Delayed Intubation & Neonatal Resuscitation Errors
Infants that are not breathing or struggling to breathe at birth may require resuscitation, intubation, or surfactant therapy. The term resuscitation refers to a revival from a state of unconsciousness; in some cases, the infant may appear to be dead prior to resuscitation. Intubation is the process of inserting a tube into the trachea (through the mouth or nose) to maintain an open airway. The tube can also be attached to a ventilator. Surfactant is a substance that is produced by the lungs. If an infant does not have enough surfactant, doctors will need to administer surfactant therapy. This will allow the lungs to properly expand and take in oxygenated air. Delays in performing resuscitative measures, intubation, or surfactant therapy can result in devastating consequences. Moreover, mistakes made while attempting resuscitation, intubation, and surfactant therapy can vastly increase the risk that a baby will have severe health issues. These procedures require highly trained personnel, who should be present at high-risk births in case there is an emergency.
Most infants transfer from life inside the womb to life outside without the need for any special assistance. However, about 10% of babies need some intervention, and 1% will require extensive resuscitative measures at birth. Thus, medical personnel who are properly trained should be readily available to perform neonatal resuscitation at every birthing location, whether or not problems are anticipated. Preterm infants are more likely to require resuscitation and develop complications from it, compared to term infants. If a preterm birth is anticipated and time permits, the mother should be transferred to a perinatal center (a center that specializes in high-risk births) prior to delivery.
A delay in performing any of the resuscitative maneuvers described below can result in the baby being deprived of oxygen and adequate blood flow. This can cause damage to the baby’s organs, including the heart and brain. Insufficient oxygen or blood in the brain can cause permanent brain damage, such as hypoxic-ischemic encephalopathy (HIE), cerebral palsy, damage to the white and gray matter of the brain, periventricular leukomalacia (PVL), hydrocephalus caused by an intraventricular hemorrhage, and seizure disorders.
Indeed, early intervention is crucial when a baby needs resuscitation. Respiratory distress can lead to cardiopulmonary arrest (the baby “codes” – heart and breathing stop). The progression is as follows:
- Respiratory distress
- Respiratory failure/shock
- Cardiopulmonary failure
- Cardiopulmonary arrest
Factors Associated with High-Risk Delivery
Infants who are at risk for needing resuscitation can be identified by certain risk factors, as well as the presence of complications that occurred during pregnancy or labor and delivery. Medical personnel (including physicians) who are adequately trained and skilled in neonatal resuscitation should be present at every high-risk birth. In addition, equipment for resuscitation should be present at the birth as well.
Risk Factors Present During Birth
- Delivery with instruments (forceps and vacuum extractor use, C-section delivery)
- Non-reassuring fetal heart rate patterns
- Asphyxia (oxygen deprivation) occurred during labor or delivery with abnormal fetal heart rate pattern
- Foul-smelling or meconium stained amniotic fluid (sign that a baby might have inhaled meconium, which is a mixture of amniotic fluid and stool)
- Mother baby has chorioamnionitis (infection of the placenta and fetal membranes)
- Mother has a systemic (affecting the entire body) infection, such as Group B Strep (GBS) or staph infection
- Abnormal presentation of the baby, such as breech, face, or transverse lie presentation
- Bleeding from the uterus/placenta
- Baby had a prolapsed umbilical cord
- Premature labor
- Mother had narcotic administration within 4 hours of birth
- Complications associated with maternal medical disease, such as active herpes simplex virus (HSV)
Risk Factors Pertaining to Fetal Condition
- Baby is premature
- Baby is past due date (postmature)
- Multiple babies (twins, triplets, etc.)
- Intrauterine Growth Restriction (IUGR)
- Macrosomia (large baby)
- Certain diseases present at birth/congenital anomalies, such as a heart defect, hydrocephalus (fluid in the brain) or spina bifida.
