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No. Most newborn infants start to breathe well without assistance and often cry immediately after birth. By 1 minute after delivery most infants are breathing well or crying. If an infant fails to establish adequate, sustained respiration after delivery (gasps only or does not breathe at all) the infant is said to have failed to breathe well at birth. About 10% of all newborn infants fail to breathe well and require some assistance to start breathing well after birth.
Infants should cry or breathe well after delivery.
Failure to breathe well will result in hypoxia if the infant is not rapidly resuscitated. Therefore failure to breathe well is an important cause of neonatal death if not managed correctly.
Hypoxia is defined as too little oxygen in the cells of the body. Hypoxia may occur in the fetus or the newborn infant. If the placenta fails to provide the fetus with enough oxygen, hypoxia will result and cause fetal distress. Similarly, with failure to breathe well after delivery the infant will develop hypoxia if not correctly managed. As a result of hypoxia, before or after delivery, the heart rate falls, central cyanosis develops and the infant becomes hypotonic (floppy) and unresponsive. Most fetal hypoxia occurs during labour (i.e. intrapartum hypoxia).
Hypoxia is defined as too little oxygen in the cells of the body.
The Apgar score is a method of assessing an infant’s clinical condition after delivery. The Apgar score is based on 5 vital signs:
Each vital sign is given a score of 0 or 1 or 2. A vital sign score of 2 is normal, a score of 1 is mildly abnormal and a score of 0 is severely abnormal. The individual vital sign scores are then totalled to give the Apgar score out of 10. The best possible Apgar score is 10 and the worst 0. An infant with a score of 0 shows no sign of life.
Normally the Apgar score is from 7 to 10. Infants with a score between 4 and 6 have moderate depression of their vital signs while infants with a score of 0 to 3 have severely depressed vital signs and are at great risk of dying unless actively resuscitated.
Due to the presence of peripheral cyanosis in most infants at delivery, it is unusual for a normal infant to score 10 at 1 minute. By 5 minutes most infants will have a score of 10. If the Apgar score is guessed, and not correctly assessed, too high a score is usually given. This is a common error in Apgar scoring.
A normal Apgar score is 7 or higher.
The Apgar score should be performed on all infants at 1 minute after complete delivery to record the infant’s clinical condition after birth. If the 1 minute Apgar score is below 7, then the Apgar score should be repeated at 5 minutes to document the success or failure of the resuscitation efforts. If the 5 minute Apgar score is still low, it should be repeated every 5 minutes until a normal Apgar score of 7 or more is achieved. In many hospitals, the Apgar score is often routinely repeated at 5 minutes even if the 1 minute score was normal. This is not necessary and the infant should rather be handed to the mother. Apgar scoring is an important way to document the infant’s clinical condition and the response to resuscitation in the hospital or clinical records.
If an infant does not breathe well after being dried, it is important to start resuscitation immediately and not wait for the 1 minute Apgar score.
All infants should receive an Apgar score at 1 minute to document the infant’s clinical condition after delivery.
There are many causes of a low Apgar score. These include:
Fetal distress due to hypoxia during labour is only one of the many causes of failure to breathe well at birth.
It is important to always try and find the cause of a low 1 minute Apgar score. If the Apgar score remains low at 5 minutes, despite good resuscitation efforts, the infant probably had fetal hypoxia before birth.
Intrapartum hypoxia is the most important cause of failure to breathe well at birth.
Resuscitation is a series of actions taken to establish normal breathing, heart rate, colour, tone and activity in a newborn infant with depressed vital signs (i.e. a low Apgar score).
All infants who do not breathe well after delivery need immediate resuscitation. Therefore, it is important to formally asses an infant’s breathing after delivery. Any infant who stops breathing or has depressed vital signs at any time after delivery or in the nursery also requires resuscitation.
All infants who do not breathe well at birth must be resuscitated.
