In most situations, after a baby is born, they immediately start to cry. That being said, approximately 10% of infants require help to begin breathing. An additional 1% need more intensive intervention, which is referred to as neonatal resuscitation.
Neonatal resuscitation can include a variety of interventions, including clearing the baby’s airway, giving them oxygen, chest compressions, the administration of epinephrine, and even intubation. These procedures are often necessary to ensure that a baby survives and that they do not suffer a birth injury. A mistake during the resuscitation process – including the failure to appropriately monitor the newborn infant – can be a form of medical negligence.
At the Birth Injury Lawyers Alliance (BILA), we advocate for parents and children who have suffered birth injuries due to preventable medical errors. Reach out today to schedule a free consultation with a birth injury lawyer in your province.
What Is Neonatal Resuscitation?
Neonatal resuscitation is a procedure or series of procedures that are designed to stimulate and assist newborn infants in breathing if they do not start breathing spontaneously immediately after labour and delivery. The extent of intervention depends on the situation, with some newborns only requiring gentle stimulation, airway clearance, and warmth. In more serious cases, an infant may require cardiopulmonary resuscitation (CPR).
Because oxygen deprivation (birth asphyxia) can cause brain damage and even death, medical staff must be properly trained in neonatal resuscitation and are ready to perform these life-saving procedures at every birth – even if no problems are anticipated. In particular, because preterm infants are more likely to require breathing intervention, medical professionals should be prepared to perform these procedures for preterm births.
Certain newborn infants are at a much higher risk of requiring neonatal resuscitation. This can be due to maternal and/or neonatal conditions, such as:
- Advanced maternal age
- Maternal hypertension
- Gestational diabetes
- Prior stillbirth, miscarriage, or neonatal death
- Substance abuse during pregnancy
- Premature birth
- Post-term pregnancy
- Placenta previa
- Placental abruption
- Intrauterine growth restriction (IUGR)
- Multiple births
- Low amniotic fluid
- Genetic or congenital anomalies
- Birth asphyxia (hypoxic-ischemic encephalopathy, or HIE)
- Breech birth
- Abnormal fetal heart rate
- Assisted delivery (the use of forceps or a vacuum)
- Emergency cesarean section
If these risk factors are present, the labour and delivery team should ensure that they are ready to perform neonatal resuscitation, including having the necessary equipment present. In some cases, the birth should take place at a more specialized hospital for high-risk births
Neonatal Resuscitation Steps and Interventions
At birth, a baby will be evaluated for five things: color, heart rate, reflexes, muscle tone, and respiration. This is known as the Apgar Score. If a baby has a low Apgar score, then immediate intervention will be required. If the baby has poor muscle tone or difficulty breathing or crying, neonatal resuscitation may be necessary.
There is a step-by-step process to resuscitate newborns who are having difficulty breathing. Just like CPR, these steps should be taken quickly to reduce the risk of damage to the brain, heart, or other organs. If a baby does not stabilize after each step, then a doctor or nurse should move on to the next step.
The steps of neonatal resuscitation are as follows:
- Initial Stabilization: medical professionals should properly position the baby and make sure that it is warm and dry. They should also provide tactile stimulation, and if necessary, clear the baby’s airway. To clear the airway, a tube may be placed to aspirate the blockage (usually from mucus or secretions). In cases of meconium aspiration, a special suctioning tube is used. Because there are risks associated with suctioning, this procedure must be used with care.
- Breathing Assistance: if the baby has not responded to initial stabilization attempts, then they should be ventilated or oxygenated.
- If the baby’s heart rate is less than 100 beats per minute (bpm) or if they have apnea (gasping), then they should be given positive pressure ventilation (PPV). Positive pressure ventilation provides newborns with air via a mask, t-piece resuscitator, or inflating bag to improve the exchange of air between the lungs and the environment. In more serious situations, endotracheal intubation may be necessary to deliver PPV. This tube is either placed through the nose and into the trachea, or through the mouth and into the trachea. It may be necessary if typical PPV methods are ineffective, if chest compressions are being performed, and/or to relieve airway obstructions.
- If the baby’s heart rate is greater than 100 bpm and they have laboured breathing or cyanosis, they should be given supplemental oxygen. In this situation, the use of a continuous positive airway pressure (CPAP) machine may also be considered. A CPAP is a non-invasive method to help a baby breathe, where the infant wears a mask and the machine delivers pressure to keep their lungs open. In more serious situations, endotracheal intubation may be necessary to deliver PPV. This tube is either placed through the nose and into the trachea, or through the mouth and into the trachea. It may be necessary if typical PPV methods are ineffective, if chest compressions are being performed, and/or to relieve airway obstructions.
