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Resuscitation of the newborn

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

The aims of resuscitation are to:

  • Establish and maintain a clear airway, by ventilation and oxygenation
  • Ensure effective circulation
  • Correct acidosis
  • Prevent hypothermia, hypoglycaemia and haemorrhage.

     

As soon as the baby is born, the clock timer should be started. The Apgar score is assessed in the normal manner at 1 minute. In the absence of any respiratory effort, resuscitation measures are commenced. The baby's upper airways may be cleared by gentle suction of the oropharynx and nasopharynx and the presence of a heartbeat verified. The baby is dried quickly, transferred to a well-lit resuscitaire and placed on a flat, firm surface at a comfortable working height and under a radiant heat source to prevent hypothermia. The baby's shoulders may be elevated on a small towel, which causes slight extension of the head and straightens the trachea. Hyperextension may cause airway obstruction owing to the short neck of the neonate and large, ill-supported tongue.

Stimulation Rough handling of the baby merely serves to increase shock and is unnecessary. Gentle stimulation by drying the baby may initiate breathing.

Warmth Hypothermia exacerbates hypoxia, as essential oxygen and glucose are diverted from the vital centres in order to create heat for survival. Wet towels are removed and the baby's body and head should be covered with a prewarmed blanket, leaving only the chest exposed. Note that it is hazardous to use a silver swaddler under a radiant heater because it could cause burning.

Clearing the airway Most babies require no airway clearance at birth; however, if there is obvious respiratory difficulty a suction catheter may be used (size 10FG, or 8FG in preterm).The catheter tip should not be inserted further than 5 cm and each suction attempt should not last longer than 5 seconds. Even with a soft catheter, it is still possible to traumatise the delicate mucosa, especially in the preterm baby. If meconium is present in the airway, suction under direct vision should be performed by the passage of a laryngoscope blade and visualising the larynx. Care should be taken to avoid touching the vocal cords, as this may induce laryngospasm, apnoea and bradycardia. Thick meconium may need to be aspirated out of the trachea through an endotracheal tube.

Ventilation and oxygenation If the baby fails to respond to these simple measures, assisted ventilation is necessary.

Facemask ventilation

  • An appropriately sized mask (usually 00 or 0/1) is positioned on the face so that it covers the nose and mouth and ensures a good seal.
  • A 500 ml bag is used, as a smaller 250 ml bag does not permit sustained inflation.
  • Care should be taken not to apply pressure on the soft tissue under the jaw, as this may obstruct the airway.
  • To aerate the lungs five sustained inflations are delivered, using oxygen or air or a combination of both, with a pressure of 30 cm H2O (water pressure) applied for 2-3 seconds and repeated five times; then continue to ventilate at a rate of 40 respirations per minute.
  • Insertion of a neonatal airway helps to prevent obstruction by the baby's tongue.
  • Note that overextension of the baby's head causes airway obstruction. A longer inspiration phase improves oxygenation. Higher inflation pressures may be required to produce chest movement.

Endotracheal intubation If the baby fails to respond to intermittent positive pressure ventilation (IPPV) by bag and mask, or if bradycardia is present, an endotracheal tube should be passed without delay. Intubating a baby requires special skill that, once acquired, must be practised if it is to be retained.

Technique for intubation

  • Position the baby on a flat surface, preferably a resuscitaire, and extend the neck into the 'neutral position'. A rolled-up towel placed under the shoulders will help maintain proper alignment.
  • The blade of the laryngoscope is introduced over the baby's tongue into the pharynx until the epiglottis is seen.
  • Elevation of the epiglottis with the tip of the laryngoscope reveals the vocal cords.
  • Any mucus, blood or meconium which is obstructing the trachea should be cleared by careful suction prior to passing the endotracheal tube a distance of 1.5-2 cm into the trachea. (Pressure on the cricoid cartilage may facilitate visualisation of the larynx.)
  • Intubation may be easier if a tracheal introducer made of plastic-covered soft metal wire is used. This will increase the stiffness and curvature of the tube.
  • After the laryngoscope is removed, oxygen is administered by IPPV to the endotracheal tube via the Ambu bag. A maximum of 30 cm H2O should be applied, as there is risk of rupture of alveoli or tension pneumothorax with higher pressures.

    The rise and fall of the chest wall should indicate whether the tube is in the trachea. This can be confirmed by auscultation of the chest. Distension of the stomach indicates oesophageal intubation, necessitating resiting of the tube.

  • Mouth-to-face/nose resuscitation In the absence of specialised equipment, assisted ventilation can be achieved by mouth-to-face resuscitation.

  • With the baby's head in the 'sniffing' position, the operator places her mouth over the baby's mouth and nose.