The following clinical situations often lead to the delivery of an infant who does not breathe well:
Remember that any infant can be born with failure to breathe well without prior warning. It is essential, therefore, to be prepared to resuscitate any newborn infant. Everyone who delivers an infant must be able to perform resuscitation.
Any infant can fail to breathe well without warning signs during labour.
It is essential that you have all the equipment needed for basic infant resuscitation. The equipment must be in good working order and immediately available. The equipment must be checked daily.
A warm, well-lit corner of the delivery room should be available for resuscitation. A heat source, such as an overhead radiant warmer, is needed to keep the infant warm. Avoid draughts. A good light, such as an angle poise lamp, is required so that the infant can be closely observed during resuscitation. A firm, level working area is needed. A thin foam mattress with a plastic covering can be easily cleaned.
The following essential equipment must be available in all hospitals and clinics where infants are delivered:
While a pulse oximeter is not essential it is very useful to monitor the infant’s heart rate and oxygen saturation response to resuscitation. Place the probe on the infant’s right hand.
All resuscitation equipment must be available and checked every day.
Immediately after birth all infants must be thoroughly dried with a warm towel and then placed in a second warm, dry towel before they are clinically assessed. This prevents rapid heat loss due to evaporation, even in a warm room. Dry the infant’s head, body, arms and legs and wipe any blood or maternal faeces off the face,Handling and rubbing the newborn infant with a dry towel is usually all that is needed to stimulate the onset of breathing. Most infants can be dried on the mother’s abdomen. There is no need to smack newborn infants to get them to breathe. Never shake an infant. If the infant does not cry or breathe well in response to drying and stimulation, the umbilical cord must be cut and clamped immediately and the infant must be moved to the resuscitation area.
Dry to stimulate breathing in all infants immediately after delivery.
Infants who are active and breathe well can stay with their mother. It is best to delay clamping their umbilical cord for 2 to 3 minutes if the infant does not need resuscitation. Then the infant should be placed in the kangaroo mother care position to keep warm. Infants who breathe well should not be routinely suctioned as this is not necessary and suctioning sometimes causes apnoea. Infants born by Caesarean section also need not be routinely suctioned. However, the infant’s mouth can be wiped with a clean towel if there are excessive secretions.
It is not necessary to routinely suction the mouth and nose of infants after delivery.
If the infant fails to respond to the stimulation of drying, then the infant must be actively resuscitated. The most experienced person, irrespective of rank, should resuscitate the infant. However, all staff who conduct deliveries must be able to resuscitate infants. It is very helpful to have an assistant during resuscitation. Stand at the head of the infant where it is easier to carry out the steps needed in resuscitation.
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. Therefore the steps in neonatal resuscitation are:
If opening the airway fails to start breathing, the infant needs ventilation. Do not waste time by giving oxygen, without also applying ventilation, if the infant does not breathe.
If an infant fails to breathe well after birth, ventilation should be started as soon as possible but preferably within one minute (‘The golden minute’). The Apgar score should be determined at 1 to assess the infant’s clinical condition.
Infants needing ventilation include:
Ventilation is indicated if the infant does not breathe well.
Most infants who breathe well will have a good heart rate and soon become centrally pink. Free-flow mask oxygen alone, without ventilation, is only indicated in the few infants who breathe well with a good heart rate but remain centrally cyanosed. Even in infants who are warm and breathe well, peripheral cyanosis may take up to 10 minutes to resolve.
Most infants can be adequately ventilated with a bag and mask in room air.
Ventilation is usually given with room air. However sometimes it may be necessary to give supplementary oxygen until good breathing efforts and heart rate are established. Set the flow meter at 5 litres per minute. Added oxygen can usually be stopped once the infant is centrally pink and the heart rate normal. It is very useful to have a blender and pulse oximeter so that the amount of oxygen can be monitored and controlled.
Remember that a self-inflating bag and mask will not deliver oxygen unless the bag is squeezed. A reservoir is needed to provide an infant with 100% oxygen.
