Perinatal Education Programme - Care of infants at birth

Resuscitation

36-31 WHAT IS RESUSCITATION?

Resuscitation is a series of actions taken to establish normal breathing, heart rate, colour, tone and response in an infant with abnormal vital signs, i.e. a low Apgar score.

36-32 WHICH INFANTS NEED RESUSCITATION?

All infants who do not breathe well by 1 minute after delivery, or have a 1 minute Apgar score below 7, need resuscitation. The lower the Apgar score the more resuscitation is usually needed. Any infant who stops breathing or has abnormal vital signs at any time after delivery or in the nursery also requires resuscitation.

ALL INFANTS WITH ASPHYXIA, OR A 1 MINUTE APGAR SCORE BELOW 7, REQUIRE RESUSCITATION

36-33 CAN YOU ANTICIPATE WHICH INFANTS WILL NEED RESUSCITATION AT BIRTH?

Yes. Any of the conditions which cause asphyxia may result in the infant needing resuscitation. However, asphyxia cannot always be predicted before delivery. Remember that any infant can be born with asphyxia without any previous warning. It is essential, therefore, to be prepared to resuscitate all newborn infants. Everyone who delivers an infant must be able to perform resuscitation.

ANY INFANT CAN HAVE ASPHYXIA AT BIRTH WITHOUT WARNING SIGNS DURING LABOUR AND DELIVERY

36-34 WHAT IS NEEDED TO RESUSCITATE A NEWBORN INFANT?

1. A suitable, warm area with good lighting.

2. The correct, clean and functioning equipment.

3. The knowledge and skills.

36-35 WHAT IS A SUITABLE RESUSCITATION AREA?

A warm area with good light and a working surface at a comfortable height is needed. In a clinic or hospital, some source of oxygen and suction should be available together with storage space for the equipment. Make sure there is no draught. The temperature of the resuscitation area should be at least 25⁰ C.
A warm, well lit corner of the delivery room is ideal for resuscitation. A heat source, such as an overhead radiant warmer or wall heater, is needed to keep the infant warm. A good light, such as an angle-poise lamp, is essential so that the infant can be closely observed during resuscitation. A firm, flat surface at waist height is best for resuscitating an infant. There is no need to have the infant lying head down, and the neck must not be overextended. It is very useful to have warm towels to dry the infant.

36-36 WHAT EQUIPMENT DO YOU NEED FOR INFANT RESUSCITATION?

It is essential that you have all the equipment needed for basic infant resuscitation. The equipment must be clean, in working order and immediately available. The equipment must be checked daily.
The following essential equipment must be available in the delivery room:

1. SUCTION APPARATUS: An electric or wall vacuum suction apparatus is ideal but the vacuum pressure should not exceed 200 cm water. Soft F 10 end-hole suction catheters are needed.
   A simple mouth suction apparatus (mucus extractor) can also be used. It consists of a 2 soft plastic catheters attached to a 20 ml plastic container. Although it is effective, there is a small risk that the staff could become infected with HIV if the secretions get into the mouth of the person suctioning the infant.
2. OXYGEN: Whenever possible, a cylinder or wall source of 100% oxygen should be available. However, oxygen is not essential for resuscitation.
3. SELF-INFLATING BAG AND MASK: A simple self-inflating bag and mask, e.g. Samson, Laerdal, Ambu, Penlon or Cardiff resuscitator, must be available to provide mask ventilation. Direct mouth-to-mouth resuscitation is dangerous due to the risk of becoming infected with HIV.
4. NALOXONE: Ampoules of naloxone (Narcan 0,4 mg in 1 ml). Small syringes and needles will be needed to administer the drug. Neonatal Narcan is no longer used, as the concentration of drug is too small.
5. WALL CLOCK or watch: To time the assessment of the Apgar score.

Although not essential for basic resuscitation, it is very useful to have an infant laryngoscope and endotracheal tubes so that infants with severe asphyxia can be intubated, if bag and mask ventilation is not adequate. If possible, everyone who regularly resuscitates newborn infants should learn how to intubate them.
The method of advanced neonatal resuscitation, including endotracheal intubation, is described in unit 16 in the Newborn Care manual of PEP.

36-37 HOW SHOULD YOU STIMULATE RESPIRATION IMMEDIATELY AFTER BIRTH?

After birth, all infants must be quickly dried in a warm towel and then placed in a second warm, dry towel. This must also be done to infants with asphyxia, before starting resuscitation. Drying the infant prevents rapid heat loss due to evaporation. Handling and rubbing the newborn infant with a dry towel is usually all that is needed to stimulate the onset of breathing. Stimulation alone will start breathing in most infants.

36-38 SHOULD ALL INFANTS BE ROUTINELY SUCTIONED AFTER DELIVERY?

No. Infants who breathe well at delivery should NOT have their mouth and throat routinely suctioned, as suctioning sometimes causes apnoea. Infants born by caesarean section also need not be routinely suctioned.

