What the Anesthesiologist Should Know before the Operative Procedure

The anesthesiologist and newborn resuscitation

Guidelines from national professional organizations clearly state that the anesthesiologist responsible for the anesthetic care of the pregnant woman during a cesarean delivery is not responsible for care of the newborn, including newborn resuscitation. These organizations include the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), and the American Heart Association (AHA). The following statements illustrate this point.

  • “At every delivery, there should be at least one person in the delivery room who can be immediately available to the baby as his or her only responsibility and who is capable of initiating resuscitation, including administration of positive pressure ventilation and assisting with chest compressions. Either this person or someone else who is immediately available to the delivery area should have the necessary additional skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications. It is not sufficient to have someone “on call” (either at home or in a remote area of the hospital) for newborn resuscitations in the delivery room. When resuscitation is needed, it must be initiated without delay” (AAP/AHA, 2011).

  • “Personnel, other than the surgical team, should be immediately available to assume responsibility for the resuscitation of the depressed newborn. The surgeon and anesthesiologist are responsible for the mother and may not be able to leave her to care for the newborn, even when a neuraxial anesthetic is functioning adequately.” (ASA, 2010)

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  • “Qualified personnel, other than the anesthesiologist attending the mother, should be immediately available to assume responsibility for resuscitation of the newborn. The primary responsibility of the anesthesiologist is to provide care to the mother. If the anesthesiologist is also requested to provide brief assistance in the care of the newborn, the benefit to the child must be compared to the risk to the mother” (ASA, 2010).

  • “Recognition and immediate resuscitation of a distressed neonate requires an organized plan of action and the immediate availability of qualified personnel and equipment. Responsibility for identification and resuscitation of a distressed neonate should be assigned to a qualified individual, who may be a physician, certified nurse midwife, advanced practice neonatal nurse, labor and delivery nurse, nurse anesthetist, nursery nurse, physician assistant, or respiratory therapist. 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, anesthesia and pediatrics. A physician, usually a pediatrician, should be designated to assume primary responsibility for initiating, supervising, and reviewing the plan for management of newborns requiring resuscitation in the delivery room” (AAP/ACOG, 2007).

This information highlights the responsibility of each health care institution with obstetric services to develop and periodically review a plan for newborn resuscitation, and that the anesthesiology department should have input into this process. The absence of an institutional newborn resuscitation plan has been the basis of successful civil litigation in the past. The most important aspect for each anesthesiologist is to read the local newborn resuscitation plan before an emergency occurs so that his or her role is clear.

Overall, in-hospital resources may vary widely between institutions, but this does not excuse the institution from maintaining the appropriate equipment and expertise at all times. Rapid response teams are gaining popularity in many clinical areas to enhance patient safety. For institutions with limited in-hospital neonatology coverage, this may be an opportunity to develop a newborn rapid response team. Some institutions have a dedicated phone line or an “emergency button” in their OB operating rooms to bring additional help for newborn resuscitation.

Newborn resuscitation is an ethical conflict for an anesthesiologist who is asked to care for two patients at the same time (mother and newborn), in different areas of an operating room during a cesarean delivery. The anesthesiologist’s first responsibility is already underway, the anesthesia care of the mother. The second potential responsibility is the time-sensitive emergency involving the newborn. The stress is increased by the natural tendency of anesthesiologists to assist during unexpected emergencies of any type.

If you are the sole anesthesia provider in the operating room and your assistance is needed by the medical practitioner responsible for newborn resuscitation, I suggest that you immediately do three things:

  • Ask the clinician who is with the newborn to immediately wheel the infant warmer and the mother to your location, so that you can take care of both patients side-by-side.

  • Call for help, as described by your institutional newborn resuscitation plan.

  • While you are helping with the newborn, explain to the mother and any visitors that you want to help but are not ethically allowed to leave the mother.

If you are supervising a resident or CRNA during a cesarean delivery and the mother is stable, it should be relatively easy to briefly assist with newborn resuscitation. However, as above, it is important to call for help as soon as any significant problem arises with newborn resuscitation. A request for your assistance usually indicates a significant problem.

Overview of newborn resuscitation

At term, approximately 90 percent of newborns will transition from the intrauterine to extrauterine environments without any additional assistance. Ten percent of term newborns will need brief ventilatory assistance, and 1% will require more extensive resuscitation techniques.

The current AHA recommendations for newborn resuscitation are summarized in the flow diagram in Figure 1. AAP and AHA, The Textbook of Neonatal Resuscitation (2011, 6th ed.) is the core resource for information on neonatal resuscitation techniques and equipment. It should be available for review by clinical personnel in all obstetric units.

Figure 1.