A T-piece infant resuscitator is a very efficient method of ventilating a newborn infant by face mask or endotracheal tube.
Oxygen: If possibly infants should be resuscitated in room air only without additional oxygen. Only if the heart rate does not increase to 100 beats per minute or if central cyanosis remains despite adequate ventilation should oxygen be given. Oxygen should be reduced then stopped as soon as possible.
Adequate ventilation is the most important step in newborn resuscitation.
Once adequate ventilation has been given for one minute, the infant’s breathing, colour and heart rate must be assessed. Stop ventilation once the infant is pink and breathing well with a heart rate above 100 beats per second. If the heart rate remains below 60 beats per minute in spite of effective ventilation for one minute seconds, chest compressions are needed. A good heart rate is the best indicator of adequate ventilation.
A good heart rate is the best indicator of adequate ventilation.
Apply chest compressions (external cardiac massage) at a rate of about 90 times a minute. Usually three chest compressions are followed by one ventilation (a breath). One or both hands can be used to give chest compressions.
Chest compressions are indicated if the heart rate is less than 60 beats per minute after one minute of adequate ventilation.
Once both effective ventilation and chest compressions have been given for one minute, again assess the infant’s breathing, colour and heart rate. When the heart rate reaches above 60 beats per minute, chest compressions can be stopped and the heart rate carefully monitored. If the heart rate has not increased above 60 beats per minute, give adrenaline (epinephrine) to stimulate the heart.
Adrenaline 1:10 000 should be given intravenously, usually into the umbilical vein or a peripheral line. Adrenaline stimulates the myocardium and increases the heart rate. 1 ml of adrenaline 1:1000 must first be diluted with 9 ml normal saline to give a 1:10 000 solution. One ml of the diluted solution can then be given to term infants and 0.5 ml to preterm infants (recommended dose is 0.25 ml/kg of diluted adrenaline). Adrenaline is important if the heart rate remains slow or if no heart beat can be detected. The dose can be repeated every 3 to 5 minutes if the heart rate does not increase to above 60 beats per minute. Do not give adrenaline subcutaneously or by intramuscular injection.
Adrenaline is indicated if the heart rate is less than 60 beats per minute after one minute of chest compressions.
If the infant has a good heart rate and is centrally pink, but still does not breathe, consider giving naloxone (Narcan) if the mother has received an opiate analgesic (pethidine or morphine) in the 4 hours before delivery.
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 narcotic depression. If so, the depressing effect of the maternal analgesia on the infant’s respiration can be rapidly reversed with naloxone (1 ml ampoule contains 0.4 mg naloxone). Naloxone 0.1 mg/kg (i.e. 0.25 ml/kg) can be given by intramuscular injection into the anterolateral aspect of the thigh. Naloxone will not help resuscitate an infant if the mother has not received an opiate analgesic during labour, or has only received a general anaesthetic, barbiturates or other sedatives. Naloxone is not a general respiratory stimulant. Never give naloxone before providing adequate ventilation.
Naloxone must only be used after adequate ventilation has been provided.
With experience and further training, additional medication (e.g. dopamine) can be given to support the blood pressure and circulation if the above steps fail to resuscitate the infant:
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:
Every effort should be made to resuscitate all infants that show any sign of life at delivery unless the infant’s gestational age, weight or severe congenital disorders indicate a very poor chance of survival. The Apgar scores at 1 and 5 minutes are not a good indicator 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 must be continued. It is important to keep repeating the Apgar score every 5 minutes until the score is normal or resuscitation is abandoned.
If the infant has not started to breathe, or only gives occasional gasps by 20 minutes, the chance of death or brain damage is extremely high. The exception is when the infant is sedated by maternal drugs. It is preferable if an experienced person decides when to abandon further attempts at resuscitation. Resuscitation can also be stopped if there are no signs of life (no heart beat) after 10 minutes.