IT IS NOT NECESSARY TO ROUTINELY SUCTION THE MOUTH AND NOSE OF INFANTS AFTER DELIVERY

36-39 WHICH INFANTS SHOULD BE SUCTIONED AFTER DELIVERY?

1. Infants who do not breathe well after stimulation.

2. Meconium stained infants.

36-40 WHEN SHOULD YOU START TO RESUSCITATE AN INFANT?

If the infant does not breathe well and fails to respond to stimulation after drying and clamping the umbilical cord, then the infant must be actively resuscitated. Drying and clamping the cord usually takes about 1 minute. These infants will have a low 1 minute Apgar score. Although resuscitation usually starts after 1 minute, if the infant obviously has severe asphyxia, resuscitation should be started sooner.

36-41 CAN RESUSCITATION OF AN INFANT WITH SEVERE ASPHYXIA RESULT IN BRAIN DAMAGE?

Some people are worried that resuscitation may result in a live, but brain damaged infant, who would have died without resuscitation. This is very uncommon. Not all infants with severe asphyxia die. Therefore, it is better to give good resuscitation early to all infants with asphyxia and reduce the risk of brain damage that may occur if no resuscitation is given. The only infants who may not be offered resuscitation are those with a lethal congenital abnormality, such as anencephaly.

36-42 WHO SHOULD RESUSCITATE THE INFANT?

The most experienced person, irrespective of rank, should resuscitate the infant. However, everyone who conducts deliveries must have the skills and equipment to resuscitate infants. It is very helpful to have an assistant during resuscitation.

36-43 HOW DO YOU RESUSCITATE AN INFANT?

There are 4 main steps in the basic resuscitation of a newborn infant. They can be easily remembered by thinking of the first 4 letters of the alphabet, i.e. "ABCD" - AIRWAY - BREATHING - CIRCULATION - DRUGS.

STEP 1. CLEAR THE AIRWAY.

GENTLY CLEAR THE THROAT. The infant may be unable to breathe because the airway is blocked by mucus or blood. Therefore, if the infant fails to breathe after stimulation, gently suction the back of the mouth and throat with a soft F 10 catheter. Too much suctioning, especially if too deep in the region of the vocal cords, may result in apnoea and bradycardia. This can be prevented by holding the catheter 5 cm from the tip when suctioning the infant's throat. There is no need to suction the nose. Simply turning the infant onto the side will often clear the airway.
If wall suction or a suction machine are not available, a mucus extractor can be used to suction the infant’s mouth and throat. Because of the small risk of HIV infection, wall suction or a suction machine is best.
CORRECTLY POSITION THE HEAD. The upper airway (pharynx) can be opened by placing the infant’s head in the correct position. With the infant lying on its back on a flat surface, slightly extend the neck so that the face is pointing towards the ceiling. Do not overextend the neck.
If the infant is not breathing well after the airway have been suctioned and the head correctly positioned, stop suctioning and move to step 2.

STEP 2. START THE INFANT BREATHING.

If stimulation and suctioning and correct position of the head fail to start breathing, MASK AND BAG VENTILATION MUST BE STARTED. Giving mask oxygen alone often does not help. Keep the infant's neck slightly extended and hold the mask firmly over the infant’s face. Most infants can be adequately ventilated with a bag and mask, such as a Samson, Laerdal, Ambu, Penlon or Cardiff resuscitator. Ventilation is the most important part of resuscitation. Usually oxygen is used with mask and bag ventilation. However, mask and bag ventilation can be given with room air.

VENTILATION IS MORE IMPORTANT THAN OXYGEN

Respiratory stimulants, such as Vandid, must not be used, as they are dangerous and do not help.

STEP 3. OBTAIN A GOOD CIRCULATION.

If the heart rate remains below 80 beats per minute after effective ventilation has been started, apply external cardiac massage at about 120 times a minute.

STEP 4. DRUGS TO REVERSE PETHIDINE AND MORPHINE.

If the mother has received either pethidine or morphine during the 4 hour period before delivery, the infant's poor breathing may be due to drug depression. If so, the respiratory depression caused by the analgesic can be rapidly reversed with Narcan (a 1 ml ampoule contains 0,4 mg naloxone). Narcan 0,1 mg/kg (i.e. 0,25 ml/kg) can be given by intramuscular injection into the anterolateral aspect of the thigh. Intramuscular Narcan takes a few minutes before it starts to act. Do not use Neonatal Narcan, as this preparation requires too big a volume.
Narcan will not help resuscitate an infant if the mother has not received a narcotic analgesic during labour, or has received a non-opioid general anaesthetic, barbiturates or other sedatives.

MASK AND BAG VENTILATION IS THE MOST IMPORTANT STEP IN RESUSCITATING AN INFANT

36-44 HOW DO YOU GIVE OXYGEN TO AN INFANT?

Usually wall oxygen is used. Otherwise an oxygen cylinder or an oxygen concentrator is needed. Oxygen is best given by mask and bag ventilation. Sometimes oxygen by mask alone is adequate.