Risk Factors During Pregnancy
- Placental anomalies, such as placenta previa
- Oligohydramnios (low fluid in the womb)
- Polyhydramnios (too much fluid in the womb)
Risk Factors Associated with Maternal Condition
- Age > 40 years
- Age < 16 years
- Poor socio-economic status (poverty, malnutrition)
- Detrimental habits (smoking, drug and/or alcohol use)
- Diabetes, hypertension (high blood pressure), chronic heart and/or lung disease, kidney disease/urinary tract infections (UTIs), blood disorders (such as anemia and thrombocytopenia)
- Serious infection during pregnancy, such as group B strep (GBS), herpes simplex virus (HSV), bacterial vaginosis (BV), or staph infection
- Prior fetal loss or early neonatal death
- Prior birth of a high-risk infant
- Hemorrhage (sudden and severe bleeding during pregnancy)
- Premature rupture of membranes (PROM)
Neonatal Resuscitation: Steps
If a premature birth is anticipated, a pre-warmed incubator and polyethylene bags and wraps should be available to keep the baby warm. A physician skilled in placing breathing tubes (intubation) in very small babies must be present, and equipment for surfactant delivery should be available.
If the baby has good tone and is breathing and crying, resuscitation is not necessary at the time, and routine care can be given.
If the baby fails to exhibit any one of these traits, she should be warmed, her airway should be cleared if necessary, and she should be dried and stimulated.
Scenario 1: heart rate is below 100 beats per minute (bpm)
Emergency intervention must be initiated if after being stimulated, etc, the baby exhibits the following signs:
- The baby fails to breathe, cry, and have good tone
- The baby’s heart rate is below 100 bpm
- The baby is gasping, with periods of apnea (breathing cessation)
When these signs occur in the baby, the physician must immediately start positive pressure ventilation (PPV). In PPV, medical personnel place a mask over the baby’s nose and mouth, attach a bag that is filled with air, and squeeze the bag so that air is pushed into the baby’s lungs. Sometimes this type of PPV is referred to as “bagging.”. PPV is a method of breathing for the baby, and once this is started, a pulse-oximeter must be placed on the baby’s skin. A pulse oximeter is a non-invasive device that continuously reads the level of oxygen in the baby’s blood so medical personnel can see how well the baby is oxygenating.
Once PPV is initiated (and anytime a baby is at risk for needing resuscitation), the baby’s heart rate and breathing (respiratory rate) should be assessed every 30 seconds. In addition, the baby’s lungs should be listened to and watched; the medical personnel should make sure each side of the chest is rising equally.
If, after initiation of PPV, the baby’s heart rate remains below 100, corrective ventilation corrective steps should be taken.
When performing ventilation corrective steps, medical personnel should:
- Adjust the mask on the face
- Reposition the head to ensure an open airway. Re-attempt PPV.
If not effective,
- Suction the mouth and nose.
- Perform PPV with the baby’s mouth slightly open and the jaw lifted forward.
If not effective,
- Gradually and cautiously increase bagging pressure every few breaths, making sure there are bilateral (equal) breath sounds and visible chest movement.
If not effective,
- Consider airway alternatives, such as an endotracheal (ET) tube connected to a ventilator, or a laryngeal mask airway.
If the ventilation corrective steps are not effective and the baby’s heart rate is below 60 bpm, chest compressions should be performed, and these should be coordinated with PPV. In most cases, the baby should be intubated at this point. Intubation allows a ventilator to breathe for the baby (this is another form of PPV).
If the heart rate remains below 60 bpm, a drug called epinephrine should be administered through an IV. This drug stimulates heart action and increases blood pressure.
Scenario 2: baby’s heart rate is above 100 bpm, and she is not gasping or apneic
If the baby’s heart rate is above 100 bpm and she is not gasping or having apneic periods (after she has been stimulated, etc.), she should be assessed to determine if her breathing is labored and/or she is cyanotic (skin is a blueish color, meaning her body isn’t getting enough oxygen). If the baby has laborious breathing or she has persistent cyanosis, her airway should be cleared again, close monitoring with the pulse-oximeter must take place (pulse-ox should already be in place for a high-risk baby), and continuous positive airway pressure (CPAP) should be considered (described below).
If CPAP fails to achieve adequate oxygenation and ventilation (movement of air in and out of lungs, which can be measured by carbon dioxide level in the blood), or the baby has labored breathing and/or a lot of apneic periods with decrease in heart rate, the baby should be intubated, in most cases. The goal is to intubate the baby before she is in full respiratory/ventilatory failure. Medical personnel must watch for impending respiratory/ventilatory failure.