Infants that start breathing as soon as mask and bag ventilation is provided can be observed with their mothers. However infants who require more prolonged ventilation must be carefully observed in the newborn nursery for at least 4 hours after delivery. Their temperature, pulse and respiratory rate, colour and activity should be recorded and their blood glucose concentration checked. 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.
If the infant has signs of respiratory difficulty, or is centrally cyanosed in room air after resuscitation, it is essential to provide oxygen while the infant is being moved to the nursery. Some infants may even require ventilation during transport.
Careful notes must be made describing the infant’s condition at birth, the resuscitation needed and the probable cause of the failure to breathe well at birth.
Yes. All infants that have meconium-stained amniotic fluid (liquor) need special care to reduce the risk of severe meconium aspiration after delivery. Whenever possible all these at-risk infants should be identified before delivery, especially infants with thick meconium in the amniotic fluid.
As a result of hypoxia before delivery, the fetus may pass meconium. Some hypoxic fetuses will also make gasping movements which can suck meconium into the upper airways together with amniotic fluid. Fortunately most of the meconium is unable to reach the fluid-filled alveoli of the fetus. Only after delivery, when the infant inhales air, does meconium enter the small airways and alveoli.
Meconium contains enzymes from the fetal pancreas that can cause severe lung damage and even death if inhaled into the alveoli after delivery. Meconium also obstructs the airways. This results in respiratory distress due to meconium inhalation. Meconium aspiration sydrome remains a common problem is many developing countries.
Many cases of meconium aspiration syndrome can be prevented with the correct care of the infant during delivery. A suction apparatus and a F10 end-hole catheter must be ready at the bedside. If possible, the person conducting the delivery should have an assistant to suction the infant’s mouth when the head delivers.
After delivery of the head, the shoulders should be held back and the mother asked to pant to prevent delivery of the trunk. The infant’s face is then turned toward the assistant so that the mouth and pharynx can be well suctioned. Only when no more meconium can be cleared, should the infant be completely delivered. The same process should be followed if a meconium-stained infant is delivered by Caesarean section. Suctioning should not take more than 30 seconds.
Some infants develop apnoea and bradycardia as a result of the suctioning and, therefore, may need mask ventilation for a few minutes after delivery.
Meconium-stained infants must be suctioned before delivery of the shoulders.
No further suctioning is needed if the infant was well suctioned during delivery and cries well at birth. The mouth can be wiped with a towel and meconium can be removed from the skin during routine drying.
If a meconium-covered infant needs resuscitation, it is better to intubate the infant immediately to clear the airways. Once intubated, direct suction can be applied to the endotracheal tube. Withdraw the endotracheal tube slowly while applying suction. Repeat intubation and suction until no more meconium is obtained. This aggressive method of suctioning is very successful in preventing severe meconium aspiration. Alternatively the pharynx can also be suctioned under direct vision using a laryngoscope, before ventilation is started. Do not use bag and mask ventilation before adequately suctioning meconium-stained infants as this can blow meconium from the pharynx into the lungs.
Meconium-stained infants who require resuscitation need suctioning before starting ventilation.
Meconium gastritis may be prevented by washing out the stomach with normal saline or 2% sodium bicarbonate (mix 4% sodium bicarbonate with an equal volume of sterile water). Five ml of normal saline or 2% sodium bicarbonate is repeated injected into the stomach via a nasogastric tube and then aspirated until the gastric aspirate is clear. Only heavily meconium-stained infants should have a stomach washout on arrival in the nursery. This should be followed by a feed of colostrum. Routine stomach washouts in all preterm infants or infants born by Caesarean section are not needed. A stomach washout is also not needed if there is only lightly meconium-stained amniotic fluid.
Meconium-stained infants do not need to be washed or bathed immediately after delivery but should be carefully wiped with a warm towel.
A stomach washout is only needed if the infant is covered with thick meconium.
If the cells of the fetus or newborn infant do not receive enough oxygen, many organs may be damaged. This may result in either:
Fetal hypoxia may cause brain damage.
