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All newborn infants should be cared for by a team of expert physicians and other trained health care providers in the context of a family-centered environment. Individuals trained in neonatal resuscitation may be present in the delivery room and ready to perform timely resuscitation, if needed. Obstetricians are trained to manage key aspects of birth process, including protecting the maternal perineum and fetus from trauma and providing initial support to the newborn. Historically, the initial support for the newborn has included: suctioning the oronasopharynx; immediate clamping of the cord and providing 100% oxygen if resuscitation is necessary. The American Academy of Pediatrics (AAP) recently modified its recommendations on the initial support and alternated several practices, which are discussed in this review (1). At birth, infants are quickly stabilized and assessed to determine the level of care required. All infants undergo an identification process, and copies of maternal and newborn medical records are transferred from the obstetrical to neonatal care teams. Simple recommendations to patients during that transition period may save precious newborn lives. Given the paucity of data in the obstetrical literature, obstetricians and midwives are conceivably less comfortable addressing issues regarding newborn safety.
The purpose of this document is to provide education about current recommendations and guidelines regarding initial assessment and resuscitation of newborns, at or near term. Obstetricians develop relationships with patients over the course of 1 year, with frequent visits, and are in a unique position to provide advice and guidance during this period when patients are highly motivated to learn. The lack of education regarding the newborn state during the antepartum period is a missed opportunity for obstetrical-providers. The Women's Health and Education Center (WHEC) with its partners has launched the series on Newborn Care to disseminate updated literature and guidelines to the health care providers regarding newborn safety. Current guidelines are summarized in this segment. Each child and family are unique; therefore, these Recommendations for Preventive Health Care, in this review, are designed for the care of children who are receiving competent parenting, have no manifestations of any health problems, and are growing and developing in a satisfactory fashion. Developmental, psychological, and chronic disease issues for children and adolescents may require frequent counseling visits separate for preventive care visit. Additional visits also may become necessary if circumstances are different from normal.
Term (37 0/7 to 41 6/7 weeks of gestational age) and late-preterm infants (34 0/7 to 36 6/7 weeks of gestation age) are closely observed during the transition period, the first 4 to 8 hours after birth. Infants who are healthy and stable should remain with their mothers during this period. If possible, an infant should be placed naked on his or her mother's chest and allowed to breastfeed. The infant should be kept warm and assessed by a detailed clinical examination that includes intrauterine growth status, evaluation for gestational age, and a comprehensive risk assessment for neonatal conditions that require additional monitoring or intervention. Neonatal nutrition is ideally provided through breastfeeding. Initiation of breastfeeding should take place after birth, with continued monitoring of the breastfed newborn until discharge and thereafter by the newborn care provider. There are limited contraindications to breastfeeding. In the event breastfeeding is disrupted, breast milk should be collected and stored.
Preventive newborn care includes attention to hygiene; hepatitis immunization; and screening for genetic and metabolic conditions, hearing impairment, critical congenital heart disease, risk of hyperbilirubinemia, and developmental hip dysplasia. Targeted assessment of glucose homeostasis and possible sepsis are implemented on a discretionary basis, depending on individualized risk.
Delivery Room Care
Approximately 10% of term and late-preterm infants require some assistance to begin breathing that includes stimulation at birth; less than 1% will need extensive resuscitative measures. Although the vast majority do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births a sizable number of babies will require some degree of resuscitation. Recognition and immediate resuscitation of a distressed newborn infant requires an organized plan of action that includes the immediate availability of proper equipment and on-site qualified personnel. Anticipated newborn problems should be thoroughly communicated by the obstetric care provider to the responsible lead member of the resuscitation team.
Neonatal Resuscitation: Management Plan
Assessment and resuscitation of the newborn at delivery should be provided in accordance with the principles of guidelines for neonatal resuscitation. Most of the principles are applicable throughout the neonatal period and early infancy. Each hospital should have policies and procedures addressing the care and resuscitation of the newborn infant, including the qualifications of physicians and other health care practitioners who provide this care. The provision of services and equipment for resuscitation should be planned jointly by the medical and nursing directors of the departments involved in resuscitation of the newborn, usually the departments of obstetrics, pediatrics, and anesthesia. A physician, usually a pediatrician, should be designated to assume primary responsibility for initiating, supervising, and reviewing the plan for management of infants requiring resuscitation in the delivery room. The following issues should be considered in this plan (2):
- A prioritized list should be developed of known or anticipated maternal and fetal complications that would require routine, urgent, or emergent delivery. Individual(s) qualified in all aspects of newborn resuscitation should be present.
