Comprehensive Neonatal Care Notes (6th Edition)

Risk Factors Associated With the Need for Resuscitation

• Most term newborns require no resuscitation beyond maintenance of temperature and mild stimulation.
• Approximately $5\%$ of newborns need positive-pressure ventilation to begin breathing at birth.
• Only 1$-$3 in 1000$newborns require chest compressions or resuscitation medications. </li> <li>Resuscitation is more likely in newborns who are low birth weight, born to mothers with antepartum or intrapartum risk factors, and born prematurely. </li> </ul> <h3 id="antepartumandintrapartumriskassessmentforresuscitation">Antepartum and Intrapartum Risk Assessment for Resuscitation</h3> <ul> <li>When antepartum or intrapartum risk factors are present and delivery is imminent, prepare for neonatal resuscitation. </li> <li>Questions to ask pregnant patient to assess the need for resuscitation: <ul> <li>When is the baby due? (assess for prematurity) </li> <li>If membranes have ruptured, was amniotic fluid clear? </li> <li>How many babies are expected? </li> <li>Are there other possible risk factors? </li></ul></li> </ul> <h3 id="prematuritydefinitionriskspresentationcare">Prematurity (Definition, Risks, Presentation, Care)</h3> <ul> <li>Prematurity defined as birth before$37\text{ weeks}$of pregnancy. </li> <li>Risk factors include: <ul> <li>Complications during pregnancy, infection, maternal hypertension. </li> <li>Maternal age (<$18$or >$35 years).
• Low socioeconomic status, being African American, late prenatal care, stress.
• History of preterm birth, <18 months between pregnancies.
• Smoking, substance misuse; multiple gestation pregnancies.

Prematurity (Perinatal Characteristics and Prehospital Care)

• Prehospital care focuses on airway and circulatory support, maintaining body temperature, and transport to a facility with newborn services for low birth weight infants.

Physiologic Adaptations at Birth (Overview)

• Newborns undergo major physiologic adaptations at birth for survival:
  • Emptying fluids from lungs and initiating ventilation.
  • Transition of circulatory pattern.
  • Maintenance of body temperature.
• Umbilical cord clamping triggers transition from maternal oxygenation to spontaneous breathing.

Physiologic Adaptations at Birth (Lung Fluid Clearance and First Breath) (Labor & Delivery)

• Labor: adrenaline activates sodium channels and increases catecholamines, triggering clearance of lung fluid.
• Secretory chloride channels turn off; water is resorbed with sodium, clearing ~\frac{1}{3}$of fetal lung fluid prior to delivery. </li> <li>Further clearance occurs during vaginal delivery as chest compression forces fluid out of lungs into mouth/nose. </li> <li>First breath is triggered by exposure to air and temperature changes. </li> <li>As air enters alveoli, pulmonary capillaries dilate in response to oxygen, allowing pulmonary pressure to fall and blood to flow into lungs. </li> </ul> <h3 id="physiologicadaptationsatbirthcirculationoxygenation">Physiologic Adaptations at Birth (Circulation, Oxygenation)</h3> <ul> <li>Circulation transitions to normal pathway; foramen ovale begins to close. </li> <li>Oxyhemoglobin saturation may remain in$70\%$–$80\%$range for several minutes after birth, causing apparent cyanosis. </li> <li>Normal healthy newborn may not reach SpO2$\ge 90\%$for first$10$minutes. </li> <li>It may take hours to fully absorb alveolar fluid and days for ductus arteriosus and foramen ovale to close. </li> </ul> <h3 id="physiologicadaptationsatbirthhypoxiasensitivity">Physiologic Adaptations at Birth (Hypoxia Sensitivity)</h3> <ul> <li>Newborns are sensitive to hypoxia; significant and irreversible brain injury can occur from prolonged hypoxemia. </li> <li>Causes of hypoxia include: <ul> <li>Decreased cerebral blood flow. </li> <li>Decreased oxygen content in blood. </li> <li>Cardiovascular anomalies. </li></ul></li> </ul> <h3 id="physiologicadaptationsatbirththermoregulationrisks">Physiologic Adaptations at Birth (Thermoregulation Risks)</h3> <ul> <li>Newborns are at risk for rapid hypothermia due to large body surface area, low insulation, and immature temperature regulation. </li> <li>Should be delivered in a warm, draft-free area and dried with warm towels/blankets; head covered with a cap. </li> </ul> <h3 id="assessmentandmanagementofthenewbornthegoldenminuteoverview">Assessment and Management of the Newborn: The Golden Minute (Overview)</h3> <ul> <li>Prepare standard obstetrics kit plus neonatal resuscitation equipment before delivery. </li> <li>After delivery, initial assessment/management should follow AHA and AAP recommendations. </li> <li>Primary goal: newborn should be breathing well or receiving ventilation within$60\text{ s}.
• The “Golden Minute” is the time window to complete initial steps, reevaluate, and begin ventilation if required.

