The Journal of Pediatrics
Volume 148, Issue 5 , Pages 569-570, May 2006

Oxygen saturations immediately after birth

  • Ola Didrik Saugstad, MD, PhD, FRCPE

      Affiliations

    • Corresponding Author InformationReprint requests: Ola Didrik Saugstad, MD, Professor of Pediatrics, Pediatrisk Forsknings Institutt, Rikshospitalet, 0027 Oslo, Norway.

Department of Pediatric Research, The National Hospital, Oslo, Norway

Received 23 January 2006; accepted 20 February 2006.

Article Outline

Abbreviations:  SPO2, Oxygen saturation

 

The optimal oxygen saturation for newborn infants in need of resuscitation immediately after birth has been extensively discussed in recent years. Saturation guidelines need to be carefully considered because they affect the 5% to 10% of newborn infants who need some active resuscitation at birth and the 1% of infants requiring more extensive resuscitative measures.1, 2 Worldwide, every year more than 1 million newborn infants need extensive resuscitation. If oxygen saturation contributed even to small differences in outcomes, a large number of children would be affected. The debate has mainly focused on whether ambient air is preferable to 100% oxygen for newborn infants in need of ventilatory support.3, 4, 5 However, the new consensus report from ILCOR, the American Heart Association, the American Academy of Pediatrics, and the European Resuscitation Council states that initiation of resuscitation either with 100% oxygen or less oxygen—even room air—is a reasonable practice.2 The new recommendations emphasize clinical judgment and individualized care more than before. In the United States and many other places in the world, health professionals have not used oxygen concentrations <100%, in part because of liability concerns. Such concerns should now be history. The consensus report 2 also states that “administration of a variable concentration of oxygen guided by pulse oximetry may improve the ability to achieve normoxia more quickly.” It therefore is important to know the normal oxygen saturations after birth and to test the feasibility of using pulse oximetry soon after birth.

See related articles, p 585 and p 590

In this issue of The Journal of Pediatrics, 2 articles, 1 from Australia by Kamlin et al6 and the other from Canada by Rabi et al7 provide information about oxygen saturation monitoring after delivery. They used new pulse oximetry equipment to reduce poor signal quality caused by low perfusion states or patient movements and found that oxygen saturations could be measured within 1 and 2 minutes of cord clamping. In both, the median time to establish a reliable signal was 1.2 minutes.

As previously reported with older saturation monitors, Kamlin et al and Rabi et al confirm that infants >31 or 34 weeks of gestational age, respectively, who receive neither assisted ventilation nor supplemental oxygen have a gradual rise in preductal oxygen saturation during the first 5 to 10 minutes of life. The median time to reach an oxygen saturation of 90% was 5 minutes in the Kamlin article and 8 minutes in the Rabi article. Saturations were higher in infants born vaginally compared with infants born by means of caesarean section. In the study by Kamlin et al, there was an almost 2 minute delay in reaching an oxygen saturation (SpO2) of 90% for infants delivered by means of caesarean section compared with infants born vaginally (4.0 minutes versus 5.9 minutes). An SpO2 of 90% was achieved more than 2 minutes faster in babies delivered by means of caesarean section in labor compared with caesarean sections without labor (4.7 minutes versus 7.0 minutes). In the study by Rabi et al, median SpO2 for the first 10 minutes of life was 3% higher in infants born vaginally compared with that in infants born by means of caesarean section. Term babies had significantly higher saturations and reached 90% saturation faster than preterm infants (4.7 minutes versus 6.5 minutes). Maternal analgesia and anesthesia did not influence postnatal saturations in the infants.

It is perhaps surprising to many that SpO2 is so low in the first minutes of life. However, oxygen saturation is probably <60% in fetal life. Kamlin et al found the median SpO2 level at 1 minute of life to be 63%, with an interquartile range of 53% to 68%. At 3 minutes of age, the lower “normal” level, defined as a lower interquartile range, was 64%. Several studies have now shown the same pattern in oxygen saturation for the first minutes of life. Some of these data, including those from Kamlin et al, are plotted in the Figure. The studies have not consistently distinguished between pre- and post-ductal saturation values, but pre-ductal SpO2 seems to be 7% to 10% higher than post-ductal saturation for the first 10 minutes of life. Overall, the results are remarkably consistent, establishing the median SpO2 at 1 minute of life at approximately 60% to 70%. However, the lower reference range in some of these studies is as low as 40% to 50%.8, 9, 10, 11, 12 An SpO2 of 90% is reached at a mean/median by 5 minutes of life. These measurements establish the “normal” SpO2 in term or near-term infants for the first 10 minutes of life. However, we do not know whether this oxygenation pattern is optimal for infants in need of ventilatory support after birth. Oxygen supplementation may not increase SpO2, at least not in infants who have the lowest saturation levels as a result of asphyxia.12

How should we proceed from here? It would require very large randomized and blinded studies to compare the outcomes of babies having different SpO2 levels for the first 10 minutes of life. In my opinion, it is reasonable to accept that all these studies of oxygen saturations after birth define the healthy SpO2 levels for the first 10 minutes of life.