Different types of brain damage can occur depending on the gestational age of the fetus and the severity of the hypoxia:
Most infants with neonatal encephalopathy behave abnormally in the first 12 hours after delivery. Most, but not all, cases of neonatal encephalopathy are due to intrapartum hypoxia (hypoxia during labour or just before delivery). Hypoglycaemia, meningitis and brain haemorrhage can also give neonatal encephalopathy.
Neonatal encephalopathy presents with abnormal neurological signs soon after birth.
Prevent severe hypoxia, if possible, by good monitoring and care in labour and active resuscitation after delivery if needed. Once the hypoxic and ischaemic brain damage is done, there is little that can repair this.
After a normal pregnancy, an infant is born by elective caesarian section under general anaesthesia. Immediately after delivery the infant is dried and placed under an overhead radiant warmer. He is not breathing and resuscitation is started. At 1 minute after birth the infant has a heart rate of 80 beats per minute, gives irregular gasps, has blue hands and feet but a pink tongue, has some muscle tone but does not respond when dried. Resuscitation is started and at 5 minutes the infant has a heart rate of 120 beats per minute and is breathing well. The tongue is pink but the hands and feet are still blue. The infant moves actively and cries well.
The Apgar score at 1 minute is 4: heart rate=1, respiration=1, colour=1, tone=1, response=0.
Because he is not breathing well after being dried. The diagnosis of failure to breathe well is supported by the low Apgar score at 1 minute.
The general anaesthetic. Both the intravenous drugs and the anaesthetic gases cross the placenta and may sedate the fetus. These sedated infants usually respond rapidly to resuscitation.
If respiration cannot be stimulated by drying the infant, then ventilation must be started. Most infants can be adequately ventilated with a bag and mask. If good chest movement cannot be obtained with mask ventilation, the infant must be intubated and ventilated.
The Apgar score at 5 minutes is 9: heart rate=2, breathing=2, colour=1, tone=2, response=2. This indicates that the infant has responded well to resuscitation. Blue hands and feet (peripheral cyanosis) at 5 minutes are common.
Because there is no history of fetal distress to indicate that this infant had been hypoxic before delivery. The rapid response to resuscitation also suggests that there was no fetal hypoxia. There is also no good reason why the fetus should be hypoxic as the mother has had an elective Caesarean section and was not in labour. Most fetal hypoxia occurs during labour.
The infant should be kept warm and be transferred to the nursery for observation for a few hours.
After fetal distress has been diagnosed, an infant is delivered by a difficult vacuum extraction. At delivery the infant is covered with thick meconium. The infant starts to gasp. Only then are the mouth and pharynx suctioned for the first time. The Apgar score at 1 minute is 3. The infant is given face mask oxygen and by 5 minutes the Apgar score is 6. By 15 minutes the infant is active and crying well. It is decided to bath the infant and give a stomach washout in the labour ward before transferring both mother and infant to the postnatal ward.
Hypoxia resulting in fetal distress, as indicated by the passage of meconium before delivery. The difficult delivery by vacuum extraction probably resulted in failure to breathe well and a low Apgar score, while inhaled meconium may have blocked the airway.
The infant’s mouth and pharynx should have been well suctioned before the shoulders were delivered. This will usually prevent severe meconium aspiration as the airway is cleared of meconium before the infant starts to breathe.
A large catheter (F10) must be used as a small catheter will block with meconium. The catheter should have a hole at the end and not just at the side.
No. A bath should not be done until the infant has been stable for a number of hours in the nursery. As there was thick meconium, the infant should be given a stomach washout with normal saline or 2% sodium bicarbonate in the nursery followed by a breastfeed.
This infant may develop meconium aspiration syndrome as meconium was probably inhaled into the lungs after birth. The infant may also suffer brain damage or damage to other organs due to hypoxia causing fetal distress during labour.
It suggests that the infant has not been correctly resuscitated. This infant needed intubation and suctioning followed by ventilation, and not just face mask oxygen.
