Newborn resuscitation and what can go wrong

What is it?

At birth a baby has to do something remarkable in seconds. The lungs, which have been full of fluid, have to clear and inflate. The blood vessels in the lungs have to open. Circulation has to reroute.

Most babies do this on their own. Some need help.

The algorithm is a sequence. ^{2 1}

Initial steps. Warm, dry, position the airway, and stimulate. Assessed and completed within the first minute.

Positive pressure ventilation. If the baby is not breathing or the heart rate is below 100, breaths are given with a mask. This is the step that resolves most newborn resuscitations.

Corrective steps if ventilation is not working. There is a defined checklist for a mask that is not delivering breaths: repositioning the head, clearing the airway, opening the mouth, increasing pressure, and considering an alternative airway.

Intubation, where mask ventilation is not effective.

Chest compressions, if the heart rate stays below 60 despite effective ventilation, coordinated with breaths.

Medication, meaning epinephrine, and volume where blood loss is suspected.

Throughout: temperature control, monitoring of heart rate and oxygen saturation, and targeted oxygen rather than always 100 percent. ²

What changed about meconium

Routine intubation to suction a baby born through meconium who is not vigorous is no longer recommended. Evidence did not support it, and delaying ventilation to suction causes harm. ²

What does standard care look like?

Anticipation. Where a difficult birth is expected, a team trained in newborn resuscitation is present at the delivery. ¹

Equipment checked and ready before the birth.

The algorithm followed, with the initial steps within the first minute and ventilation started promptly where indicated. ²

Effective ventilation confirmed, by chest movement and by a rising heart rate, with the corrective steps used if it is not working. ²

Heart rate monitored, with electrocardiogram used where available, because assessment by listening or feeling is less reliable. ²

Temperature maintained. ²

Oxygen targeted rather than given at 100 percent throughout. ²

cord blood gas obtained where resuscitation was needed. ⁴

Assessment for therapeutic hypothermia where the baby meets criteria, within six hours of birth. ⁵

Documentation, with timed entries throughout.

What can go wrong?

Ventilation delayed. This is the most consequential failure, because effective ventilation is what resolves most newborn resuscitations. ²

Ineffective ventilation not recognized, so breaths were being given without air reaching the lungs, and the corrective steps were not worked through. ²

Time spent suctioning instead of ventilating in a baby born through meconium, which the current algorithm specifically moved away from. ²

Compressions started late, or not started when the heart rate remained below 60 despite effective ventilation. ²

No trained team present at a delivery where difficulty was anticipated. ¹

Equipment not ready or not working.

The baby allowed to become cold, which worsens outcomes. ²

cord blood gas not obtained, so there is no measure of the acid build-up at birth. ⁴

Cooling not considered, or considered too late, in a baby who met criteria. The six-hour window is the constraint. ⁵

Thin documentation, so the sequence and timing cannot be reconstructed.

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record.

Which injuries can follow?

• HIE, where the period without adequate oxygen was prolonged. ⁴
• Neonatal seizures. ⁶
• Cerebral palsy where brain injury is significant. ⁷
• Microcephaly, where head growth slows after significant injury. ⁸
• Cortical visual impairment and hearing loss. ^{9 10}
• PPHN, where the transition does not complete. ¹¹
• Injury to other organs, including kidney and liver.
• Pneumothorax, an air leak from the lung, which can follow ventilation. ¹²

What does this look like in the records?

Request the newborn resuscitation record by name. It is a timed record of the first minutes and it is often on a separate form.

What it should show

• The time of birth.
• The time the initial steps were completed.
• The time positive pressure ventilation started. ²
• Heart rate readings over time.
• Oxygen saturation and the oxygen concentration used.
• Whether corrective steps were used, and when.
• The time of intubation, if performed.
• The time chest compressions started and stopped. ²
• Medicines given, with doses, routes and times.
• Temperature.
• Who was present and when they arrived. ¹

Alongside

• The Apgar score scores at 1, 5 and 10 minutes. The 10-minute score matters most for outlook. ³
• The cord blood gas results. ⁴
• The fetal monitoring strip up to delivery. ¹³
• The decision on cooling, with the time and the reasoning. ⁵

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.