Neonatal Resuscitation Issues and Procedures
Signs of Impending Respiratory/Ventilatory Failure
- Severe work of breathing. Baby looks as though she is working hard to breathe. Examples include the use of breathing muscles that aren’t normally used (accessory muscles) and chest retractions (airway appears to be going in instead of expanding out during inspiration)
- Irregular breathing or apnea
- Cyanosis despite oxygen delivery
- Altered level of consciousness
- Diaphoresis (sweating)
Respiratory/ventilatory failure is the inability of the airway and lungs to meet the metabolic demands of the body, including the brain.
Respiratory failure, or hypoxic respiratory failure, is inadequate oxygenation. This occurs when the baby can’t get enough oxygen in; there is not enough oxygen in the blood/tissues. This is called hypoxemia/hypoxia.
Ventilatory failure, or hypercarbic respiratory failure, is inadequate ventilation. This means that the baby can’t get the carbon dioxide out of her body (out of her blood), so the blood becomes acidic (low pH), in most cases. Excess carbon dioxide is called hypercapnia or hypercarbia.
Signs of Respiratory/Ventilatory Failure
- Increase in respiratory rate
- Decrease in respiratory rate accompanied by increasing effort or increasing retractions
- Prolonged apnea with cyanosis, bradycardia (slow heart rate), or both
- Cyanosis not relieved by oxygen administration
- Hypotension (low blood pressure), pallor (pale color, meaning low oxygen in blood), decrease in peripheral perfusion (inadequate blood going to extremities)
- Tachycardia (fast heart rate) leading to bradycardia (slow heart rate)
- Gasping, and the use of accessory respiratory muscles
- Periodic breathing with prolonged respiratory pauses
- Abnormal blood gas results. By analyzing the baby’s blood (blood from an artery is best), the physician can see how much oxygen and carbon dioxide are in the baby’s blood, as well as the pH of the blood. The oxygen and carbon dioxide levels show how well the baby is oxygenating and ventilating (breathing), and the pH shows how acidic the blood is. Blood acidity is usually due to high levels of carbon dioxide, but pH can be affected by non-breathing factors, such as problems with the kidneys.
- In respiratory failure, the oxygen level is low and the carbon dioxide level is normal or low. In ventilatory failure, the oxygen level is low.
- The distinguishing factor between respiratory failure and ventilatory failure is that in ventilatory failure, the carbon dioxide level is too high.
Intubation and Mechanical Ventilation
If the baby has signs of impending respiratory/ventilatory failure, she should be intubated, in most cases. If signs of actual respiratory/ventilatory failure are present, the baby must be intubated immediately.
Intubation may also need to occur in infants that experienced a face presentation birth and have severe swelling in the upper airway. Failure to intubate when severe swelling and edema are present may cause a baby to lose her airway. In addition, children who aspirated (inhaled) meconium before or during birth may also be more likely to have respiratory/ventilatory failure.
Intubation is the placement of a flexible tube (ET tube) into the trachea (windpipe) to maintain an open airway. The tube can be placed through the nose and into the trachea, or, more commonly, through the mouth and into the trachea.
Indications for Intubation
- Baby’s heart rate is still slow after PPV (bagging)
- Apneas and bradycardias
- Baby has most of the signs of impending respiratory/ventilatory failure
- Baby is in respiratory/ventilatory failure
- If there are a lot of secretions in the airway that require frequent suctioning, intubation usually should be performed.
- Almost all babies that have aspirated meconium and are non-vigorous should be intubated.
Risks and Complications of Intubation
- Intubation should be done very quickly – in less than 20 seconds – because while the tube is being placed, the baby is not being ventilated, and the oxygen level and heart rate can drop dangerously low.
- If the physician doing the intubation does not have specialized training in airway management or is not careful, the tube could be placed into the esophagus instead of the trachea.This means all the air from bagging or the ventilator will be going into the baby’s stomach instead of the lungs, and the baby will be getting no oxygen. This could have catastrophic consequences, such as a stomach tear, brain damage, and death. To help prevent an esophageal intubation and help ensure that the tube is in the airway, an attachment that detects carbon dioxide should be placed at the end of the ET tube right after the baby is intubated.The tube may also be misplaced into the right upper airway, which means only the right lung will be ventilated. This can lead to collapse of the left lung, overinflation of the right lung, and in some cases, the baby may develop a pneumothorax. This also can cause oxygen deprivation, brain damage, and even death.