- The capabilities of individuals qualified to perform neonatal resuscitation should include the following:
- Ability to rapidly and accurately evaluate the newborn condition,
- Ability and authority to seek additional personnel and experts for immediate participation in newborn resuscitation,
- Knowledge of the pathogenesis of risk factors predisposing for the need for resuscitation (e.g. hypoxia, maternal medications, hypovolemia, trauma, anomalies, infections, and preterm birth), as well as specific indications for resuscitation,
- Skills in airway management, including bag and mask ventilation, use of a laryngeal mask airway, laryngoscopy, endotracheal intubation and suctioning of the airway, chest compressions, emergency administration of drugs and fluids, establishing emergency umbilical venous or intraosseous needle access, and maintenance of thermal stability,
- Although not required, skill in the recognition and decomp of a tension pneumothorax by needle aspiration is desirable.
- Procedures should be developed, and policies should be in place to ensure the readiness of equipment and personnel and to provide for periodic review and evaluation of the effectiveness of the system.
- Contingency plans should be created for multiple births, unusual and life-threatening maternal complications, and other unusual circumstances.
- Guidelines should be developed for documentation of the resuscitation, including the personnel involved, intervention or medication, and the response of the infant.
- Procedures should be developed and delineated for transfer of responsibility for care of the newborn.
Accurately defining and reporting perinatal deaths (i.e., fetal and infant deaths) is a critical first step in understanding the magnitude and causes of these important events. In addition to obstetrical health care providers, neonatologists and pediatricians should have easy access to current and updated resources that clearly provide nationally and internationally approved definitions and reporting requirements for live births, fetal deaths, and infant deaths. Correct identification of these vital events will improve local, state, and national data so that these deaths can be better addressed and prevented (3).
Delivery Room Assessment and Management
With careful consideration of risk factors, most infants who will need resuscitation can be identified before birth, although some infants without any apparent risk factors will require resuscitation. If the need for resuscitation is anticipated, additional skilled personnel should be recruited, and the necessary equipment prepared for immediate use.
All infants should have rapid assessment immediately after birth. Infants who are at risk of requiring interventions should have the initial steps of newborn care performed at a radiant warmer. These infants can be identified by asking three questions (4):
- Is the baby term (equal to or greater than 37 0/7 weeks of gestational age)?
- Does the baby have good muscle tone?
- Is baby breathing or crying?
If the answers to these questions are "yes", the infant should remain with the mother for the initial steps of newborn care. Observation of breathing, activity, and color should be ongoing. If the answer to any of these questions is "no", the infant should receive one or more of the following categories of action in sequence:
- Initial steps in stabilization (provide warmth, position to open the airway, clear airway if necessary, dry, stimulate breathing);
- Positive pressure ventilation, oxygen saturation monitoring, and supplemental oxygen, as needed;
- Chest compressions;
- Administration of epinephrine, or volume expansion, or both.
Approximately 60 seconds are allotted for a rapid assessment, completing the initial steps of newborn care, evaluating the baby's heart rate, and beginning positive pressure ventilation if required. The decision to progress beyond the initial steps is determined by simultaneous assessment of two vital characteristics:
- Respirations (apnea, gasping, labored or unlabored breathing)
- Heart rate (whether greater than or less than 100 beats per minutes).
Initial assessment of the heart rate should be performed using a stethoscope. Auscultation along the left side of the chest is the most accurate physical examination method of determining a newborn's heart rate. Although pulsations may be felt at the umbilical cord base, palpation is less accurate and may underestimate the true heart rate. If the heart rate cannot be determined by physical examination and the infant is not vigorous, another team member should quickly connect a pulse oximetry sensor or electrogram leads to the baby in order to evaluate the heart rate. If positive pressure evaluation is needed, assessment should consist of simultaneous evaluation of three vital characteristics:
- Heart rate,
- Respiration, and
- The state of oxygenation (the latter determined by a pulse oximeter).
The most sensitive indicator of a successful response to each step is an increase in heart rate.