A woman with an abruptio placentae delivers at 32 weeks. Before delivery the fetal heart rate was only 80 beats per minute. The infant appeared dead at birth but was intubated and ventilated. Chest compressions were also given, and the heart rate remained slow after ventilation was started. The 1 minute Apgar score was 2. Despite further efforts at resuscitation, the Apgar score at 5, 10, 15 and 20 minutes remained 2.
Fetal distress caused by fetal hypoxia. Abruptio placentae (placental separation before delivery) is a common cause of severe hypoxia and fetal distress.
If a fetal heart is heard just before delivery but the infant appears dead at birth, the duration of cardiac arrest has only been a few minutes. With ventilation and chest compressions, it is possible to resuscitate some of these infants. Many of the survivors do not suffer brain damage.
Prolonged failure to respond well to good resuscitation suggests that the infant will die due to severe hypoxic damage to the brain and heart.
The brain, heart, kidneys, gut and lungs.
Abnormal neurological behaviour of a term or near term newborn infant within hours of birth. The important features of neonatal encephalopathy are altered level of consciousness, abnormal muscle tone, poor feeding and breathing, depressed reflexes and convulsions. Neonatal encephalopathy is usually due to intrapartum hypoxia.
If there is no heart beat after 10 minutes or no attempt at breathing after 20 minutes.
After a normal labour and delivery at term, an infant cries well at birth. No maternal analgesia was needed and the amniotic fluid was not meconium stained. The infant is well suctioned after delivery as this is the routine practice in the clinic. Immediately after suctioning the infant stops breathing and becomes cyanosed. The 1 minute Apgar score is not done. The medical officer tries unsuccessfully for 5 minutes to intubate the infant. When an intramuscular injection of naloxone fails to stimulate respiration, further attempts at resuscitation are abandoned. The infant is centrally cyanosed, has a heart rate of 50 beats per minute and starts to gasp at 5 minutes. Face mask oxygen was given and eventually the infant cried weakly. No one at the clinic had been trained in basic neonatal resuscitation.
The infant’s mouth and throat should not have been suctioned as there was no clinical indication. The infant breathed well after delivery and was not meconium stained. Normal infants must not be routinely suctioned. Suctioning clear liquor from the mouth and throat before starting ventilation is probably not needed. The 1 minute Apgar score should have been done to document the infant’s clinical condition at this time.
Excessive, deep suctioning often causes apnoea. This is why routine suctioning has been stopped.
The head and neck should have been correctly positioned to open the airway. Then bag and mask ventilation should have been given. With this basic resuscitation, the infant would almost certainly have started to breathe normally and cry. The infant became more and more hypoxic while attempts were made to intubate the trachea. The Apgar should also have been done at 5 minutes and every 5 minutes thereafter to record the condition of the infant during the resuscitation attempt.
Naloxone is useful in reversing respiratory depression in the newborn infant if the mother had received pethidine or morphine during the 4 hours before delivery. There was no indication for giving naloxone in this infant as the mother had not received any analgesia. Naloxone is not a respiratory stimulant.
No. Attempts should be continued for at least 20 minutes. An urgent telephone call to the referral hospital could have provided the correct advice needed. Some infants with poor breathing at birth will eventually start gasping spontaneously even if the correct resuscitation is not given. However, during the period of inadequate resuscitation the infant becomes progressively more hypoxic. This can result in brain damage.
All the medical and nursing staff who deliver infants or care for them at delivery. Often it cannot be predicted during labour which infants will not breathe well and need resuscitation. Clinics and hospitals should not deliver infants if they do not have the correct equipment and are not able to provide good resuscitation.
Only if the heart rate remained below 60 per minute after 60 seconds of effective ventilation. With early bag and mask ventilation the heart rate would almost certainly have increased and the cyanosis disappeared.
See Figure 1-1, the important steps in basic newborn resuscitation.
Figure 1-1: The important steps in basic newborn resuscitation.