  • Using only the air in her buccal cavity, she breathes gently into the baby's airway at a rate of 20-30 breaths per minute, allowing the infant to exhale between breaths.

It may be easier with larger babies to use mouth-to-face resuscitation.

External cardiac massage Chest compressions should be performed if the heart rate is less than 60 bpm, or between 60 and 100 bpm and falling despite adequate ventilation. The most effective way of performing chest compressions is to:

  • Encircle the baby's chest with your fingers on the baby's spine and your thumbs on the lower mid-sternum
  • Depress the chest at a rate of 100-120 times per minute, at a ratio of three compressions to one ventilation, and at a depth of one-third (2-3 cm) of the baby's chest.

(Excessive pressure over the lower end of the sternum may cause rib, lung or liver damage.)

Use of drugs If the baby's response is slow or he/she remains hypotonic after ventilation is achieved, consideration will be given to the use of drugs. In specialist obstetric units, pulse oximetry may be employed to monitor hypoxia and blood obtained through the umbilical artery or vein to ascertain biochemical status. Results will enable appropriate administration of resuscitation drugs:

Naloxone hydrochloride Naloxone is a powerful anti-opioid drug for the reversal of the effects of maternal narcotic drugs given in the preceding 3 hours. It should be used with caution and only in specific circumstances.

  • Ventilation should be established prior to its use.
  • It must not be given to apnoeic babies.
  • A dose of up to 100 ?g/kg body weight may be administered intramuscularly for prolonged action.
  • As opioid action may persist for some hours, the midwife must be alert for signs of relapse when a repeat dose may be required.
  • It should [italics]not be administered to babies of narcotic-addicted mothers, as this may precipitate acute withdrawal.

     

Sodium bicarbonate

This is not recommended for brief periods of cardiopulmonary resuscitation.

  • Once tissues are oxygenated by lung inflation with 100% oxygen and cardiac compression, the acidosis will self-correct unless asphyxia is very severe.
  • If the heart rate is less than 60 bpm despite effective ventilation, chest compression and two intravenous doses of adrenaline (epinephrine) then sodium bicarbonate 4.2% solution (0.5 mmol/ml) can be administered using 2-4 ml/kg (1-2 mmol/kg) by slow intravenous injection.
  • It should be given at a rate of 1 ml/minute in order to avoid rapid elevation of serum osmolality with the attendant risk of intracranial haemorrhage.
  • It should [italics]not be given prior to ventilation being established.
  • THAM 7% (tris-hydroxymethyl-amino-methane) 0.5 mmol/kg may be used in preference to sodium bicarbonate.

     

Adrenaline (epinephrine)

This is indicated if the heart rate is less than 60 bpm despite 1 minute of effective ventilation and chest compression.

  • An initial dose of 0.1-0.3 ml/kg of 1:10 000 solution (10-30 ?g/kg) can be given intravenously; this may be repeated after 3 minutes for a further two doses.
  • The Royal College of Paediatrics and Child Health (1997) recommends a higher dose of 100 ?g/kg intravenously, if there is no response to the boluses. It is reasonable to try giving one dose of adrenaline (epinephrine) 0.1 ml/kg of 1:1000 via the endotracheal tube, as this sometimes has an immediate effect.

Hypoglycaemia is not usually a problem unless resuscitation has been prolonged. A solution of dextrose 10% 3 ml/kg may be given intravenously to correct a blood sugar of less than 2.5 mmol/l.

Observations and after-care Throughout the resuscitation procedure the baby's response is monitored and recorded. An accurate written record detailing the resuscitation events is essential. The endotracheal tube may be left in place for a few minutes after the baby starts to breathe spontaneously. Suction may be applied through the endotracheal tube as it is removed. Explanation must be given to the parents about the resuscitation and the need for transfer to hospital (if the baby was born at home) or to the neonatal unit. The principles of resuscitation of the newborn are applicable wherever and whenever apnoea occurs. The midwife must be able to implement emergency care while awaiting medical assistance:

Key points for practice

  • Anticipation of problems
  • Checking of resuscitation equipment
  • Starting clock
  • Suctioning
  • Keeping baby warm
  • Apgar score
  • Bag and mask ventilation
  • Endotracheal ventilation
  • Cardiac massage
  • Drugs
  • Other problems

     

Resuscitation action plan

A Anticipation        Assessment (Apgar)       Airway - clear debris

B Breathing           Bag + mask

C Circulation         Cardiac massage            Caring - warmth, comfort

D Doctor                Drugs                              Documentation

E Explanation        Environment                   Endotracheal tube

F Follow-up care   Family

Further reading

Resuscitation Council UK. (2015) Resuscitation and support of transition of babies at birth. https://www.resus.org.uk/resuscitation-guidelines/resuscitation-and-support-of-transition-of-babies-at-birth/

 

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