Targeted preductal blood oxygen saturation (SpO2) after birth (5)
|Time in Minutes||SpO2 Levels|
|1 minute||60% to 65%|
|2 minute||65% to 70%|
|3 minute||70% to 75%|
|4 minute||75% to 80%|
|5 minute||80% to 85%|
|10 minute||85% to 95%|
Initial Steps of Newborn Care
Maintenance of Body Temperature
Immediately after delivery, the vigorous term infant should be placed skin-to-skin with the mother and dried. Then both mother and infant should be covered with a warm, dry blanket.
Infants born preterm, those without good muscle tone, and those who are not breathing, or crying should be placed under a preheated radiant warmer. The radiant warmer will reduce heat loss and allow easy access to the infant during resuscitation procedures. Preterm infants less than 32 weeks of gestation are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss. For this reason, additional warming techniques are recommended (e.g. pre-warming the delivery room to 26oC (78.8oF), covering the infant in plastic wrapping (food or medical grade, heat-resistant plastic), placing the infant on an exothermic mattress). The infant's temperature must be monitored closely because overheating has been described when plastic wrap is used in combination with an exothermic mattress. The goal should be an axillary temperature of approximately 36.5oC (97.7oF).
Clearing the Airway
When the newborn infant is vigorous, defined as strong respiratory effort and good muscle tone, routine oral or nasopharyngeal suctioning is not necessary. During the past half century, the first action a healthcare provider delivering the baby after delivering the fetal head was to perform oronasopharyngeal suctioning, using a bulb or DeLee device. The aim has been to remove secretions that might interfere with initial breathing by the newborn. Recent expert guidance, however, recommends that the healthcare provider cease this practice (6). Vigorous or deep suctioning of the posterior pharynx should be avoided because this may produce significant reflex bradycardia and may damage the oral mucosa, leading to interference with suckling because of pain.
For a healthy newborn suctioning appears to do more harm than good because it can cause cardiorespiratory complications. Given the lack of evidence of benefit, and evidence of potential harm, reserve suctioning for newborns who have obvious respiratory difficulty caused by secretions. If you determine that suctioning is required, perform gentle bulb suctioning of the mouth and nares with minimal stimulation of the posterior pharynx, which can cause a vagal response and bradycardia.
When meconium is present in amniotic fluid, evidence does not support routine intrapartum oropharyngeal or nasopharyngeal suctioning, as these interventions do not prevent or alter the course of meconium aspiration syndrome. Vigorous newborns who have been birthed through meconium-stained amniotic fluid do not need airway suctioning (7). If an infant is born through meconium-stained amniotic fluid and has depressed respirations or poor muscle tone, the infant should be placed under the radiant warmer and the initial steps of newborn care as aforementioned performed. If the baby is not breathing or the heart rate is less than 100 beats per minute (bpm) after the initial steps are completed, positive pressure ventilation should be initiated.
Clamping of Umbilical Cord
At birth, when a newborn is placed on the maternal abdomen or held below the vaginal introitus and the cord, according to new recommendations, is not clamped immediately. Approximately 25 mL of blood for every kilogram of birth weight is transfused from the placenta-cord into the newborn. Most of that transfusion occurs in the first 2 minutes after birth; in some infants, transfusion continues for as long as 5 minutes (8).
Autotransfusion significantly increases hemoglobin concentration in a newborn, it is notable that newborn obtains benefit from delayed clamping whether it has been placed on its mother's abdomen or held below the vaginal introitus - suggesting that gravity alone is not responsible for cord-to-newborn transfusion. Note: if you are concerned about waiting 1 to 5 minutes to clamp the cord because it might delay resuscitation of an infant, milking the cord four times appears to provide significant cord-to-fetus transfusion (9).
- An increase in red blood cell volume, with improvement in hemoglobulin concentration of approximately 2 to 5 g/L,
- An increase in serum ferritin level at 6 months of age,
- A diminished likelihood of being diagnosed with anemia in the first year of life.
- An increase in the risk of neonatal jaundice,
- An increase in the need for phototherapy,
- An increase in blood viscosity immediately after birth,
- Delayed administration of a postpartum uterine tocolytic.
In a healthy term infant who has access to good prenatal nutrition, the benefits of delayed cord clamping are likely limited to a modest increase in hemoglobulin concentration. The problem with delayed cord is an increased risk of jaundice and need for phototherapy (11).