Newborn Resuscitation Algorithm. (American Heart Association, 2010)

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Basic clinical physiology in newborn resuscitation

Neonatal bradycardia is a stress response, with hypoxemia as the most common cause. Hypoxemia may be a primary problem from the intrauterine environment, with exacerbation by postdelivery hypoventilation. In the absence of additional information, neonatal bradycardia is assumed to be secondary to inadequate oxygen delivery.

Neonatal apnea that does not respond rapidly to normal postdelivery stimulation is secondary apnea that will require clinical intervention such as clearing of the airway, CPAP, or positive pressure ventilation.

The neonatal oxygen saturation normally changes significantly over the first 10 to 15 minutes after birth, as shown in Figure 2. This information is necessary for optimal clinical care, so that supplemental oxygen therapy can be adjusted to mimic normal physiology. The clinical convention is to measure preductal oxygen saturation with a pulse oximetry probe on the right hand or wrist. Several studies have shown that the postdelivery oxygen saturation transition is slightly slower after cesarean delivery and in preterm infants than after vaginal delivery.

Figure 2.

Pre- and post-ductal oxygen saturation by pulse oximetry during the first 15 minutes after birth. (from Mariana G, et al. J Pediatr 150:418-21, 2007)

2. Preoperative evaluation

Clinical evaluation in newborn resuscitation

The clinical evaluation of the newborn should follow the newborn resuscitation algorithm shown in Figure 1. The main clinical parameters are respirations, heart rate, and preductal pulse oximetry (or skin color if pulse oximetry is not available). For neonatal heart rate, the thresholds for clinical decision making are 100 and 60 bpm.

A scoring system for neonatal clinical status was developed and validated by anesthesiologist Virginia Apgar in 1953. The Apgar scoring system is based on five neonatal clinical parameters; heart rate, respiration, muscle tone, reflex irritability, and color. Each parameter can have a score of 0, 1, or 2 for a total Apgar score between 0 and 10.These parameters are assessed at 1 and 5 minutes after birth, with additional scores at 5-minute intervals if clinical events remain unstable. It is a tribute to Dr. Apgar that this scoring system remains in widespread use throughout the world today. An expanded Apgar score form that incorporates information from neonatal resuscitation has been recommended by AAP and ACOG (Figure 3).

Figure 3.

Expanded Apgar Score form (from AAP/ACOG).

The current recommendation from AAP and AHA is to not use the Apgar score as the clinical decision tool for neonatal resuscitation, primarily because of concerns about delaying immediate evaluation and therapy in the first minute after delivery.The Apgar score remains as an important communication tool between members of the neonatal care team. Everyone who participates in neonatal care should be familiar with the Apgar scoring system.

Special circumstances in newborn resuscitation

1. Meconium: The presence of meconium-stained amniotic fluid raises the possibility of meconium in the upper airway and subsequent pulmonary morbidity from the meconium aspiration syndrome. Historically, the clinical recommendations were to suction, immediately after delivery, the trachea of any infant born with meconium-stained amniotic fluid.

These clinical guidelines have changed, based on subsequent clinical research. The current recommendations are based on the initial clinical condition of the newborn. A vigorous newborn, delivered in the presence of meconium-stained amniotic fluid, requires only observation and expectant care. A depressed newborn delivered with meconium-stained amniotic fluid should NOT receive immediate positive-pressure ventilation. Instead, this infant should have immediate endotracheal intubation with suctioning via the endotracheal tube as it is withdrawn from the airway. This is repeated until the trachea is clear of meconium, followed by positive-pressure ventilation by mask or endotracheal tube.

It is important to remember that this sequence of events balances the risk of meconium aspiration syndrome against continued delay of ventilation in a neonate who already may be hypoxemic and acidotic. Therefore, the endotracheal suctioning should be conducted by the most experienced member of the newborn resuscitation team to avoid unnecessary additional delays in neonatal ventilation.

2. Preterm neonates: Preterm infants pose additional challenges in newborn resuscitation:

a. Extra emphasis on prevention of hypothermia is required.

b. Utilize the same postductal oxygen saturation targets but anticipate slightly slower post-delivery increases and the necessity of slightly higher fractional concentrations of inhaled oxygen.

c. Avoid the head-down position,

d. Avoid rapid IV volume expansion.

e. Consider pulmonary surfactant administration via an endotracheal tube.

f. Consider CPAP (4-6 cm H2O).