Watching chest movement and listening with a stethoscope for breath sounds on both sides of the chest is a way of ensuring proper placement of the tube. A quick, bedside chest x-ray can verify placement.
*Other complications include the following: damage or spasm of the trachea and upper airway, constriction of airways, vocal cord injury, bradycardia, hypotension, vomiting and inhalation of vomit.
Positive Pressure Ventilation (PPV) with a Bag (Bagging)
When a baby needs help breathing, she will either be intubated or given a mask. PPV with a bag is a procedure in which a cylindrical, inflatable bag (sometimes called an ambu bag, resuscitation bag, or bag valve mask) is attached to the baby’s ET tube or mask, and medical personnel breathe for the baby by squeezing the bag. This forces air into the baby’s lungs. When a baby cannot breathe on her own, this is a temporary method of breathing for her. Bagging is the method of breathing for a baby during an emergency situation, such as during CPR, or while waiting to place the baby on a ventilator. The medical team can determine how much oxygen goes to the baby through the bag; room air can be used, or the oxygen can be turned all the way up to 100%. (100% is always an approximation – it is difficult to actually get 100%, even when only oxygen is flowing into the bag.)
More recently, hospitals are using a device called a Neopuff that attaches to the baby’s mask or ET tube (instead of a bag). Thus, instead of the volume of air going to the baby being controlled by a team member’s hand, a T-piece and tubing is attached to the baby’s mask. The end of the tubing is attached to a machine that shows how much pressure is going to the baby’s lungs each time a breath is delivered. A breath is delivered simply by using a finger to push down on the T-piece.
Indications for Bagging
- If, after the baby is suctioned, she has a slow heart rate and is either apneic or having difficulty breathing.
- If attempted intubation is prolonged and unsuccessful, especially if there is a persistent bradycardia.
- If chest compressions are performed during CPR.
- If the baby starts to deteriorate (there is a drop in heart rate, blood pressure, and/or oxygen level, and/or a big increase in carbon dioxide level).
Risks and Complications of Bagging
- If the mask is not tightly sealed (this can happen if it does not fit properly), ventilation will be ineffective.
- With a mask, there is a chance of a lot of air going to the baby’s stomach.
- Bagging can cause a baby to inhale vomit into her lungs (aspiration) if she vomits while being bagged.
- It is easy to breathe too much or too little for the baby since bagging is done by hand, and is not controlled by a machine. This is why it is essential to keep track of the rate and volume of breaths, and to monitor the oxygen and carbon dioxide in the blood.
- If the breaths given are too big, this could cause damage to the baby’s lungs.
- Air might get trapped in the baby’s lungs if not enough time is given in between breaths (for exhalation).
When performing chest compression on an infant, two or three fingers are used to gently press down on the center of the baby’s chest to help push blood through the heart and surrounding vessels. When chest compressions are combined with bagging, it is called CPR (cardiopulmonary resuscitation). The goal is to restore spontaneous breathing and blood circulation, and to provide partial flow of oxygenated blood to the brain so that the tissue doesn’t die and brain damage doesn’t occur or is minimized. Medications are sometimes given during CPR to try and help restore the baby’s breathing, heart function, and circulation. The longer a baby is deprived of sufficient oxygen and blood flow, the greater the chance of severe problems, including brain damage and death. It is essential that the medical team initiate CPR quickly and skillfully when it is indicated.
Indications for Chest Compressions
Chest compressions are indicated when the baby’s heart rate is less than 60 bpm despite adequate assisted ventilation (PPV with the mask or ET tube, or on the ventilator) for 30 seconds.
Risks and complications of Chest Compressions
If chest compressions and CPR are not done with skill, the baby could have a bruised heart and broken rib and chest bones, which could puncture the lungs and liver. If bagging is done too forcefully, air may build up in the stomach, which puts pressure on the lungs. In addition, the baby could vomit and the vomit could be pushed into the baby’s lungs by the bagging, which can cause lung damage, problems oxygenating, and pneumonia.
Defibrillation is a process in which an electronic device sends a shock to the baby’s heart to restore the normal heart rhythm.