Delayed clamping of the cord is likely to provide the greatest benefit to preterm newborns. In some studies, delayed clamping in very preterm infants (<32 weeks' gestation) reduced the incidence of intraventricular hemorrhage and late-onset sepsis. For example, in this study, 72 mother-infant were randomized to delayed cord clamping or immediate cord clamping, intraventricular hemorrhage occurred in 14% of infants in the delayed group and in 36% of the immediate-clamping group (12).
In some centers, umbilical cord blood is collected and stored in a public cord blood bank for use in a bone marrow transplantation program. Autotransfusion of blood from the cord to the newborn reduces the success rate of cord blood collection for public banking because fewer stem cells are obtained from a depleted cord.
Infants should be placed on their backs, with the neck slightly extended. This position (known as sniffing position) readily aligns the posterior pharynx, larynx, and trachea for optimal air entry. The infant's mouth nose may be wiped with a towel or suctioned gently to remove excess mucus or blood.
Drying provides enough tactile stimulation for most infants; however, if the infant does not have adequate respirations, briefly rubbing the back, trunk, or extremities may stimulate spontaneous respirations. If the infant does not respond to brief additional stimulation, positive pressure ventilation should be initiated. Prolonged stimulation of an apneic infant is not effective and delays the initiation of effective ventilation.
Administration of Supplemental Oxygen
The goal of resuscitation is to achieve a heart rate of at least 100 bpm and a preductal oxygen saturation value in the interquartile range for each minute after birth as measured in healthy term babies after vaginal birth at sea level (see the table 1). Among infants born greater than or equal to 35 weeks of gestation, published data indicate that positive pressure ventilation should be initiated with air (21% oxygen). Among infants born at less than 35 weeks of gestation, positive pressure should be initiated with an oxygen concentration between 21% and 30%. The oxygen concentration should be titrated, as needed to achieve an SpO2 in the target range. It is recommended that oximetry be used when resuscitation is anticipated, supplemental oxygen is administered, positive pressure is administered for more than a few breaths, or when cyanosis persists. Hyperoxemia and hypoxemia should be avoided. If blended oxygen is not available, resuscitation should be initiated with air.
Reduce the use of 100% oxygen (O2) during resuscitation (13). Use of 100% O2 may be associated with more harm than benefit when a newborn requires resuscitation. It may increase the level of free oxygen radicals, thereby damaging tissue. In fact, some studies report that use of 100% O2 is associated with an increased risk of neonatal mortality (13). When a newborn requires resuscitation, the recommendations are (1),(14):
- Initial resuscitation with blended O2, if this is not available, use ambient air,
- Adjust the O2 concentration to achieve SpO2 targets that are based on minutes-since-birth (see table 1),
- Use 100% O2 if the infant's heart rate is below 60 bpm at 90 seconds of resuscitation - but only until the heartbeat reaches a normal rate.
The normal newborn infant breathes within seconds of birth and usually has established regular respiration within 1 minute after birth. An infant who is apneic or is gasping or whose heart rate is less than 100 bpm requires positive pressure ventilation, which can be administered with a self- or flow-inflating bag or a T-piece resuscitator. Inflation and aeration in the infant's lungs is the single most effective intervention during neonatal resuscitation. For most infants, positive pressure ventilation is the only resuscitation maneuver required to establish regular respirations. Effective ventilation almost always results in improved heart rate. If the heart rate does not increase and there is no chest movement with ventilation, it is likely that the lungs are not being inflated and aerated. In this case, corrective steps, such as adjusting the mask, repositioning the head, opening the mouth, suctioning the oropharynx, increasing the pressure used to deliver breaths, or insertion of an alternative airway should be performed (15).
Endotracheal intubation may be performed at various points during resuscitation, depending on clinical circumstances. Indications for intubation include the following (16):
- Poor response to ventilation with mask and bag or T-piece resuscitator,
- The need to enhance coordination of ventilation and chest compressions are necessary,
- Direct tracheal suction if the airway is obstructed by thick secretions,
- Other possible indications for intubation include the need for surfactant administration, and suspected or known congenital diaphragmatic hernia.
Exhaled carbon dioxide detection is recommended method to confirm endotracheal tube placement; however, critically ill infants with poor cardiac output and poor or absent pulmonary blood flow may not exhale sufficient carbon dioxide to be detected reliably, and thus may give false-negative test results. As with bag and mask ventilation, effective assisted ventilation with an endotracheal tube should result in an increased heart rate. If the heart rate does not improve, esophageal intubation should be suspected.