3. Percutaneous umbilical blood sampling (PUBS): PUBS is an intrauterine diagnostic and/or therapeutic technique, performed by obstetricians under ultrasound guidance. The major current indications for PUBS are immune-mediated fetal hemolytic disease or assessment of possible fetal thrombocytopenia. A needle is inserted through the maternal abdominal wall and the amniotic fluid, until the tip of the needle is within the umbilical vein, usually near the junction of the umbilical cord and the placenta. To avoid the needle moving within the umbilical cord, the obstetrician may inject a nondepolarizing muscle relaxant directly into the umbilical vein to minimize subsequent fetal movements during the procedure.

If an urgent cesarean delivery is necessary during or shortly after the PUBS procedure, the infant will be born with significant but time-limited neuromuscular weakness from the nondepolarizing muscle relaxant. The neonatal resuscitation team should be informed of this situation and it should anticipate endotracheal intubation of the neonate with ventilatory support until the medication effect resolves spontaneously or is reversed pharmacologically.

Newborn surveillance after resuscitation

A newborn who responds quickly and easily from primary or secondary apnea after delivery should be able to have routine postdelivery care, as long as the clinical condition remains stable.

Any infant who requires extensive newborn resuscitation should be continuously observed after delivery, until examined by a credentialed pediatric care provider, who will decide on the appropriate next level of care.

3. What are the implications of co-existing disease on perioperative care?


b. Cardiovascular system


c. Pulmonary


d. Renal-GI:


e. Neurologic:


f. Endocrine:


g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)


4. What are the patient's medications and how should they be managed in the perioperative period?


h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?


i. What should be recommended with regard to continuation of medications taken chronically?


j. How To modify care for patients with known allergies –


k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.


l. Does the patient have any antibiotic allergies? [Tier 2- Common antibiotic allergies and alternative antibiotics]


m. Does the patient have a history of allergy to anesthesia?


5. What laboratory tests should be obtained and has everything been reviewed?


Intraoperative management: What are the options for anesthetic management and how to determine the best technique?

Equipment for newborn resuscitation

All institutions that provide obstetric care are required to provide and maintain adequate equipment for neonatal resuscitation, based on state and national accreditation standards. This equipment is reviewed in detail in AAP and AHA, Textbook of Neonatal Resuscitation (2011, 6th ed.). In general, anesthesiologists are very experienced in all aspects of airway management including equipment. The following information should serve as a reminder about airway management in neonates.

1. There are three commonly available positive-pressure ventilation devices in neonatal resuscitation:

a. Self-inflating bag: Does not require compressed gas source to fill the bag, but usually does not have free flow of oxygen through the distal opening for blow-by supplementation.

b. Flow-inflating bag: Similar to the bag on a Mapleson or standard anesthesia circuit.

c. T-piece resuscitator (usually less familiar to anesthesiologists).

2. Positive-pressure ventilation bags for neonates should have a volume in the range of 200 to 750 mL.

3. Oxygen-air blender: Important for controlling inspiratory oxygen concentration (see below). If possible, keep the total gas flow at 5 liters/minute or less to minimize heat and moisture losses.

4. Uncuffed endotracheal tube sizes for neonates are estimated based on body weight and gestational age, with a usual range of inner diameters from 2.5 to 4.0 mm.

5. The LMA for term neonates is a size 1.

I strongly recommend that you familiarize yourself with the specific neonatal resuscitation equipment provided by your institution, prior to an emergency situation. In particular, if a T-piece resuscitator is in use, you need to know how to adjust the peak inspiratory pressure, PEEP, and the maximum pressure relief valve. There may be institutional guidelines on some of these settings. Also, the oxygen-air blender is similar to the flowmeters on an anesthesia machine, but you should be familiar with the overall apparatus to facilitate troubleshooting in an emergency.

6. What is the author's preferred method of anesthesia technique and why?

Treatment in newborn resuscitation

Treatment follows the newborn resuscitation algorithm in Figure 1. The table on the right side of Figure 1 shows preductal oxygen saturation targets for term infants during the first 10minutes after delivery. “Ventilation is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn . . . regardless of the concentration of oxygen being used” (AAP/AHA).

Recent studies and guidelines support the use of room air as the initial gas for positive-pressure ventilation of the depressed newborn, with a stepwise increase in fractional inspired oxygen titrated to preductal oxygen saturation as measured by pulse oximetry. As discussed earlier and as illustrated in Figure 1 and Figure 2, the expected preductal oxygen saturation normally increases over the first ten minutes after delivery from 60%-65% to 85%-95%.

When providing positive-pressure ventilation, it is important to minimize the risk of barotrauma by utilizing normal tidal volumes and keeping the peak airway pressure in a safe range. This cannot be emphasized enough because unexpected involvement in newborn resuscitation may be a stressful situation for the anesthesiologist and result in large and vigorous tidal volumes. The usual tidal volume for a neonate is 10 to 25 mL or 4 to 6 mL/kg. Ideally, initial peak airway pressures should be less than 20 cm H2O, but effective ventilation may require higher peak pressures for the initial few breaths.

