

11.Gaiser R, Lewin SB, Cheek TG, Guttsche BB. Anesthesiologists’ interest in neonatal resuscitation certification. Journal of Clinical Anesthesia. 2001;13(5):374–376. 

12.Finer NN, Rich W, Craft A, Henderson C. Comparison of methods of bag and mask ventilation for neonatal resuscitation. Resuscitation. 2001;49(3):299–305.