How Do You Do CPR On a Newborn?

Neonatal resuscitation (CPR) provides oxygen, stimulates breathing and gets the heart to start pumping normally. Most premature babies and babies with certain congenital conditions require extensive resuscitation.

Neonatal resuscitation is a procedure performed if a newborn infant does not start breathing spontaneously immediately after birth. Neonatal resuscitation provides oxygen, stimulates breathing and gets the heart to start pumping normally.

A majority of babies start breathing on their own and need only routine neonatal care. Approximately 10% of newborn require some assistance for the transition from fetus to newborn, and about 1% require extensive resuscitative measures. 

Most premature babies and babies with certain congenital conditions require extensive resuscitation.

Preparation

Readiness and capability in handling a potential emergency during delivery are two most important components of successful neonatal resuscitation. Preparation for neonatal resuscitation includes the following:

• Skilled personnel: Medical personnel in the delivery room must be skilled in neonatal resuscitation. The Neonatal Resuscitation Program is a highly respected training program for delivery room personnel, developed jointly by the American Academy of Pediatrics (AAP) and the American Heart Association (AHA).
• Resuscitation equipment: The delivery room should be equipped with all the tools required for neonatal resuscitation.
• Anticipation of potential problems: Anticipation and identification of the risk factors, though not always possible, is greatly helpful in successful neonatal resuscitation.
• Rapid assessment: The infant must be rapidly assessed to determine need for resuscitation. Resuscitation must be considered and/or initiated if the answer is “no” to any of the following questions:
  • Is the baby born after full gestation term?
  • Is the amniotic fluid clear of meconium (baby’s first stool) and signs of infection?
  • Is the baby breathing and crying?
  • Does the baby have good muscle tone?

Initial steps

The initial steps in neonatal resuscitation include:

• Thermoregulation
  • Maintaining adequate warmth during neonatal resuscitation is of primary importance. Loss of heat increases the newborn’s metabolic rate in order to generate heat. As a result, the oxygen requirement also is driven up, which is dangerous in a baby already under respiratory distress.
  • Some of the measures taken to keep the baby warm include the following:
    • Using pre-warmed towels to dry the baby
    • Using pre-warmed blankets and bed warmers
    • Maintaining a room temperature of 75 F to 80 F based on the baby’s gestational age and birth weight.
    • Using heat-resistant food grade plastic wrap around premature infants with low birthweight
    • Using an adequately pre-warmed incubator
  • The AAP and AHA state that the baby’s body temperature should be maintained at 97.7 F (36.5 C). Temperature is recorded as soon as possible after birth and every 10 to 15 minutes thereafter.
• Airway management
  • The newborn is properly positioned to keep the airway (trachea) open. The mouth and nose are gently suctioned to remove any amniotic fluid or meconium aspirated during delivery.
• Stimulation
  • Drying and suctioning is often sufficient stimulation for the newborn to start breathing. If more stimulation is required, gently slapping the soles of the feet or rubbing the back can initiate breathing.
• Evaluation
  • The initial steps should be completed with an evaluation of the baby’s respiratory rate, heart rate and skin color, within 30 seconds after birth. If the baby is pink, breathing normally, and has a heart rate of over 100 beats per minute (BPM), no further intervention is required. The baby stays under observation and receives routine neonatal care.
  • If the newborn does not meet the criteria for routine care after the initial steps, supplemental oxygen with assisted ventilation is initiated within the next 30 seconds.
• Assisted ventilation
  • Assisted ventilation is a procedure performed with a mask or a thin tube inserted into the trachea to provide oxygen and stimulate breathing.
• Supplemental oxygen
  • If the baby is breathing adequately and sustains a heart rate of over 100 BPM, but remains blue (cyanotic), supplemental oxygen is provided with a mask or oxygen tubing. Supplemental oxygen is maintained until the saturation level in the blood is at 92% to 96% in full term babies and 88% to 92% in preterm babies.
  • Supplemental oxygen is usually delivered at the concentration it is present in the room air, which is 21%, but may be increased if required. If oxygen requirement continues for a relatively long period, heated and humidified oxygen is supplied with an oxygen hood.
• Positive pressure ventilation
  • If the baby continues to be blue and in respiratory distress (gasping or not breathing), with a heart rate below 100 BPM, positive pressure ventilation (PPV) is initiated. PPV maintains a continuous flow of air under stable pressure and helps inflate the airway and lungs, and stimulate breathing.
  • A continuous positive airway pressure (CPAP) device provides ventilation through a mask. The baby is evaluated after 30 seconds of PPV and if the baby’s respiration and heart rate continue to be depressed, the next steps are intubation and cardiopulmonary resuscitation (CPR).

CPR is initiated if the baby’s heart rate remains below 60 BPM after 30 seconds of PPV. CPR involves intubation, chest compressions and administration of medications that raise the heart rate.

