Special circumstances

1.9. Resuscitation in special circumstances

The extremely preterm infant less than 28 weeks’ gestation

Extremely premature infants are at risk of hypothermia:

• Extremely preterm infants should be placed immediately after birth into a polyethylene bag (food grade, heat resistant) or polyethylene wrap/sheet whilst still wet and warm.

• When using a polyethylene bag, the infant’s entire body should be in the bag, which is then zip locked up.
• The infant’s head should be left outside the bag or wrap.  Dry the  head well and place a woollen hat onto the infant’s head.

• Placing an extremely premature infant into a polyethylene bag or wrap effectively reduces heat loss during resuscitation and should be the standard of care.

Infants born before 28 weeks’ gestation will usually require some form of respiratory support:

• Infants born in tertiary perinatal centres may be given CPAP from birth via a mask and/or nasal prongs. Some will require intubation and ventilation.

• Extremely premature infants who require ex-utero transfer to a tertiary NICU may require intubation to protect their airway during transport, especially for air transport and transport over long distances.

Suspected fetal haemorrhage

• An infant who is pale, with poor perfusion and weak pulses, who fails to respond to resuscitation measures may be hypovolaemic secondary to blood loss.

• Although blood loss following a placenta previa, vasa previa or placental abruption will predominately be maternal, even a small fetal haemorrhage can result in significant hypovolaemia in the fetus.

• Following birth, these infants may not respond to standard resuscitation measures until they have received fluid resuscitation.

• After attention to establishing an airway and ensuring adequate ventilation and oxygenation, an infant with suspected blood loss should receive a rapid infusion of 20mL/kg of Rh O negative uncross- matched blood.

• Newborns who have lost a significant proportion of their blood volume may require several rapid infusions of 20mL/kg of Rh O negative blood before beginning to respond.

Suspected upper airway obstruction

Upper airway obstructions may present at birth and may not have been diagnosed antenatally.

• Choanal atresia should be suspected in an infant who is pink when crying but becomes cyanotic when their mouth is closed (e.g during breast feeding) or during quiet periods.

• Newborns with Pierre Robin Sequence (micrognathia, cleft palate, posterior displacement of the tongue) tend to obstruct their airway when laying supine as their tongue flops backwards, therefore:

• • • An oro-pharyngeal airway (Guedel) may be used
    • Nursing the infant prone can help to prevent the tongue obstructing the airway
    • Some infants will require intubation, which can be difficult

• Infants with cranio-facial abnormalities may obstruct their airway to such an extent that intubation or laryngeal mask is required. Intubation can be very difficult in such infants.

Suspected pneumothorax

• Use of excessive pressure during positive pressure ventilation can result in a pneumothorax, especially in preterm infants when high pressures continued to be used beyond the first few positive pressure inflations.

• Bradycardia, chest recession, tachypnoea, deceased breath sounds on one side of the chest or bulging of the chest wall on one side may indicate a pneumothorax.

• While transillumination of the chest may reveal increased lucency on the affected side, a chest X-ray must be performed for a definitive diagnosis.

• A severely compromised newborn may require immediate needle aspiration of the chest (thoracentesis) but generally it is best to confirm the pneumothorax by chest X-ray before undertaking thoracentesis.

Suspected congenital heart disease (CHD) or persistent pulmonary hypertension of the newborn (PPHN)

• Newborn infants who remain cyanosed despite adequate ventilation, oxygenation and circulation may have congenital heart disease associated with decreased pulmonary blood flow (previously referred to as “cyanotic heart disease”) or persistent pulmonary hypertension of the newborn (PPHN).

• These two conditions can be difficult to differentiate clinically. Improvement in pre-ductal oxygen saturation readings above 95 -100% following the administration of oxygen usually indicates that duct dependant congenital heart disease is less likely to be the cause of cyanosis.

• Intubation is not always indicated in a cyanotic newborn in whom CHD is suspected. If the infant has a heart rate above 100 bpm, does not have increased or laboured work of breathing and is well perfused, intubation is not indicated.

• Newborn infants with suspected CHD or PPHN require echocardiographic evaluation by a Paediatric Cardiologist and as such, should be referred to the neonatal retrieval team (In Victoria, contact PIPER) as early as possible after birth for stabilisation advice and will require transport to a tertiary centre.

Multiple births

• Multiple births are at higher risk in terms of requiring resuscitation as they are more likely to be premature and more likely to have abnormalities of cord blood flow (e.g. twin to twin transfusion) and abnormalities of placental function.

• Each infant requires their own resuscitaire and their own resuscitation team. If the infants are premature or at high risk of requiring resuscitation, then each infant should have a person with advanced resuscitation skills attend their birth.

Antenatal diagnosis of congenital diaphragmatic hernia (CDH)

• Immediate intubation in the birth room should be performed to minimise air entry into the gastrointestinal tract that can occur in a spontaneously breathing infant or when positive pressure ventilation is provided via a face mask.

• A wide bore oro-gastric tube (Fg 8 or Fg 10) should be inserted to decompress the small bowel and to minimise lung compression from air in the gastrointestinal tract.

• Extreme care must be taken not to over-ventilate these infants.

The infant who appears to be stillborn

• An infant who is born without a detectable heart rate should be intubated immediately after birth.

• Higher inflation pressures (higher PIP) may be required for the first few inflations as the lungs will be fluid filled.

• External chest compressions should be provided and adrenaline administered if positive pressure ventilation via the endotracheal tube does not result in a rapid increase in heart rate.

ANZCOR suggest:

” In a newly born baby, it is appropriate to consider stopping resuscitation if the heart rate is undetectable and remains so for 10 minutes, because both survival and quality of survival deteriorate precipitously by this time” (ANZCOR, 2016, Guideline 13.10).

• Please read the following page: Discontinuation and/or withdrawal of resuscitation efforts for further guidelines regarding discontinuation of resuscitation efforts in an infant who appears to have been stillborn.