Resuscitation of the newborn
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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:
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.
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
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:
(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.
This is not recommended for brief periods of cardiopulmonary resuscitation.
This is indicated if the heart rate is less than 60 bpm despite 1 minute of effective ventilation and chest compression.
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
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
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/