If the heart rate does not increase about 60 bpm at least 30 seconds of effective ventilation, chest compression should be instituted while coordinated ventilation is continued using 100% oxygen. The two-thumb encircling hand technique is recommended (17). There should be a 3:1 ratio of compressions to ventilations, with approximately 90 compressions and 30 ventilations per minute. Pulse oximetry may not detect the infant's pulse; therefore, heart rate monitoring by ECG (electrocardiogram) is recommended if chest compressions are required. If the heart rate does not increase after 45 to 60 seconds of effective chest compressions, endotracheal intubation (if not already done) should be performed and epinephrine, preferably by the intravenous or intraosseous route, should be administered.
The use of medications during newborn resuscitation rarely is necessary. It should be considered only after effective ventilation and chest compressions have been established but the heart rate remains low. A list of drugs and volume expanders for resuscitation, with appropriate dosages, should be readily available, preferably in a prominent place in the resuscitation area.
- Epinephrine: It is indicated when the heart rate remains less than 60 bpm, despite adequate ventilation and chest compressions. The recommended dose is 0.1 to 0.3 mL per kg of a 1:10,000 solution (equal to 0.01 - 0.03 mg per kg) given as rapidly as possible through an emergently placed umbilical venous catheter or intraosseous needle (18). The efficacy of endotracheal epinephrine is unproven, and use of this route results in lower and unpredictable blood levels that may not be effective. Healthcare providers may choose to give epinephrine through the endotracheal tube while the umbilical venous catheter is being placed. If this route is used, administration of a higher dose (0.05 to 0.1 mg per kg, or 0.5 to 1 mL per kg of a 1:10,000 preparation) may be considered, but the safety and efficacy of this practice have not been evaluated. The higher dose should not be administered intravenously.
- Volume expanders: Routine volume expanders is not recommended during or after resuscitation. Volume expansion should be considered when an infant is not responding to resuscitation and blood loss is known or suspected. Normal saline (or type O Rh-negative packed red blood cells if fetal anemia is known or suspected) is recommended for volume expansion in the delivery room. The recommended initial dose if 10 mL per kg given over a span of 5 to 10 minutes through an emergently placed umbilical venous catheter or intraosseous needle, which may need to be repeated. Rapid transfusion of large fluid volumes should be avoided in preterm infants (18),(19).
- Naloxone: Administration of naloxone is not recommended as part of initial resuscitative efforts for infants with respiratory depression associated with maternal narcotic analgesia. Adequate support of ventilation should be sufficient to restore normal heart rate and oxygenation.
The Apgar score is useful for conveying information about the infant's over all status and response to resuscitation. However, resuscitation must be initiated before the 1-minute score is assigned. Therefore, the Apgar score is not used to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to use them. The score is reported at 1-minute and 5-minutes after birth for all infants, and at 5-minute intervals thereafter until 20 minutes for infants with a score less than 7. When an infant has an Apgar score of 5 or less at 5 minutes, umbilical artery blood gas from a clamped section of umbilical cord should be assessed, if possible.
The details about the Apgar score are reviewed and discussed in the next chapter.
Newborn in the Delivery Room
Immediately after delivery, the newborn infant must be assessed for individual needs to determine the best location for care. An infant with known or anticipated medical needs may be admitted to the special care nursery or neonatal intensive care unit (NICU) in the birth hospital or transferred to a hospital that provides the appropriate level of care (20).
A healthy-appearing newborn infant should remain with the mother. If the infant's condition is stable and the infant does not require further intervention, immediate and sustained skin-to-skin contact between the mother and her infant should be provided. Early, sustained skin-to-skin contact improves neonatal temperature stability and increases neonatal glucose levels. For mothers who have chosen to breastfeed, evidence from randomized controlled trial shows that skin-to-skin contact increases duration of breastfeeding by approximately 42 days (21). The nursing staff in labor, delivery, recovery, and postpartum areas should be trained in assessing and recognizing problems in the newborn and in assessing and assisting with breastfeeding. In most circumstances, the baby can be transported safely with the mother from the delivery to postpartum area.
Infants who require intervention in the delivery room are at risk of developing subsequent complications. Such infants, and infants at risk of developing neonatal abstinence syndrome, and should be evaluated frequently during the immediate neonatal period (22). These infants should be managed in an area where frequent vital signs can be obtained, and the nursing staff is familiar with the signs and symptoms of an infant who is in distress. Some of these infants may require transport to another hospital for a higher level of care.
