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?
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
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.
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.
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?
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.
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.
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?
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.
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:
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
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.
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
Edited by Aldo Campana,