What is the next intervention for a full-term newborn with persistent bradycardia despite initial resuscitative efforts, including epinephrine (adrenaline) IV, chest compressions, and endotracheal intubation, in the context of maternal hemorrhage?

Administer Repeat Dose of Epinephrine IV

The next intervention is epinephrine IV (Option D), administered at 0.01-0.03 mg/kg, given every 3-5 minutes when heart rate remains below 60 bpm despite ongoing adequate ventilation and chest compressions. 1

Rationale for Repeat Epinephrine

This newborn has already received one dose of epinephrine IV but continues to have profound bradycardia (heart rate 48 bpm) with signs of shock (pallor, weak pulses). The 2020 International Consensus on Cardiopulmonary Resuscitation explicitly recommends administering further doses of epinephrine every 3 to 5 minutes, preferably intravascularly, if the heart rate remains less than 60/min. 1

• The intravenous route is strongly preferred over endotracheal administration because IV epinephrine achieves higher plasma concentrations more rapidly and results in shorter time to return of spontaneous circulation (ROSC). 1
• The recommended IV dose remains 0.01-0.03 mg/kg per dose, with 0.02 mg/kg being a practical middle-ground dose that works across a wide range of birth weights. 2
• Higher IV doses (>0.03 mg/kg) are not recommended and may be harmful, as pediatric data suggest increased mortality risk without improved long-term survival. 1, 3

Why Not the Other Options?

Blood transfusion (Option C) would be the appropriate choice if there were clear evidence of ongoing or severe blood loss causing hypovolemic shock. While this infant's birth was complicated by maternal hemorrhage, the immediate priority is addressing the persistent bradycardia with repeat epinephrine. 1

• Volume expansion with blood products is indicated when there is documented blood loss and the infant is not responding to resuscitation. 1
• However, epinephrine takes precedence when heart rate remains <60 bpm despite adequate ventilation and chest compressions. 1, 4
• If the infant fails to respond to repeat epinephrine doses, then blood transfusion should be strongly considered given the maternal hemorrhage history. 1

Albumin IV (Option A) is not recommended as a first-line intervention. Current guidelines suggest that in the absence of documented blood loss, there is limited evidence of benefit from volume administration during resuscitation unresponsive to chest compressions and epinephrine, with some animal studies suggesting potential harm. 1

Atropine IV (Option B) has no role in neonatal resuscitation. Neonatal bradycardia during resuscitation is caused by inadequate lung inflation and hypoxemia, not vagal tone or primary cardiac pathology. 4, 5

Critical Clinical Algorithm

1. Continue chest compressions and ventilation with 100% oxygen using 3:1 compression-to-ventilation ratio. 4
2. Administer repeat IV epinephrine 0.01-0.03 mg/kg (preferably 0.02 mg/kg) immediately. 1, 2
3. Reassess heart rate after 60 seconds of continued resuscitation. 4
4. If heart rate remains <60 bpm, repeat epinephrine every 3-5 minutes while continuing compressions and ventilation. 1
5. Consider volume expansion (10 mL/kg normal saline or O-negative blood) if no response after 2-3 doses of epinephrine, especially given maternal hemorrhage history. 1

Common Pitfalls to Avoid

• Do not delay repeat epinephrine while preparing for blood transfusion or other interventions—time is critical for survival and neurologic outcomes. 1, 5
• Do not use high-dose IV epinephrine (>0.03 mg/kg), as this increases mortality risk without improving outcomes. 1, 3
• Ensure ventilation is truly adequate before each epinephrine dose—inadequate ventilation is the most common reason for failed resuscitation in newborns. 4, 5
• Verify IV access is functioning before each dose to ensure intravascular delivery rather than extravasation. 1