36-45 HOW SHOULD YOU USE A SELF-INFLATING BAG AND MASK TO VENTILATE AN INFANT?

1. THE POSITION OF THE INFANT: The infant must lie face up on a flat surface. The infant’s neck should be slightly extended. Do not over extend the neck. The infant’s face should look towards the ceiling. Infants should be kept in a warm towel during resuscitation.
2. THE APPARATUS: A number of bag and mask sets are suitable, such as the Samson, Laerdal, or Ambu resuscitators. Make sure that both the bag and mask are designed for newborn infants. If possible, the bag should be attached to an oxygen source providing 5 litres per minute. It is important that the correct size mask is used to cover the nose and mouth.
3. THE POSITION OF THE MASK: The mask must be placed over the infant’s mouth, nose and chin. Hold the mask tightly against the face so that there are no air leaks.
4. USING THE SELF-INFLATION BAG: The mask should be held in place with the left hand while the bag is squeezed at about 40 breaths per minute with the right hand. If the little and ring finger of the left hand are placed under the angle of the jaw, the jaw can be gently pulled upwards to keep the tongue from falling back. The position of the mask is the same with all types of bag. When giving mask and bag ventilation, watch the movement of the chest. Squeeze the bag hard enough to move the chest with each inspiration. Continue giving mask and bag ventilation at about 40 breaths per minute until the infant starts to cry or breathes well. A small percentage of infants with severe asphyxia will not respond to mask ventilation and need intubation and ventilation.

36-46 HOW DO YOU GIVE CARDIAC MASSAGE?

Place the infant on its back with the head towards you. Place both hands under the infant's back and press on the lower half of the sternum with both your thumbs. This will depress the sternum by about 2 cm. Push down on the sternum about 100 times a minute. Pressing on the sternum squeezes blood out of the heart and causes blood to circulate to the lungs and body.
It takes 2 people to both mask ventilate and give cardiac massage. An assistant should ventilate the infant while you give cardiac massage. After every third push on the sternum the assistant should squeeze the bag to give 1 breath after every 3 heart beats. Continue cardiac massage until the infant’s heart rate increases to 100 or more beats per minute. If you are resuscitating an infant alone, good mask ventilation is more important that cardiac massage.

36-47 HOW CAN YOU ASSESS WHETHER THE RESUSCITATION HAS BEEN SUCCESSFUL?

The 4 steps in resuscitation are followed step by step until the 3 most important vital signs of the Apgar score have returned to normal:

1. A PULSE RATE ABOVE 100 BEATS PER MINUTE.  Easily assessed by palpating the base of the umbilical cord or listening to the chest with a stethoscope.

2. A GOOD CRY OR GOOD BREATHING EFFORTS.  This assures adequate breathing.

3. A PINK TONGUE.  This indicates a good oxygen supply to the brain.  Do not rely on the colour of the lips.

With good resuscitation the Apgar score at 5 minutes should be 7 or more.

36-48 WHEN IS FURTHER RESUSCITATION HOPELESS?

Every effort should be made to resuscitate all infants that show any sign of life at delivery. The Apgar scores at 1 and 5 minutes are not good indicators of the likelihood of hypoxic brain damage or the possibility of an unsuccessful resuscitation. If the Apgar score remains low after 5 minutes, efforts at resuscitation should be continued. However, if the infant has not started to breathe, or only gives occasional gasps, by 10 minutes the chance of death or brain damage is high. Resuscitation is usually stopped if the Apgar score at 20 minutes is still low with no regular breathing. It is best if an experienced person decides when to abandon further attempts at resuscitation.
Resuscitation will not save all infants with asphyxia, but it will help most.

36-49 WHAT POST RESUSCITATION CARE IS NEEDED?

All infants that require resuscitation must be carefully observed for at least 12 hours. Their temperature, pulse and respiratory rate, colour and activity should be recorded and their blood glucose concentration measured. Keep these infants warm and provide fluid and energy, either intravenously or orally. Usually these infants are observed in a closed incubator. Do not bath the infant until the infant has fully recovered.
Careful notes must be made describing the infant's condition at birth, the resuscitation needed and the probable cause of the asphyxia.

36-50 WHAT ABOUT THE MOTHER DURING RESUSCITATION?

It is very frightening for a mother to know that her infant needs resuscitation. Therefore, it is important to tell the mother that her infant needs some help and to explain to her what is being done to the infant. Remember that the mother may start bleeding while the staff are busy resuscitating the infant.

36-51 HOW IS THE RESUSCITATION EQUIPMENT CLEANED?

It is imporant that all the resuscitation equipment is kept clean and in good working order. After a resuscitation all the equipment must be cleaned to prevent the spread of infection. The masks and mucus extractors must be washed with water and soap or detergent and rinsed. The self-inflating bags, e.g. Laerdal, Ambu and Penlon must be sterilised.

Text prepared by Dave Woods

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Edited by Aldo Campana,