the posterior pharynx, larynx, and trachea to facilitate air entry This maneuver may also be accomplished by placing a towel or blanket beneath the upper back of the supine infant Avoid flexion or hyperextension of the newborn’s neck, which is likely to exacerbate airway obstruction Suctioning If needed, clear secretions with a bulb syringe or suction catheter Many newborns have excessive secretions related to amniotic fluid, cervical mucus, or meconium Suctioning may cause bradycardia or apnea; additionally, excessive suctioning may contribute to atelectasis Therefore, suctioning is reserved for the newly born infant whose airway appears obstructed or if PPV is required Meconium-Stained Fluid Management of meconium-stained amniotic fluid has changed substantially over the last two decades Approximately 2% to 5% of infants born with meconium in the amniotic fluid will experience some degree of aspiration syndrome, ranging from mild tachypnea to very severe pneumonitis with persistent pulmonary hypertension ( Fig 9.18 ) Vigorous infants with good spontaneous respiratory effort and muscle tone who are born through meconium-stained amniotic fluid may receive routine postnatal care with the parents Gentle clearing of meconium from the mouth and nose may be accomplished with a bulb syringe Infants with inadequate respiratory effort and poor muscle tone should be moved to a radiant warmer bed and initial resuscitation steps initiated Begin PPV for apnea or HR less than 100/min following initial steps Routine intubation for tracheal suction in the setting of meconium-stained amniotic fluid is not recommended Appropriate intervention to support oxygenation and ventilation of these infants should be initiated as clinically indicated, and may include intubation and suction if the airway is obstructed FIGURE 9.18 Meconium aspiration radiograph Assessment of Heart Rate Use a 3-lead ECG for rapid and accurate assessment of heart rate during the resuscitation of term and preterm newborns Clinical assessment (auscultation of the precordium) with pulse oximetry used as an adjunct to provide noninvasive continuous assessment of HR during resuscitation has been shown to be unreliable and inaccurate Pulse oximeter use is be reserved for continuous evaluation of the newborn’s oxygenation Assessment of Need for Supplemental Oxygen Pulse oximetry should be used during resuscitation, during administration of PPV, when supplemental oxygen is administered, or when central cyanosis persists beyond the first to 10 minutes of life UMBILICAL CORD MANAGEMENT Evidence has emerged in recent years to suggest that delayed cord clamping (DCC) is favorable for newly born infants who not require immediate resuscitation Specifically, DCC is associated with less IVH, higher blood volume, higher blood pressure, less need for blood transfusion, and less necrotizing enterocolitis (NEC) To date, there is no evidence of decreased mortality; there is an association with slight increases in serum bilirubin level Based on the available evidence, the national recommendation is that DCC be practiced when possible, for no longer than 30 seconds, for both term and preterm infants who not require resuscitation at birth There is insufficient evidence to make recommendations on cord clamping for infants who require resuscitation Evidence on cord milking is insufficient to suggest routine use in newly born infants, and should be explicitly avoided in infants born at less than 29 weeks’ gestational age INTERVENTIONS Oxygenation and Ventilation Administration of Oxygen Recent studies have shown improved survival for newborns resuscitated with room air (21% oxygen at sea level) compared to 100% oxygen Titrate supplemental oxygen to achieve preductal SpO2 in the normal range values per minute-of-life, as described in Figure 9.17 This is applicable to the resuscitation of term as well as preterm infants Initiating resuscitation of preterm newborns with high oxygen (>65%) is not recommended, as data has not demonstrated benefit for the clinically important outcomes of IVH, bronchopulmonary dysplasia (BPD), or retinopathy of prematurity (ROP) Deliver warm, humidified oxygen when possible to maintain temperature Positive Pressure Ventilation If initial management interventions are unsuccessful and the newborn is still not breathing or is gasping, or the heart rate is less than 100 bpm, PPV must be initiated A flow-inflating or self-inflating bag may be used Studies suggest that addition of PEEP to resuscitation of newly born preterm infants does not lead to more rapid improvement in HR, reduced need for ET intubation or chest compressions, or improved mortality However, there is evidence to support decreased degree of supplemental oxygen necessary for resuscitation when using PEEP, therefore when PPV is administered to preterm newborns, the use of cm H2 O PEEP is suggested Success of ventilations is best judged by good chest wall rise and breath sounds and heart rate response An assisted ventilatory rate of 40 to 60 breaths/min will provide effective ventilation and oxygenation If BVM ventilation is required for longer than several minutes, an orogastric tube should be placed to decompress the stomach If respirations are restored and the heart rate is >100 bpm, PPV may be slowly discontinued If respirations remain inadequate or the HR 34 weeks’ gestational age, >2,000 g), particularly in cases ... chest wall rise and breath sounds and heart rate response An assisted ventilatory rate of 40 to 60 breaths/min will provide effective ventilation and oxygenation If BVM ventilation is required