Intubation

Intubation procedure involves inserting a thin flexible tube (endotracheal tube) into the infant’s trachea. The endotracheal tube helps keep the airway clear and open and delivers oxygen to the lungs directly. A newborn may require intubation in the following situations:

• Before starting chest compressions
• To suction the trachea directly
• Ineffective bag-mask ventilation
• Prolonged need for ventilation
• To administer medications
• Suspected congenital hernia in the diaphragm

Chest compressions

• After positive pressure ventilation (PPV) with intubation for 30 seconds, if the heart rate remains below 60 BPM, chest compressions are performed.
• Chest compressions are performed on the lower third of the breastbone (sternum) to a depth of approximately one-third of the anterior-posterior diameter of the chest. Compressions are delivered with thumbs on the sternum with the fingers encircling the chest.
• Ideally, the CPR cycle consists of three chest compressions to one breath from the ventilator at the rate of 90 compressions/30 breaths per minute. This is 3:1 ratio of compressions to ventilations comprises a single set of compressions/ventilations. After each set of 3 compressions/ventilations, the chest is allowed to fully re-expand with the ventilatory breath and exhalation takes place with the first compression of the next cycle.
• The baby’s respiration, heart rate and color are evaluated every 60 seconds and chest compressions are discontinued when the baby’s spontaneous heart rate goes (and remains) above 60 BPM.

Medications

Medications are administered if the baby’s heart rate remains below 60 BPM after 60 seconds of chest compressions and ventilation, while continuing with the next cycle of CPR. Currently recommended medications include:

• Epinephrine: To increase the heart rate and blood pressure.
• Saline solution: To increase the blood volume.
• O-negative packed red blood cells: To supplement red blood cells in the event of blood loss. 

The medications may be administered through the endotracheal tube into the lungs or intravenously through an umbilical catheter.

After completion of successful resuscitation, the newborn is continuously monitored to make sure the baby’s vital signs stay normal. Full-term babies who sustain spontaneous breathing and heart rates above 100 BPM with initial steps of resuscitation or supplemental oxygen are placed close to the mother and kept under observation.

Babies who are extremely premature and babies who undergo PPV and more extensive resuscitation will need post resuscitation care which may include the following:

• Once the lungs and heart start functioning, mechanical ventilation may be continued for a period. Babies requiring assisted ventilation for a prolonged period will be ventilated with humidified and heated oxygen until they can be weaned off assisted ventilation safely.
• Glucose, fluid and electrolytes levels are monitored and maintained with appropriate infusion of glucose and fluids to achieve a normal balance (homeostasis).
• Babies who require continued intensive care, extremely premature babies for instance, are moved to a remote neonatal intensive care unit for further care, placed in humidified incubators, and monitored closely with appropriate interventions as needed.

Many congenital and other conditions can lead to complications during neonatal resuscitation. Some of the main reasons for complications include:

Extreme prematurity

Extremely premature infants are fragile and vulnerable to injury because they are not fully developed. Low birth weight and underdevelopment puts premature babies at a greater risk for:

• Respiratory failure requiring extensive resuscitative measures and prolonged ventilation with its associated risks such as:
• Injury to the delicate trachea and lungs
• Fluctuations in cerebral blood flow

Complications because of a thin, immature skin, such as:

• High water and heat loss
• Increased risk for bacterial skin infections
• Toxic reactions to any skin applications
• Low blood glucose levels

Intraventricular hemorrhage (bleeding in the brain’s fluid-filled areas known as ventricles) and periventricular leukomalacia (brain tissue death from bleeding), because the brain’s blood vessels are not fully developed. These disorders can lead to permanent neurodevelopmental disabilities.

Airway problems

Airway problems include:

• Choanal atresia: Blocked nasal passage from incomplete fetal development.
• Pierre Robin syndrome: A condition in which a baby has a very small lower jaw resulting in displacement of the tongue, blocking the airway.
• Tracheal webbing: A web of tissue near the vocal cords blocking the airway.
• Esophageal atresia: A blind esophagus unconnected to the stomach. There are several types of this disorder with or without an abnormal connection to the trachea.
• Cystic adenomatoid malformation: Masses in the lung.
• Cystic hygromas: Congenital deformity of the lymphatic channels leading to accumulation of lymphatic fluid and compression of the airway.

Pulmonary compression

Conditions that cause pulmonary compression include:

• Congenital diaphragmatic hernia: Incomplete development of the diaphragm resulting in a hernia with abdominal organs pushing in and compressing the lungs.
• Pneumothorax and pneumomediastinum: Rupture of pulmonary tissue resulting in air leak in the space around the lungs or in between the lungs.

Other conditions

Other situations that can pose problems in the delivery room include the following:

• Multiple gestation: Multiple gestation infants are often premature and require adequate equipment and trained personnel during delivery.
• Hydrops fetalis: A condition in which fluid accumulates in the spaces around organs and compartments in the body. The fluid has to be removed as it can compromise lung and heart function.
• Gastroschisis and omphalocele: Gastroschisis is a defect in the abdominal wall near the umbilical cord and omphalocele is the herniation of abdominal organs which bulge out through the umbilical opening.
• Congenital anomalies: Severe malformations that can affect effective resuscitation.