The recommended volume expanders for neonatal resuscitation include crystalloid fluids and red blood cells (RBCs). These fluids are indicated when blood loss is known or suspected. Clinical indicators of insufficient volume include pale skin, poor perfusion, weak pulse, and lack of heart rate improvement after other resuscitative measures are tried.

The recommended crystalloid fluid is 0.9% normal saline solution. Packed RBCs for volume replacement are best when there is severe fetal anemia. The maternal and newborn history may reveal associated risk factors.

Packed RBCs must be appropriately typed and cross-matched to the mother to ensure that any maternal antibodies circulating in the newborn’s bloodstream will not be affected. If cross-matched blood is not readily available, the provider may choose a non-cross-matched type O and Rh-negative packed RBCs.

Newborn receiving a blood transfusion.

Volume expanders are delivered at a dose of 10 mL/kg. If the baby does not respond, another dose of 10 mL/kg can be given. The preferred route of administration, especially with severe hypovolemic shock, is through an umbilical venous catheter or an IO needle. 

Volume expanders should be given as a steady infusion over 5 to 10 minutes. Rapid administration of volume expanders to preterm babies carries a risk of intraventricular hemorrhage.

No Response to Volume Expanders

If the baby’s heart rate remains < 60 bpm after chest compressions, medications, and volume expanders, the team must reassess the resuscitation quality. Chest compressions continue, and epinephrine administration continues every 3–5 minutes. A STAT X-ray may be helpful. The team also seeks expert consultation with a neonatologist.

After failed resuscitation efforts, the team must perform the reassessment steps previously discussed:

• Is there chest rise with each breath?
• Are breath sounds equal bilaterally?
• Does the advanced airway have an obstruction?
• Is the oxygen concentration set to 100%?
• Are all compressions at the appropriate depth?
• Is there full chest recoil after each compression?
• Were the epinephrine doses correct?
• Is the route of drug administration patent?
• Does the baby have a pneumothorax?