The newborn (particularly a preterm infant) responds paradoxically to hypoxia with apnea rather than tachypnea as occurs in adults. Episodes of intrauterine asphyxia also may depress the neonatal central nervous system. If recovery of the fetal heart rate occurs as a result of improved uteroplacental perfusion, fetal hypoxia and acidosis may resolve. Nonetheless, if the effect on the respiratory center is more severe, a newborn may not initiate an adequate ventilatory response at birth and may undergo another episode of asphyxia.
The Apgar examination, a rapid scoring system based on physiologic responses to the birth process, is a good method for assessing the need to resuscitate a newborn (Table 58-8).At intervals of 1 minute and 5 minutes after birth, each of the five physiologic parameters is observed or elicited by a qualified examiner. Full-term infants with a normal cardiopulmonary adaptation should score 8 to 9 at 1 and 5 minutes. Apgar scores of 4 to 7 warrant close attention to determine whether the infant’s status will improve and to ascertain whether any pathologic condition is contributing to the low Apgar score.
By definition, an Apgar score of 0 to 3 represents either a cardiopulmonary arrest or a condition caused by severe bradycardia, hypoventilation, or central nervous system depression. Most low Apgar scores are caused by difficulty in establishing adequate ventilation and not by primary cardiac pathology. In addition to an Apgar score of 0 to 3, most infants with asphyxia severe enough to cause neurologic injury also manifest fetal acidosis (pH <7); seizures, coma, or hypotonia; and multiorgan dysfunction. Low Apgar scores may be caused by fetal hypoxia or other factors listed in Table 58-7. Most infants with low Apgar scores respond to assisted ventilation by face mask or by endotracheal intubation and usually do not need emergency medication.
Resuscitation of a newborn with a low Apgar score follows the same systematic sequence as that for resuscitation of older patients, but in the newborn period this simplified ABCD approach requires some qualification (Fig. 58-2). In the ABCD approach, A stands for securing a patent airway by clearing amniotic fluid or meconium by suctioning; A is also a reminder of anticipation and the need for knowing the events of pregnancy, labor, and delivery. Evidence of a diaphragmatic hernia and a low Apgar score indicate that immediate endotracheal intubation is required. If a mask and bag are used, gas enters the lung and the stomach, and the latter may act as an expanding mass in the chest that compromises respiration. If fetal hydrops has occurred with pleural effusions, bilateral thoracentesis to evacuate the pleural effusions may be needed to establish adequate ventilation.
B represents breathing. If the neonate is apneic or hypoventilating and remains cyanotic, artificial ventilation should be initiated. Ventilation should be performed with a well-fitted mask attached to an anesthesia bag and a manometer to prevent extremely high pressures from being given to the newborn; 100% oxygen should be administered through the mask.
Yes, stay
Term gestation? Routine care
Breathing or crying?
Good tone?  Clear airway if necessary  Dry  Ongoing evaluation
Warm, clear airway if necessary, dry, stimulate
NoHR below 100,30 sec gasping, or apnea?
Yes Labored breathing or persistent cyanosis?
Yes No Clear airway SpO2 monitoringPPV, Consider CPAP Postresuscitation care HR below 100? Take ventilation corrective steps SpO2 monitoring
No HR below 60?
Consider intubation Chest compressions Coordinate with PPV Take ventilation corrective steps Intubate if no chest rise! HR below 60? IV epinephrine