Indications for Defibrillation
- Defibrillation is performed to correct life-threatening fibrillations (rapid, ineffective heart rhythms) of the heart, which could result in cardiac arrest. It should be performed immediately after identifying that the baby is experiencing a cardiac emergency, has no pulse, and is unresponsive.
- Fibrillations cause the heart to stop pumping blood, leading to brain damage and/or cardiac arrest. About 10% of the ability to restart the heart is lost with every minute that the heart stays in fibrillation. Death can occur in minutes unless the normal heart rhythm is restored through defibrillation. Medications to treat possible causes of the abnormal heart rhythm may be administered.
Risks and Complications of Defibrillation
Defibrillation should not be performed on a baby who has a pulse or is alert, as this could cause a lethal heart rhythm disturbance or cardiac arrest.
Drugs are rarely indicated in newborn resuscitation. Slow heart rate is usually the result of poor lung inflation or serious oxygen deprivation, and establishing good ventilation is the most important step toward correcting it. However, if the heart rate remains less than 60 bpm despite adequate ventilation and 100% oxygen and chest compressions, Epinephrine and blood pressure and volume expansion (blood volume) drugs may be indicated.
- Epinephrine: This drug increases the volume of blood pumped out by the heart per minute. Too much epinephrine can cause exaggerated increase in blood pressure, decreased heart function, and poor brain function.
- Volume expansion (blood volume) drugs: Actual blood or volume expansion drugs, which increase the amount of the blood in the baby, should be considered when blood loss is known or suspected (pale skin, weak pulse) and the baby’s heart rate has not responded adequately to other resuscitative measures. Care should be taken in giving this treatment to premature infants because rapid infusion of large volumes have been associated with brain bleeds/intraventricular hemorrhages.
The administration of oxygen can mean the difference between life and death of the baby. Without it, permanent organ damage and/or organ failure can occur.
Indications for Supplemental Oxygen
As with all resuscitation procedures, the medical team must follow guidelines and target ranges for oxygen levels in the baby to ensure that the baby gets enough oxygen into the blood, but not so much that it can cause damage. In fact, initial resuscitation efforts should be done using regular air, and oxygen should be added only if the baby’s oxygen saturation falls below the target range.
Risks and Complications of Supplemental Oxygen
- In premature babies or babies with low birth weight, too much oxygen can cause permanent damage to the baby’s delicate eyes, called retinopathy of prematurity (ROP).
- 100% oxygen can displace the nitrogen in the lungs, which can cause collapse of the small airways (atelectasis). This lung collapse can cause air to be trapped in the lungs. It also can cause problems getting oxygen into the bloodstream and the rest of the baby’s body.
- Excessive oxygen may also cause inflammation and swelling in the lungs, and it can cause damage to the cells.
A premature baby often has difficulty breathing, and one of the common causes of this is respiratory distress syndrome (RDS). In RDS, the baby’s immature lungs don’t produce enough surfactant. Surfactant allows the inner surface of the lungs to expand properly. When a baby’s lungs aren’t mature, the physician should administers 3 doses of surfactant within 72 hours. The first dose is usually given immediately after birth, or shortly after breathing problems are revealed. Surfactant therapy works amazingly well, and has been shown to substantially reduce mortality and respiratory morbidity in premature infants. Indeed, RDS can cause many problems that can cause oxygen deprivation, which is why it is crucial for this condition to be properly treated.
This is the process of putting a tube into the baby’s trachea and applying suction pressure to draw out or aspirate the mucus and secretions that are in the upper airway. Physicians use a special ET tube with a suction catheter attached that is made especially for suctioning meconium when an infant has suffered meconium aspiration.
Indications for Suctioning
- Immediately after delivery, the physician inserts a tiny tube/suction catheter into the baby’s trachea and suctions the trachea for no longer than 5 seconds. If meconium is retrieved and the heart rate isn’t too slow, this should be repeated. If the heart rate is lower than 60, the physician should not keep suctioning. The medical team should bag the baby, and try again later.
- Suctioning prevents meconium and other secretions that are in the large, upper airways from being inhaled deep into the lungs. Meconium causes multiple lung complications. Airway secretions, mucus, and meconium in the lungs can lead to pneumonia, prevent oxygen from getting into the baby’s bloodstream and tissues, and block the baby’s upper airway.