Immediate plans for the newborn infant should be discussed with the parents or other support person(s), preferably before leaving the delivery room. Whenever possible, the parents should have the opportunity to see, touch, and hold the infant before transfer to another facility. The physician or other health care provider delivering the infant also should be advised to the status and plans for the infant, including potential transfer or admission to a special care nursery or NICU.
Parents should be active participants in the decision-making process concerning the treatment of severely ill infants. This approach requires honest and open communication. Ongoing evaluation of the condition and prognosis of the high-risk infant is essential, and the physician, as the spokesperson for the health care team, must convey this information accurately and openly to the parents of the infant.
Newborn Care Training and Perinatal Mortality in Developing Countries
Of the 3.7 million neonatal deaths and 3.3 million stillbirths each year, 98% occur in developing countries (23). An evaluation of community-based interventions designed to reduce the number of these deaths is needed. Without a major reduction in neonatal deaths in the first 7 days after birth, achievement of the United Nations' Sustainable Development Goal 4 - a reduction in mortality by two-thirds among children younger than 5 years of age - is unlikely to be realized. In areas of the world with high rates of home delivery, stillbirths are prevalent, but they are difficult to distinguish from early neonatal deaths (24). Therefore, examining both stillbirths and early neonatal deaths is important in an evaluation of perinatal programs that are designed to reduce mortality. Major global causes of perinatal mortality are asphyxia at birth, low-birth weight, and prematurity. Low-cost interventions, including training in neonatal resuscitation and "kangaroo" (skin-to-skin) care, may effectively reduce deaths from these causes. It has been estimated that introducing these interventions as a package might decrease perinatal deaths by 50% or more (25). A recent study that used a "before-and-after" implementation design showed that training in the World Health Organization (WHO) Essential Newborn Care Course improved midwives' skill and knowledge and reduced neonatal deaths in the first 7 days after birth among low-risk women who delivered in first-level clinics in Zambia (26). This systematic review of the literature suggests that perinatal mortality may be decreased by training birth attendants. Thus, wide-scale implementation and evaluation of evidence-based interventions are needed to improve perinatal outcomes, particularly in rural settings, where more than 50% of neonatal deaths occur.
This large, multicenter study conduced in rural communities in developing countries showed that training in and implementation of the Essential Newborn Care program were not associated with a decrease in the primary outcome of neonatal death (27). In this study, training birth attendants in Essential Newborn Care was not associated with a reduction in neonatal mortality but was associated with reduced rates of stillbirth; further training in neonatal resuscitation did not have significant effect on outcomes. These data suggest that training in basic neonatal care may have a role in improving perinatal outcomes in the developing world, although more work is needed to further reduce perinatal mortality.
A detailed clinical examination and assessment of the infant is performed by the clinical care team soon after birth and includes the following: evaluation of airway patency and skin color; auscultation of the heart and lungs; ascertainment of anal patency; assessment of muscle tone, level of consciousness, response to handling; measurement of vital signs (i.e. body temperature, heart rate, and respiratory rate); and measurement of head circumference, body length, and body weight. Each newborn infant must be kept warm during weighing. The scale pan should be covered with clean paper before each newborn is weighed. Additional targeted evaluations may include assessment of capillary refill, blood pressure, oxygen saturation, and need for supplemental oxygen. Obstetrical and neonatal medicine practices are evolving in ways that might surprise you. Obstetrical providers have a unique relationship with pediatric colleagues regarding the care of mother and her newborn. Simple recommendations to patients during the transition period may save precious newborn lives.