Assessment and Management of the Newborn: The Golden Minute (Initial Questions)

• Immediately following delivery, answer:
  • Is the newborn term?
  • Does the newborn have good tone?
  • Is the newborn breathing or crying?
• If yes to all, baby may stay with mother for routine care.
• If any are no, perform stabilization steps:
  • Warm and maintain normal temperature; position; clear secretions only if copious/obstructing airway; dry and stimulate.
  • Ventilate, apply pulse oximeter, oxygenate.
  • Initiate chest compressions if needed.
  • Administer epinephrine and/or volume expanders.

Assessment and Management of the Newborn: The Golden Minute (Interventions Based on Heart Rate)

• If heart rate < 100\ \text{beats/min}$after initial steps: Start PPV. </li> <li>If heart rate falls to$\le 60\ \text{beats/min} after 30 seconds of PPV with chest movement: Escalate to chest compressions and epinephrine.

Assessment and Management of the Newborn: The Golden Minute (Summary of Steps)

• If HR < 60 after 60 seconds of effective resuscitation: escalate to chest compressions with ventilation, consider epinephrine.

Postresuscitation Care (Complications)

• Common postresuscitation complications:
  • Endotracheal (ET) tube migration or dislodgement.
  • Tube occlusion by mucus/meconium.
  • Pneumothorax.
• Suspect with: decreased chest movement, diminished breath sounds, bradycardia recurrence, unilateral chest expansion decrease, altered breath sounds intensity, increased resistance to manual ventilation.
• Management: adjust ET tube, reintubate, suction, consider needle decompression for pneumothorax (guided by medical direction).
• Induced therapeutic hypothermia is offered to newborns >36\text{ weeks}$with evolving moderate to severe hypoxic-ischemic encephalopathy; institution in hospital under physician supervision. </li> </ul> <h3 id="neonataltransportinitialtransportprinciples">Neonatal Transport (Initial Transport Principles)</h3> <ul> <li>After establishing effective ventilation and circulation, transport mother and newborn. </li> <li>During transport: maintain body temperature, ensure warm ambulance, maintain oxygenation, cover the head, apply blankets, support ventilations. </li> </ul> <h3 id="neonatalresuscitationpostresuscitationandstabilizationgeneralconcepts">Neonatal Resuscitation, Postresuscitation, and Stabilization (General Concepts)</h3> <ul> <li>Continuously assess and monitor newborns with respiratory distress for treatable causes. </li> <li>Asystole and pulseless arrest are uncommon in the newborn period; usually due to hypoxia, apnea, bradycardia, or persistent fetal circulation. </li> <li>Assessment findings indicating distress include peripheral cyanosis, inadequate respiratory effort, and ineffective or absent heart rate. </li> <li>Risk factors for cardiac arrest include congenital malformations and intrauterine exposures. </li> <li>Resuscitation includes airway, ventilatory, circulatory support, pharmacologic therapy (epinephrine), and rapid transport. </li> <li>Decision to withhold or discontinue resuscitation in the prehospital setting must consider parental wishes and medical direction. </li> </ul> <h3 id="psychologicalandemotionalsupportfamilyinvolvement">Psychological and Emotional Support (Family Involvement)</h3> <ul> <li>Be aware of normal family emotions during emergencies; communicate clearly to keep families informed. </li> <li>If parents have named the baby, use the name. </li> <li>Do not discuss survival chances or provide false hope. </li> <li>If resuscitation is terminated in the field, wrap the baby warmly and allow parents to hold the infant. </li> </ul> <h3 id="apneadefinitionandmanagement">Apnea (Definition and Management)</h3> <ul> <li>Apnea: absence of spontaneous breathing. </li> <li>Primary apnea is self-limited and reversible with stimulation. </li> <li>Secondary apnea lasts$> 20\text{ s}$without spontaneous breathing, leading to hypoxemia and bradycardia. </li> <li>Common in preterm newborns; initiates PPV and resuscitation. </li> <li>Emergency care begins with stimulating the newborn to breathe. </li> </ul> <h3 id="bradycardiadefinitionandriskfactors">Bradycardia (Definition and Risk Factors)</h3> <ul> <li>Bradycardia: heart rate$< 100\ \text{beats/min}.
• Risk factors include inadequate ventilation and vagal stimulation from suctioning or invasive procedures during resuscitation.
• Bradycardia should be promptly investigated and managed.