Risks and Complications of Suctioning
- The potential benefits of suctioning the trachea must be weighed against the need for other resuscitation maneuvers, such as quickly securing the baby’s airway (making sure the ET tube is in place and secure) and administering breaths to the baby. While the baby is being suctioned, she is not receiving any breaths or oxygen; in fact, suctioning usually decreases the baby’s oxygen level. Keeping the oxygen level up is very important for an already compromised baby. Heart rate and the oxygen level of the baby must be closely monitored during suctioning.
- Suctioning for too long can add to the baby’s respiratory distress.
- Suctioning can also cause a very slow – even dangerously slow – heart rate, as well as airway irritation/constriction.
When resuscitation procedures are started, it is crucial to monitor the baby’s temperature, blood pressure, heart rhythm and rate, as well as the oxygen level in the blood.
- Pulse Oximetry: Pulse oximetry is a method of continuously monitoring the baby’s oxygen level. A sensor is placed on the baby’s finger or toe, and a wire connects this sensor to a machine that continuously displays the oxygen level in the baby’s arterial blood. There are many things that can interfere with the accuracy of this, and pulse oximetry is not very accurate when the baby’s blood flow is compromised, as in a situation in which a baby needs resuscitation.
- Umbilical Arterial Catheter: An umbilical artery catheter (UAC) allows blood to be taken from the baby at different times, without repeated needle sticks. It is used to continuously monitor the baby’s blood pressure, and to draw arterial blood that shows the baby’s oxygen level and important things about the way the lungs and kidneys are functioning. This is the most accurate way to measure the oxygen, carbon dioxide, and pH levels of the baby’s blood. This catheter should be placed in the baby immediately after birth if there is any suspicion that the baby could have heart or breathing problems.
- Blood Pressure Cuff: If there is no UAC, a machine connected to a small blood pressure cuff wrapped around the baby’s arm or leg can be used to measure blood pressure. The cuff automatically takes the baby’s blood pressure at regular times and displays the numbers on a screen.
- Cardiopulmonary Monitor: In most cases, the baby should have a cardiopulmonary monitor, which is a machine that tracks the baby’s heart and breathing rates. It is connected to the baby by small adhesive monitoring pads placed on the chest. A monitor displays information on the screen, which can be printed onto paper.
CPAP is a non-invasive method used to help a baby breathe. Physicians typically try CPAP before they move to the invasive method of ventilatory support, intubation. With CPAP administration, the baby wears a special mask or nasal prongs. A machine delivers continuous pressure to keep the baby’s lungs open. CPAP maintains low pressure expansion of lungs during inspiration and expiration when the baby is breathing spontaneously. The baby has to initiate all breaths with regular CPAP. Forms of CPAP such as non-invasive positive pressure breathing (NPPV) give the baby a set amount of full breaths (breaths that the baby does not have to initiate) to give the baby even more help breathing.
Benefits of CPAP
- Improves oxygenation
- Maintains lung volume
- Lowers upper airway resistance (makes it easier to breathe)
- Conserves surfactant and reduces fluid build up in the lungs
Indications for CPAP
- Early onset respiratory distress in preterm infants (<34 weeks gestation) with good respiratory effort
- Can be helpful in respiratory distress in infants of >34 weeks gestation, especially with clinical features of RDS.
- Recurrent apnea in preterm infants
- Atelectasis (collapsed parts of the lungs [collapsed alveoli]).
Many premature infants suffer from a condition called apnea of prematurity (AOP). This is when a baby has apneic episodes, which are periods of breathing cessation that last for about 15 – 20 seconds or more. Often, the apnea is accompanied by a drop in heart rate and oxygen level in the baby’s blood and body. AOP is caused by immature respiratory control; receptors in the brain that control the baby’s drive to breathe are immature and not properly working. In addition, an immature baby may also not be able to maintain airway patency. One characteristic of having an airway that is not patent is collapse of the airway due to poor upper airway muscle tone.
