What is the immediate management for a newborn with birth asphyxia?

Immediate Management of Birth Asphyxia

For a newborn with birth asphyxia, immediately dry and stimulate the infant while assessing breathing and heart rate within the first 60 seconds ("Golden Minute"), then promptly initiate positive-pressure ventilation if the infant is not breathing or has a heart rate below 100 bpm, as this is the single most critical intervention for survival. 1, 2

Initial Assessment and Stabilization (0-60 Seconds)

Upon delivery, rapidly evaluate three questions: Is the infant term gestation? Does the infant have good tone? Is the infant breathing or crying? 1, 3

• If any answer is "no," immediately move the infant to a radiant warmer for resuscitation 1, 3
• Simultaneously dry the infant vigorously and provide tactile stimulation (back rubbing or foot flicking) while maintaining temperature 1, 2
• Position the airway using head tilt-chin lift or jaw thrust maneuver with the head in "sniffing" position 1
• Attach pulse oximetry to the right upper extremity to guide oxygen management 2

Critical pitfall: Do not delay positive-pressure ventilation beyond 60 seconds while attempting prolonged tactile stimulation, as effective ventilation is the cornerstone of successful resuscitation 2, 3

Positive-Pressure Ventilation (If No Response After Initial Steps)

Begin PPV immediately if the infant has absent/gasping respirations, heart rate <100 bpm, or persistent labored breathing after initial steps 1, 2

Ventilation parameters:

• Start with room air (21%) or 21-30% oxygen, titrated by pulse oximetry 2
• Target oxygen saturations: 60-65% at birth, gradually increasing to 85-95% by 10 minutes 2
• If intubation is required: PIP 20-25 cmH₂O, PEEP 5 cmH₂O, rate 40-60 breaths/min 2
• Use exhaled CO₂ detection to confirm endotracheal tube placement 2

Critical pitfall: Avoid initiating resuscitation with 100% oxygen, as it provides no advantage over room air and may increase oxidative injury 2

Chest Compressions (If Heart Rate Remains <60 bpm Despite Effective Ventilation)

If heart rate stays below 60 bpm after 30 seconds of effective PPV, initiate chest compressions 1, 2

• Use the 2-thumb, hands-encircling-the-chest method 2
• Compress the sternum at the lower third, approximately one finger's breadth below the nipple line 1
• Depth of compression: approximately 3 cm 1
• Rate: 100 compressions per minute 1
• Maintain 3:1 compression-to-ventilation ratio (90 compressions and 30 breaths per minute) 2

Medication Administration (If Heart Rate Remains <60 bpm Despite Ventilation and Compressions)

Administer epinephrine if heart rate remains below 60 bpm despite adequate ventilation and chest compressions 1, 2

• Epinephrine dose: 0.01-0.03 mg/kg IV (preferred route) 2
• Consider volume expansion with normal saline 10 mL/kg if signs of hypovolemia are present 2

Post-Resuscitation Care

Once spontaneous circulation is restored, focus on preventing secondary injury 1, 2

• Initiate therapeutic hypothermia within 6 hours of birth for moderate to severe hypoxic-ischemic encephalopathy under clearly defined protocols 1, 2
• Continuously monitor heart rate (most sensitive indicator of resuscitation efficacy), oxygen saturation, blood pressure, and neurological status 2
• Avoid routine hyperventilation, as it can decrease cerebral blood flow 1, 2
• Control temperature to prevent hyperthermia 1
• Transfer to neonatal intensive care unit for multidisciplinary management 2

Critical pitfall: Do not delay therapeutic hypothermia when indicated, as the window for neuroprotection closes after 6 hours 2

Key Monitoring Parameters

• Heart rate is the most sensitive indicator of effective resuscitation 2
• Do not rely on color assessment; use pulse oximetry instead 2
• Assess for complications including transient myocardial ischemia (check ECG for T wave inversions or abnormal Q waves), tricuspid/mitral regurgitation, and persistent pulmonary hypertension 4