Respiratory Distress and Cyanosis (Overview)

• Prematurity is the most common cause of respiratory distress and cyanosis in the newborn; often <1.2\text{ kg} and <30\text{ weeks}$gestation. </li> <li>Related to immature lungs and central respiratory control. </li> <li>Other risk factors: multiple gestations, maternal complications, birth defects, CNS disorders, diaphragmatic hernia, tracheoesophageal fistula, pneumonia, metabolic acidosis, meconium/amniotic fluid aspiration, pulmonary hypertension, shock, sepsis. </li> <li>Signs: tachypnea, paradoxical breathing, intercostal retractions, nasal flaring, expiratory grunting, central cyanosis. </li> </ul> <h3 id="hypovolemiarecognitionandintervention">Hypovolemia (Recognition and Intervention)</h3> <ul> <li>May result from dehydration, hemorrhage, trauma, or sepsis. </li> <li>Signs: mottled/pale color, cool skin, tachycardia, diminished peripheral pulses, delayed capillary refill. </li> <li>Management when signs present: give IV fluid bolus of$10\ \text{mL/kg}$over$5$-$10\ \text{min} (isotonic crystalloid). Reassess the newborn.

Seizures (Causes and Emergency Care)

• Seizures occur in a small percentage of newborns and may indicate developmental abnormalities, drug withdrawal, hypoglycemia, hypoxic-ischemic encephalopathy, intracranial hemorrhage, meningitis/encephalopathy, or metabolic disturbances.
• Prolonged/frequent seizures may cause metabolic and cardiopulmonary issues. The emergency care includes airway, ventilation, circulation support; rapid blood glucose check; maintain body temperature. Management begins with benzodiazepines; dextrose may treat hypoglycemia.

Fever (Definition and Implications)