Premature infants can start having apneic episodes very soon after birth. Thus, it is crucial that physicians monitor for AOP and promptly initiate AOP treatment. Indeed, a severe apneic episode (or episodes) can cause a baby to “crash” and require resuscitation. PPV and caffeine are important in the treatment of AOP. PPV by CPAP (or intubation and mechanical ventilation if indicated) help keep the airway open/patent. Caffeine helps the brain’s receptors respond appropriately to factors that cause a baby (and all people) to take a breath. For example, in a mature, healthy brain, a build-up of carbon dioxide in the blood alerts the brain to tell the baby to take a breath. A premature baby may not respond to carbon dioxide build-up (or to other signs that tell a baby to take a breath), which will cause the baby’s breathing to stop for a period. Caffeine helps the baby’s brain respond to carbon dioxide and other factors that tell the brain and body to breathe. Even if a baby is intubated and getting a lot of support from the ventilator (which will eliminate apneic episodes), research shows that caffeine decreases the length of time a baby will have to remain on the ventilator.
In fact, caffeine can be given prophylactically, before a baby even has apnea. Research isn’t clear if this early use of caffeine actually prevents apnea. It may prevent apneic episodes, but what is clear is that early use of caffeine is associated with lower rates of lung problems, such as bronchopulmonary dysplasia (BPD). In addition, caffeine lowers the risk of patent ductus arteriosis (PDA), which is when the ductus arteriosis, a major blood vessel, doesn’t close after birth as it should. Research also indicates that caffeine may reduce the effects of hypoxia (low oxygen in the blood and tissues) on white matter brain injury. PDA and BPD can both cause significant oxygenation problems and hypoxia. Experts recommend prophylactic use of caffeine in all extremely low birth weight infants (birth weight < 1,000 grams) to avoid intubation and mechanical ventilation.
Delayed Intubation, Neonatal Resuscitation Mistakes and Medical Malpractice
It is essential that the medical team be skilled in resuscitative procedures. Slow or improper performance of these procedures – and failure to perform procedures when indicated – can cause the baby to be critically deprived of adequate oxygen and blood flow. Seconds matter during resuscitation, and deprivation of oxygen and blood can lead to disability and permanent brain injuries, such as HIE, cerebral palsy, PVL, and IVH with resultant hydrocephalus. The type and severity of the brain damage depends on many factors, including how long the baby was deprived of adequate blood flow and oxygen. Accurate monitoring of the baby’s vital signs and medical status also is critical.
If a physician and/or medical team fail to quickly and appropriately carry out resuscitation procedures when indicated, it is negligence. If medical personnel fail to follow other standards of care, which include having necessary equipment readily available, it is negligence. If this negligence leads to injury in the baby, it is medical malpractice.
Award-Winning Birth Injury Attorneys Helping Children with Injuries from Neonatal Resuscitation Mistakes
Reiter & Walsh ABC Law Centers was established to focus exclusively on birth injury cases. Since the firm’s inception in 1997, our legal team has handled a number of cases involving neonatal resuscitation errors and their related birth injuries. We’ve helped clients across the United States receive compensation for lifelong care. Many of our clients have come from Michigan, Ohio, Tennessee, Wisconsin, Arkansas, Mississippi, Washington D.C., Texas, Pennsylvania, and other states.
If you suspect your baby experienced neonatal resuscitation mistakes and your child now has seizures, HIE, brain damage, cerebral palsy, or any other long-term condition, contact Reiter & Walsh today in any of the following ways:
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Related Reading on Resuscitation Errors, Birth Injury and Medical Malpractice
- Labor and delivery errors and cover-ups: how to identify them and get help
- The link between cerebral palsy and birth asphyxia (oxygen deprivation)
- Fernandes CJ. Neonatal resuscitation in the delivery room. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
- Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S909.
- American Academy of Pediatrics. Overview and principles of resuscitation. In: Textbook of Neonatal Resuscitation, 5th ed, Kattwinkel J (Ed), American Academy of Pediatrics, 2006.
- Jukkala AM, Henly SJ. Provider readiness for neonatal resuscitation in rural hospitals. J Obstet Gynecol Neonatal Nurs 2009; 38:443.
- Chien LY, Whyte R, Aziz K, et al. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol 2001; 98:247.
- Batton DG, Committee on Fetus and Newborn. Clinical report–Antenatal counseling regarding resuscitation at an extremely low gestational age. Pediatrics 2009; 124:422.
- Kattwinkel J, Perlman JM, Aziz K, et al. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010; 126:e1400.
- Perlman JM, Wyllie J, Kattwinkel J, et al. Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010; 126:e1319.