It is wise for the consensus report to recommend options ranging from room air to 100% oxygen supplementation for newborn resuscitation. However, it is reasonably well documented that 100% oxygen may be detrimental even when oxygen is given for only a few minutes. A new report published after the consensus report was finished supports this conclusion.13 I do not think that 100% oxygen should be used in the initial phase of newborn resuscitation.

The studies by Kamlin et al and Rabi et al have shown that it is feasible with modern technology to monitor oxygen saturations in term or near-term infants by 1 to 2 minutes of life.6, 7 Whether pulse oximetry should be used routinely for newly born infants in need of resuscitation is, however, still not clear. Although pulse oximetry could be used to adjust the oxygen concentration after 2 minutes of life, we do not know whether the range of SpO2 seen in healthy infants is appropriate for sick term or preterm infants. The use of supplemental oxygen, therefore, still will need to be based on clinical judgment. I suggest starting resuscitation with a low oxygen concentration and increasing the oxygen according to heart rate and color response, and perhaps also with pulse oximetry readings.

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References 

  1. Niermeyer S , Kattwinkel J , Van Reempts P , Nadkarni V , Phillips B , Zideman D , et al.   International Guidelines for Neonatal Resuscitation: an excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science . Pediatrics . 2000;106:E29
  2. International Liaison Committee on Resuscitation . Part 7 (neonatal resuscitation) . Resuscitation . 2005;67:293–303
  3. Tan A , Schulze A , O’Donnell CP , Davis PG . Air versus oxygen for resuscitation of infants at birth . Cochrane Database Syst Rev . 2005;18: CD002273
  4. Davis PG , Tan A , O’Donnell CP , Schulze A . Resuscitation of newborn infants with 100% oxygen or air (a systematic review and meta-analysis) . Lancet . 2004;364:1329–1333
  5. Saugstad OD , Ramji S , Vento M . Resuscitation of depressed newborn infants with ambient air or pure oxygen (a meta-analysis) . Biol Neonate . 2005;87:27–34
  6. Kamlin CO , O’Donnell CPF , Davis PG , Morley CJ . Oxygen saturation in healthy infants immediately after birth . J Pediatr . 2006;148:585–589
  7. Rabi Y , Yee W , Chen SY . Oxygen saturation trends immediately after birth . J Pediatr . 2006;148:590–594
  8. House JT , Schultetus RR , Gravenstein N . Continuous neonatal evaluation in the delivery room by pulse oximetry . J Clin Monit . 1987;3:96–100
  9. Dimich I , Singh PP , Adell A , Hendler M , Sonnenklar N , Jhaveri M . Evaluation of oxygen saturation monitoring by pulse oximetry in neonates in the delivery system . Can J Anaesth . 1991;38:985–988
  10. Rao R , Ramji S . Pulse oximetry in asphyxiated newborns in the delivery room . Indian Pediatr . 2001;38:762–766
  11. Toth B , Becker A , Seelbach-Gobel B . Oxygen saturation in healthy newborn infants immediately after birth measured by pulse oximetry . Arch Gynecol Obstet . 2002;266:105–107
  12. Saugstad OD , Ramji S , Rootwelt T , Vento M . Response to resuscitation of the newborn (early prognostic variables) . Acta Paediatr . 2005;94:890–895
  13. Vento M , Sastre J , Asensi MA , Vina J . Room-air resuscitation causes less damage to heart and kidney than 100% oxygen . Am J Respir Crit Care Med . 2005;172:1393–1398

PII: S0022-3476(06)00141-7

doi:10.1016/j.jpeds.2006.02.039

Refers to article:

  • Oxygen saturation in healthy infants immediately after birth

    C. Omar F. Kamlin, Colm P.F. O’Donnell, Peter G. Davis, Colin J. Morley
    The Journal of Pediatrics May 2006 (Vol. 148, Issue 5, Pages 585-589)

  • Oxygen saturation trends immediately after birth

    Yacov Rabi, Wendy Yee, Sophie Yue Chen, Nalini Singhal
    The Journal of Pediatrics May 2006 (Vol. 148, Issue 5, Pages 590-594)

The Journal of Pediatrics
Volume 148, Issue 5 , Pages 569-570, May 2006

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