Suggested Reading and Resources
- World Health Organization (WHO)
- Partnership for Maternal, Newborn & Child Health (PMNCH)
- Every Newborn Action Plan
- Perlman JM, Wyllie J, Kattwinkel J, et al. Neonatal Resuscitation Chapter Collaborators. Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Pediatrics 2010;26(5)e1319-1344
- American Academy of Pediatrics, American Heart Association. Textbook of neonatal resuscitation. 7th ed. Elk Grove Village (Il): AAP; Dallas (TX): AHA; 2016
- Barfield WD. Standard terminology for fetal, infant, and perinatal deaths. Committee on Fetus and Newborn. Pediatrics 2016;137
- Benitz WE. Hospital stay for healthy term newborn infants. Committee on Fetus and Newborn, American Academy of Pediatrics. Pediatrics 2015;135:948-953
- Wyckoff MH, Aziz K, Escobedo MB, et al. Neonatal resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics 2015;136(suppl):S196-218
- Gungor S, Kurt E, Teksoz E., et al. Oronasopharyngeal suction versus no suction in normal and term infants delivered by elective cesarean section: a prospective randomized controlled trial. Gynecol Obstet Invest 2006;61(1):9-14
- Committee on Obstetric Practice; American College of Obstetricians and Gynecologists. ACOG Committee Opinion 379. Management of the delivery of a newborn with meconium-stained amniotic fluid. Obstet Gynecol 2007;110(3):739
- Farrar D, Alrey R, Law GR, et al. Measuring placental transfusion for term births: weighing babies with cord intact. BJOG 2011;118(1):70-75
- Rabe H, Jewison A, Alvarez RF. Brighton Perinatal Study Group. Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial. Obstet Gynecol 2011;117(2 Pt 1): 205-211
- Hutton EK, Hassan ES. Late versus early clamping of the umbilical cord in full term neonates: systematic review and meta-analysis of controlled trials. JAMA 2007;297(11):1241-1252
- McDonald SJ, Middleon P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev 2008;(2):CD004074
- Mercer JS, Vohr BR, McGrath MM, et al. Delayed cord clamping in very preterm infants reduces the influence of intraventricular hemorrhage and late-onset sepsis: a randomized controlled trial. Pediatrics 2006;117(4):1235-1242
- Tan A, Schulze A, O'Donnell CP, et al. Air versus oxygen for resuscitation of infants at birth. Cochrane Database Sys Rev 2005;(2):CD002273
- Rabi Y, Rabi D, Yee W. Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation 2007;72(3):353-363
- Atkins DL, Berger S, Duff JP, et al. Pediatric basic life support and cardiopulmonary resuscitation quality. Pediatrics 2015;136(suppl 2):S167-S175
- American Health Association Guidelines; 2015. Update for cardiopulmonary resuscitation and emergency cardiovascular care. Available at: http://pediatrics.aappublications.org/content/pediatrics/136/Supplement_2/S167.full.pdf Accessed on 2 January 2018
- March S, Tschan F, Semmer NK, et al. ABC versus CAB for cardiopulmonary resuscitation: a prospective, randomized simulator-based trial. Swiss Med Wkly 2013;143w13856. doi:10.4414/smw.2013.13856
- Sutton RM, French B, Niles DE, et al. 2010 American Health Association recommended compression depths during pediatric in hospital resuscitation are associated with survival. Resuscitation 2014;85:1179-1184
- American Academy of Pediatrics. Recommendations for preventive pediatric health care. Elk Grove Village (IL): AAP at https://www.aap.org/en-us/Documents/periodicity_schedule.pdf Accessed on 8 January 2018
- Insoft RM, Schwartz HP, Romito J, editors. Guidelines for air and ground transport of neonatal and pediatric patients. American Academy of Pediatrics. Section on Transport Medicine. 4th ed. Elk Grove Village (IL): American Academy of Pediatrics; 2015
- Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:423-428
- Asti L, Magers JS, Keels E, et al. A quality improvement project to reduce length of stay for neonatal abstinence syndrome. Pediatrics 2015;135:e1494-1500
- World Health Organization. Neonatal and perinatal mortality: country, regional and global estimates 2016. Geneva, Switzerland. Available at: http://www.who.int/gho/child_health/mortality/neonatal/en/ Accessed on 22 December 2017
- Stanton C, Lawn JE, Rahman HZ, et al. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006;367:1487-1494
- Haws RA, Thomas AL, Bhutta ZA, et al. Impact of packaged interventions on neonatal health: a review of the evidence. Health Policy Plan 2007;22:193-215
- Carlo WA, McClure EM, Chomba E, et al. Impact of World Health Organization (WHO) Essential Newborn Care Course (ENC) training: a multicenter study. Presented at the Annual Meeting of the Pediatric Academic Societies. Baltimore, May 2-5, 2009. Abstract
- Waldemar A, Carlo MD, Shivaprasad S, et al. Newborn care training and perinatal mortality in developing countries. N Engl J Med 2010;362:614-623
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