When choosing between effective ventilation and peak airway pressure levels, effective ventilation is the most important issue. The goal of effective positive pressure ventilation is a neonatal heart rate above 100 bpm.

Chest compression techniques are discussed in detail in AAP and AHA, Textbook of Neonatal Resuscitation (2011, 6th ed.). In general, neonatal chest compressions are indicated when the neonatal heart rate remains below 60 bpm despite effective positive-pressure ventilation. This level of newborn resuscitation requires at least two individuals, one for the chest compressions and one to continue positive-pressure ventilatory support by mask or endotracheal tube. The recommended rate of resuscitation is 90 chest compressions and 30 breaths per minute.

If the neonatal heart rate remains below 60 bpm despite effective chest compressions and positive-pressure ventilation, the next step is epinephrine therapy. The guidelines no longer recommend epinephrine administration via an endotracheal tube. Instead, an umbilical vein catheter should be placed and epinephrine administered IV as 0.1 to 0.3 mL/kg of a 1:10,000 epinephrine solution.

CAUTION: The usual epinephrine solution in adult anesthetizing locations has a concentration of 1:1,000 or 1 mg/mL. This is ten times more concentrated than the appropriate epinephrine solution for newborn resuscitation (1:10,000). The techniques for umbilical vein catheter placement and safe positioning are reviewed in detail in the Textbook of Neonatal Resuscitation (2011, 6th ed.).

Continued lack of response to these resuscitation measures may be followed by IV volume expansion, with a crystalloid such as normal saline or lactated Ringer’s solution. The recommended volume is 10 mL/kg over 5 to 10 minutes.

a. Neurologic


b. If the patient is intubated, are there any special criteria for extubation?


c. Postoperative management

Newborn surveillance after resuscitation

A newborn who responds quickly and easily from primary or secondary apnea after delivery should be able to have routine postdelivery care, as long as the clinical condition remains stable.

Any infant who requires extensive newborn resuscitation should be continuously observed after delivery, until examined by a credentialed pediatric care provider, who will decide on the appropriate next level of care.

What's the Evidence?

Textbook of Neonatal Resuscitation. 2011. (This is the definitive textbook with updated information on all clinical aspects of newborn resuscitation. It is the text for the Neonatal Resuscitation ProgramTM, an educational product of the AAP/AHA.)

(Comments on newborn resuscitation, from the national professional organization for anesthesiologists in the United States.)

(Additional comments on newborn resuscitation, from the national professional organization for anesthesiologists in the United States.).

Guidelines for Perinatal Care. 2007. pp. 205-15. (Comments on newborn resuscitation, from the national professional organizations for pediatricians and obstetricians in the United States.)

Kattwinkel, J, Perlman, JM, Aziz, K. “Part 15: Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation an Emergency Cardiovascular Care”. Circulation . vol. 122. 2010. pp. S909-19. (The newborn resuscitation section of the overall cardiopulmonary guidelines in 2010, a joint product of AAP/AHA.)

Dawson, JA, Kamlin, COF, Vento, M. “Defining the reference range for oxygen saturation for infants after birth”. Pediatrics. vol. 125. 2010. pp. e1340-7. (One of several studies measuring the normal increase in preductal oxygen saturation in the first 10 minutes after delivery. Additional subpopulations in this study include cesarean vs. vaginal deliveries, and term vs. preterm infants.)

Apgar, V. “A proposal for a method of evaluation of the newborn infant”. Curr Res Anesth Analg. vol. 32. 1953. pp. 260-7. (The landmark work of Dr. V. Apgar, a pioneer and hero in OB anesthesia.)

“The Apgar score: Committee Opinion No. 333”. Obstet Gynecol . vol. 107. 2006. pp. 1209-12. (A recent committee opinion from ACOG, with a perspective on the current role of the Apgar score and an expanded Apgar score form that includes newborn resuscitation information.)

Rabi, Y, Rabi, D, Yee, W. “Room air resuscitation of the depressed newborn: a systematic review and meta-analysis”. Resuscitation. vol. 72. 2007. pp. 353-63. (One of several reviews that describe equivalent or superior neonatal outcomes using room air instead of high oxygen concentrations during initial positive pressure ventilation of depressed newborns, including a discussion of the limitations of the existing clinical research data.)

Wiswell, TE, Gannon, CM, Jacob, J. “Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial”. Pediatrics . vol. 105. 2000. pp. 1-7. (Report of an important clinical study with significant impact on the clinical management of meconium during newborn resuscitation.)

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