• Fever: rectal temperature > 38.0\,^\circ\mathrm{C}$(100.4°F). </li> <li>In healthy asymptomatic newborns fever may reflect limited temperature control or dehydration; symptomatic fever is serious and may indicate acute infection including neonatal sepsis. </li> <li>Core temperature rise increases oxygen demand, glucose metabolism, and may cause metabolic acidosis. </li> <li>Assessment findings can include rashes, petechiae, warm skin; care is supportive; cooling and antipyretics are delayed until hospital care. </li> </ul> <h3 id="hypothermiadefinitionfindingsandcare">Hypothermia (Definition, Findings, and Care)</h3> <ul> <li>Hypothermia: core body temperature$< 35.0\,^{\circ}\mathrm{C}$(95°F). </li> <li>Can cause metabolic acidosis, pulmonary hypertension, hypoxemia; may be a sign of sepsis. </li> <li>Findings: pale color, cool skin (especially extremities), respiratory distress, apnea, bradycardia, central cyanosis, acrocyanosis, irritability (early), lethargy (late), shivering may be absent. </li> <li>Prehospital care: cardiac life support and rapid transport; keep newborn dry and warm; use warmed hands; transport in a heated ambulance. </li> </ul> <h3 id="hypoglycemiadefinitionriskfactorsfindingsandcare">Hypoglycemia (Definition, Risk Factors, Findings, and Care)</h3> <ul> <li>Hypoglycemia: blood glucose$< 40\ \text{mg/dL}$for term newborns (preterm$< 30\ \text{mg/dL}) in 0–4 hours of life or < 45\ \text{mg/dL}$after 4 hours. </li> <li>Risk factors: asphyxia, toxemia, twin-twin problems, CNS hemorrhage, maternal diabetes, sepsis. </li> <li>Findings: twitching/seizure, hypotonia, lethargy, irritability, eye rolling, high-pitched crying, apnea, irregular respirations, cyanosis. </li> <li>Prehospital care: secure airway/ventilation/circulation; maintain temperature; rapid transport; administer IV dextrose$10\%$(per medical direction). </li> </ul> <h3 id="vomitingassessmentandprehospitalcare">Vomiting (Assessment and Prehospital Care)</h3> <ul> <li>Vomiting with mucus and blood is common in first hours. </li> <li>Abnormal vomiting: persistent/projectile within first 24 hours may indicate upper GI obstruction or increased intracranial pressure. </li> <li>Non–bilious vs bilious vomiting (dark green) may indicate obstruction and is a surgical emergency. </li> <li>Dark blood in vomit is a warning sign. </li> <li>Findings with abnormal vomiting: distended abdomen, signs of infection, dehydration, increased intracranial pressure. </li> <li>Prehospital care: maintain airway free of vomit, adequate oxygenation, IV fluids per medical direction. </li> </ul> <h3 id="diarrheaoverviewandcare">Diarrhea (Overview and Care)</h3> <ul> <li>Normal: five to six stools per day, especially during breastfeeding. </li> <li>Abnormal diarrhea can lead to dehydration and electrolyte imbalance. </li> <li>Causes: bacterial/viral infections, bacterial enteritis, cystic fibrosis, lactose intolerance, NAS (drug withdrawal), thyrotoxicosis, viral gastroenteritis (rotavirus). </li> <li>Findings: loose stools; decreased urinary output; dehydration signs. </li> <li>Prehospital care: support vital functions, IV fluids per medical direction, immediate transport. </li> </ul> <h3 id="newbornjaundicephysiologyandpathology">Newborn Jaundice (Physiology and Pathology)</h3> <ul> <li>High levels of unconjugated bilirubin in blood and yellowing of skin/mucous membranes/eyes. </li> <li>Physiologic jaundice affects$3/5$newborns; resolves within ~2 weeks as the liver matures. </li> <li>More serious causes include Rh disease, sepsis, liver dysfunction, G6PD deficiency. </li> <li>Risk factors: prematurity, difficult delivery, bruising, sibling history of jaundice, East Asian or Mediterranean descent. </li> <li>If jaundice does not resolve, consider phototherapy or exchange transfusion or IVIG. </li> </ul> <h3 id="sepsisoverviewandonset">Sepsis (Overview and Onset)</h3> <ul> <li>Newborn sepsis is usually caused by viral or bacterial infections. </li> <li>Late-onset sepsis occurs$8$-$28$days after birth. </li> <li>Signs/symptoms: temperature instability (only ~$50\% have temp > 100^{\circ}\mathrm{F}$), respiratory distress, feeding changes, apnea, cyanosis, parental concern, GI changes, CNS features, increased sleep, risk factors include prematurity and low birth weight. </li> </ul> <h3 id="commonbirthinjuriesoverview">Common Birth Injuries (Overview)</h3> <ul> <li>Incidence ~$31.1 per 1000 hospital births in the U.S.; higher with maternal obesity, abnormal fetal presentation, and newborn weight <8.8\text{ lb}$($4\text{ kg}$). </li> <li>Cranial injuries, soft-tissue injuries from forceps, intracranial hemorrhage, facial nerve injury, skull fracture. </li> </ul> <h3 id="congenitalanomaliesoverview">Congenital Anomalies (Overview)</h3> <ul> <li>Congenital anomalies are birth defects occurring during fetal development; present in$3\%$of