Evidence-Based Practices for the Fetal to Newborn Transition

Judith S. Mercer, CNM, DNSc; Debra A. Erickson-Owens, CNM, MS, ; Barbara Graves, CNM, MN, MPH; Mary Mumford Haley, CNM, MS


J Midwifery Womens Health. 2007;52(3):262-272. 

In This Article

Room Air Versus Oxygen for Neonatal Resuscitation

Current research addressing the potential benefits and risks of use of oxygen versus room air for neonatal resuscitation included six intervention studies[64,65,66,67,68,69] and a Cochrane Library review.[70] The outcomes of these studies demonstrate no differences between the oxygen and room air groups in mortality, Apgar scores, time to first cry, time to onset of regular respirations, hypoxic ischemic encephalopathy, or neurologic follow-up examination results ( Table 5 ).[71] One study evaluated markers of oxidative stress.[68]

By the 1950s, it was recognized that the administration of high levels of oxygen to premature infants led to vasoconstriction of the retinal arteries followed by disordered vessel growth causing retrolental fibroplasias, now known as retinopathy of prematurity.[72] Research in the late 1970s demonstrated that administration of 100% oxygen also reduced cerebral blood flow in the newborn infant.[73,74]

Saugstad[75] conducted animal studies, which suggested that the use of 100% oxygen during neonatal resuscitation might result in excess oxygen radicals and slower response to resuscitation. A pilot study with human infants supported the safety of using room air during newborn resuscitation.[65] A follow-up multicenter, international quasiexperimental study of 599 infants weighing more than 1000 gm who required positive pressure ventilation for resuscitation (ResAir 2), found no differences in outcomes when infants were resuscitated with room air versus 100% oxygen ( Table 5 ).[67]

To investigate the effect of supplemental oxygen on cerebral blood flow, Lundstom[64] randomized 70 preterm infants to receive either room air (group I) or 80% oxygen (group II) during initial stabilization in the delivery room. The primary outcome of cerebral blood flow was significantly higher in group I randomized to room air (median 15.9; interquartile range 13.6-21.9 mL/100 g/min) compared to group II with 80% oxygen (median 12.3; interquartile range 10.7-13.8 mL/100 g/min; P < .0001) at 2 hours of age.

Vento et al.[68,69] measured the effect of resuscitation with room air or 100% oxygen on levels of markers of oxidative stress in term infants delivered vaginally ( Table 5 ). Nineteen asphyxiated infants were randomized to resuscitation with room air, 21 were randomized to 100% oxygen, and 26 infants without asphyxia served as controls. The markers of oxidative stress were initially higher in the umbilical arteries of both the asphyxiated groups compared to the controls. At 72 hours of age, the oxygen group had levels of oxygen-free radicals that were statistically higher than the newborns in the room air group. By 28 days of age, the infants in the room air group had values similar to the values of the newborns in the control group, whereas the infants in the oxygen group continued to have statistically higher oxygen-free radical values than either the room air subjects or controls. Even a short exposure to 100% oxygen may result in prolonged oxidative stress.

The American Academy of Pediatrics/American Heart Association Neonatal Resuscitation Program provides an authoritative set of recommendations. The fifth edition of Textbook of Neonatal Resuscitation[76] contains a significant change in the use of 100% oxygen from earlier editions. Although the authors continue to recommend the use of 100% oxygen, they acknowledge that research suggests that "less than 100% may be just as useful."[77] The new guideline recommends use of room air at time of resuscitation, but if there is not an appropriate response within 90 seconds, oxygen is indicated.


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