- Supplemental oxygen can be administered in the delivery room. Medical professionals should use pulse oximetry to determine whether the administration of supplemental oxygen is appropriate.
- Chest Compressions: if the baby’s heart rate stays under 60 bpm despite effective ventilation for 30 seconds, then chest compressions may be used. Chest compressions involve placing two or three fingers on the center of the baby’s chest and gently pressing down to push blood through the heart, arteries, and veins. They should always be done in conjunction with PPV.
- Epinephrine Administration: if the baby is still not responding, then epinephrine can be administered through an intravenous (IV) line. This medication can increase heart rate and blood pressure.
- Volume Expansion: while it is used infrequently, volume expansion medication can be administered to prevent decreased blood flow (neonatal hypovolemia) if the baby’s heart rate stays below 60 bpm at this point. These drugs help to increase a baby’s blood volume, and should only be used in specific situations, such as when blood loss is known or expected.
Other potential procedures may be used in neonatal resuscitation. For example, surfactant therapy can be used for babies with respiratory distress syndrome (RDS). With RDS, a baby fails to make enough surfactant, which prevents the lungs from expanding properly. A surfactant can be administered to keep the lungs from sticking together and prevent injury and infection in the lungs.
Importantly, once newborn resuscitation procedures have begun, the medical team should carefully monitor the baby’s temperature, blood pressure, blood oxygen levels, and heart rate. This can be done using various equipment, such as:
- Pulse oximetry, which involves placing a sensor on a newborn’s finger to monitor the oxygen saturation of the blood
- An umbilical arterial catheter (UAC) is placed minutes after birth and can be used to continuously monitor blood pressure and to take arterial blood samples without repeated needle sticks. Arterial blood samples provide critical information about oxygen concentrations, carbon dioxide, and pH levels of the blood.
- Blood pressure cuffs are used if a UAC is not possible.
- Cardiopulmonary monitor, which involves placing small adhesive monitoring pads on the chest. This machine then tracks the baby’s heart rate and breathing.
Neonatal Resuscitation Errors
Newborn resuscitation techniques are often life-saving. That being said, they do carry certain risks. A mistake in administering these procedures- or a failure to start resuscitation efforts within minutes after birth – can often lead to serious injury or even death. Similarly, a failure to recognize the need for these efforts can lead to severe or fatal injuries.
Slow or badly performed newborn resuscitation techniques can lead to the deprivation of adequate oxygen and blood flow to the baby. In turn, this can cause permanent brain injuries such as HIE, cerebral palsy (CP), periventricular leukomalacia (PVL) and brain bleeds. These injuries can cause permanent disabilities.
The medical team should also closely monitor the baby’s vital signs and overall status. If they fail to do so, then they may miss important signs that further intervention is needed. Alternatively, they may take an unnecessary step – such as giving a preterm infant supplemental oxygen when they receive effective ventilation through PPV.
Is Newborn Resuscitation Always Necessary?
No. In most births, a baby will start breathing on their own immediately. However, medical professionals should always be prepared to start resuscitation efforts, particularly if for preterm infants and other high-risk births. With any labour and delivery, the team should be prepared to start resuscitation efforts immediately after birth.
A failure to take these steps can be a form of medical negligence. If you suspect that your child did not receive the appropriate care and has suffered a birth injury as a result, we can help. Reach out to BILA to schedule a free consultation with a birth injury lawyer in your province.
Will My Baby Be Intubated?
It depends. Intubation is generally only needed if other steps, such as bag-mask ventilation, do not work. If it is necessary, intubation can help to ensure your baby’s safety and well-being.
Intubation can carry risks, including if it is done properly. If you believe that your baby suffered a birth injury related to neonatal resuscitation, call BILA to schedule a free consultation with a birth injury lawyer in your province.
How BILA Can Help
Oxygen deprivation during labour and delivery and in the first moments of a baby’s life can cause disability and death. When performed properly and properly, neonatal resuscitation techniques can reduce the risk of these more dire outcomes. However, when a mistake is made, then a baby may suffer a birth injury.
If you believe that your child suffered a preventable birth injury due to medical negligence, you may be able to file a lawsuit against the at-fault medical provider. A birth injury lawyer can advise you of your legal options. For help with HIE cases or other types of birth injury claims, call BILA today at 1-800-300-BILA or fill out our online contact form to schedule a free initial consultation with a lawyer in your province.
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