births and responsible for$20\%$of deaths. </li> <li>May be heritable or caused by maternal infection, alcohol or drug use; insufficient maternal folic acid; and other factors. </li> </ul> <h3 id="anomaliesoftheairway1of6to6of6">Anomalies of the Airway (1 of 6) to (6 of 6)</h3> <ul> <li>Choanal atresia: blockage between nose and pharynx; occurs in$1\text{ in } 5{,}000$-$7{,}000$live births; may affect one or both sides; bilateral obstruction causes ventilation problems. Symptoms include chest wall retractions, dyspnea, and difficulty nursing while breathing. Management: insert oropharyngeal airway or partial ET tube with tip behind tongue (posterior pharynx) to improve status until facility arrival. </li> <li>Tracheoesophageal fistula (TEF): abnormal connection between esophagus and trachea; occurs in$1\text{ in } 3{,}000$-$5{,}000$live births; signs include copious salivation, choking, coughing, regurgitation during feeding, cyanosis; may require early surgery. </li> <li>Cleft lip/palate: lip cleft or palate fissure; may involve one/both sides; can extend into nasal cavity; risks include feeding and speech difficulties; frequency: cleft lip with cleft palate$1\text{ in }1{,}600$; cleft lip only$1\text{ in }2{,}800$; corrected surgically. </li> <li>Pierre Robin sequence: complex of anomalies with small mandible, retruded/large tongue, often with cleft palate; occurs$1\text{ in } 8{,}500$-$14{,}000$; complications include breathing difficulties, poor feeding, potential cerebral hypoperfusion, pulmonary hypertension, heart failure; management includes prone positioning for dyspneic newborns and cautious airway management (small nasal/oral tube; difficult bag-mask ventilation; LMA as rescue). </li> </ul> <h3 id="anomaliesoftheheart1of20to20of20">Anomalies of the Heart (1 of 20) to (20 of 20)</h3> <ul> <li>Defects in heart structure during development; most common birth defect; affects about$40{,}000$newborns per year; about$25\% have hemodynamic effects. Causes include genetics, Down syndrome, maternal diabetes/obesity, smoking, alcohol/drug exposure, certain meds. Prehospital care focuses on comfort and transport; surgery may be required.
• Left-to-right shunt: oxygenated blood is shunted from left to right (pulmonary) circulation, causing increased venous return to lungs and left ventricular/pulmonary overcirculation; can lead to pulmonary hypertension.
• Coarctation of the Aorta (CoA): narrowing of the aorta; left ventricle works harder; presents in first month with absent pulse or lower body cyanosis; decompensated shock signs; risk of HTN, ruptured aorta, aneurysm, stroke; management includes keeping the ductus arteriosus open, improving ventricular function, and possible surgical repair or stent.
• Septal defects: ASD and VSD.
  • ASD: hole in atrial septum; blood returns from left atrium to right atrium; many have few symptoms; surgical closure may prevent problems later.
  • VSD: hole between ventricles; left ventricle blood to right ventricle; heart overworks; possible pulmonary hypertension; large defects may require surgery; hallmark murmur.
• Patent Ductus Arteriosus (PDA): ductus arteriosus fails to close; causes some oxygenated blood to flow back to lungs; large PDA may cause fatigue, slow growth, increased infections; surgical repair often required; NSAIDs or acetaminophen can stimulate closure in some cases.
• Truncus Arteriosus: single great vessel with large VSD; blood flows to body and lungs; low systemic vascular resistance promotes left-to-right shunt; high pulmonary hypertension; symptoms include dyspnea and fatigue; surgical repair needed.
• Valvular defects: stenosis or regurgitation; effects include LV hypertrophy, clot risk, potential heart failure; symptoms may include palpitations, chest pain, fatigue, dizziness, fever, rapid weight gain.
• Single-ventricle defects: one ventricle underdeveloped (complex/rare). Examples: Tricuspid atresia, Pulmonary atresia, Hypoplastic left heart syndrome. End-tidal CO2 may be unreliable during CPR due to rapid hemodynamic changes.
• Tetralogy of Fallot (ToF): four defects (large VSD, pulmonary stenosis, right ventricular hypertrophy, overriding aorta) causing cyanosis; ToF infants may have hypoxic “tet spells”; management includes calming the child, kneeling/flexing legs to reduce venous return if distressed, and earlier surgical repair.
• Transposition of the great arteries: aorta and pulmonary artery are switched; systemic and pulmonary circulations run in parallel; early surgery leads to survival >94\%$. </li> <li>Total anomalous pulmonary venous return (TAPVR): pulmonary veins fail to attach to left atrium and instead connect to right-sided structures; oxygen-rich blood recirculates to lungs; newborns appear critically ill with lethargy, poor feeding, tachypnea, poor growth, frequent infections, cyanosis. </li> <li>Congenital dysrhythmias: conduction system defects; include atrial fibrillation, atrial flutter, reentry tachycardia, heart blocks; higher incidence with moderate/severe congenital heart defects. </li> </ul> <h3 id="anomaliesoftheabdomenandlowerbackoverviewandspecificanomalies">Anomalies of the Abdomen and Lower Back (Overview and Specific Anomalies)</h3> <ul> <li>Intestinal malrotation: abnormal intestinal rotation around the superior mesenteric artery; presents as surgical emergency; occurs in$~1\text{ in }500$live births; bilious emesis common; symptoms include recurrent abdominal pain, diarrhea/constipation, solid food intolerance, jaundice, lower GI bleeding, GER reflux; severe symptoms lead to shock and hypoperfusion. </li> <li>Pyloric stenosis: pylorus muscles enlarge, narrowing the pylorus; progressive forceful vomiting; dehydration signs (dry mucous membranes, slow capillary refill, sunken fontanels, decreased urine). Surgery required. </li> <li>Diaphragmatic hernia: hole in diaphragm allows abdominal organs into chest; usually left side; lung development impaired causing hypoplasia; signs include respiratory distress, cyanosis unresponsive to ventilation, tachypnea, tachycardia, irregular chest wall movement, displaced heart sounds, decreased breath sounds, bowel sounds in chest, scaphoid abdomen. Care: elevate head and thorax, intubate to prevent stomach insufflation, place orogastric tube with suction to decompress stomach, surgical repair. </li> <li>Abdominal wall defects: <ul> <li>Gastroschisis: intestines protrude outside abdomen through abdominal wall without a protective sac; usually to the right of the umbilicus; incidence rising; requires protective handling. </li> <li>Omphalocele: intestines protrude through the base of the umbilical cord in a sac; varies by size/location; differentiation from gastroschisis important; protective management. </li></ul></li> <li>Spina bifida (neural tube defect): failure of vertebral arches to close; exposure of spinal cord tissue; management includes surgical repair, meds, physical therapy; four types: occulta, meningocele, myelomeningocele, encephalocele; immediate delivery precautions: protect exposed sac, place infant prone or on side if possible, avoid touching defect; after resuscitation, cover sac with saline-soaked nonadherent gauze and secure; use nonlatex sterile gloves. </li> <li>Anomalies of the Abdomen and Lower Back (Care Guidance) <ul> <li>Cover exposed viscera; handle gently; roll towels to cradle sac (donut technique). </li> <li>If resuscitation not needed immediately, position prone or to the side. </li> <li>After resuscitation, cover sac with sterile saline-soaked gauze and secure. </li></ul></li> </ul> <h3 id="anomaliesoftheairwaypracticalprehospitalcareexpanded">Anomalies of the Airway: Practical Prehospital Care (Expanded)</h3> <ul> <li>Choanal atresia and TEF management considerations (above) are repeated here for clarity: airway obstruction requires careful airway management; LMA may be used as rescue; ET intubation challenging in some anomalies; partial or alternative airway strategies as needed. </li> </ul> <h3 id="anomaliesoftheheartexpandedpracticalinsightsforprehospitalcare">Anomalies of the Heart (Expanded Practical Insights for Prehospital Care)</h3> <ul> <li>See above for left-to-right shunts, CoA, ASD, VSD, PDA, truncus arteriosus, ToF, transposition, TAPVR, etc. </li> <li>Prehospital care emphasizes comfort measures and rapid transport; definitive treatment often surgical. </li> </ul> <h3 id="anomaliesoftheabdomenandlowerbackexpanded">Anomalies of the Abdomen and Lower Back (Expanded)</h3> <ul> <li>Gastroschisis and Omphalocele management emphasize gentle handling of exposed viscera; delivery planning; surgical repair after stabilization. </li> <li>Spina bifida types and protective handling during delivery. </li> </ul> <h3 id="summaryofmeasurementsdosesandthresholdskeyequationsanddoses">Summary of Measurements, Doses, and Thresholds (Key Equations and Doses)</h3> <ul> <li>PPV ventilation rate:$40$-$60\ \text{breaths/min}$</li> <li>Chest compressions: ratio$3:1$with total rate$120\ \text{per minute}$to achieve approx.$90\text{ compressions}$and$30\text{ breaths/min}$</li> <li>Epinephrine and volume expanders (IV preferred): <ul> <li>IV dose:$0.01\text{ to }0.03\ \text{mg/kg per dose}$</li> <li>ET dose:$0.05\text{ to }0.1\ \text{mg/kg per dose}$</li> <li>Epinephrine concentration:$0.1\ \text{mg/mL}$</li></ul></li> <li>Volume expanders:$10\ \text{mL/kg}$(isotonic crystalloid), given when blood loss is suspected or shock present, repeated as needed. </li> <li>Temperature targets: <ul> <li>Normal term newborn temperature:$97.7^{\circ}\mathrm{F} \text{ to } 99.5^{\circ}\mathrm{F}}$$\approx 36.5^{\circ}\mathrm{C} \text{ to } 37.5^{\circ}\mathrm{C}
• Ideal ambulance/ambient: maintain warmth; avoid hypothermia.