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The Apgar score determines the infant’s clinical condition after birth. It consists of scoring the infant’s heart rate, breathing, colour, tone and response to stimulation.
The heart rate can be counted by listening to the heart with a stethoscope, or by feeling the pulsations of the umbilical arteries at the base of the umbilical cord. The femoral, brachial and carotid arteries are difficult to feel immediately after birth. Usually the heart rate is counted for 30 seconds and then multiplied by 2, or counted for 15 seconds and multiplied by 4. A wall clock with a second hand is needed in all delivery rooms.
The normal heart rate is 140 beats per minute with a range of 120 to 160. If the heart rate is 100 or more, a score of 2 is given. A score of 1 is given if the heart rate is less than 100, while a score of 0 is given if no heart beat can be detected.
Observe the infant’s respiratory movements. If the infant breathes well or cries, a score of 2 is given. If there is poor or irregular breathing, or occasional gasping only, a score of 1 is given. A score of 0 is given if the infant does not make any attempt to breathe. If infants are being ventilated, stop the ventilation for a few seconds to assess any spontaneous respiration.
The infant’s tongue must be examined to determine the presence or absence of central cyanosis (blue). Normally the tongue is pink. Do not look at the infant’s lips or mucous membranes of the mouth as their colour is not reliable. Also look at the infant’s hands and feet for peripheral cyanosis (blue or grey). Most infants have peripheral cyanosis for the first few minutes after birth. This is normal.
If the tongue, hands and feet are pink the infant is given a score of 2. If the tongue is pink but the hands and feet are cyanosed, a score of 1 is given. A score of 0 is given if the tongue, hands and feet are all cyanosed.
The normal infant has good muscle tone at delivery. When lying face up, the arms and feet are moved actively in the air or are held in a flexed position against the body. If the tone and movement appear normal, a score of 2 is given. If there is some movement of the limbs but the tone appears decreased, then a score of 1 is given. With decreased tone the limbs are usually not flexed but lie in an extended position away from the body and resting on the towel. If the infant is completely limp and does not move at all, a score of 0 is given. Healthy, normal preterm infants often have poor tone and are given a score of only 1.
The infant can be stimulated by simply drying with a towel. There is no need to repeatedly flick the feet to assess a response to stimulation. If the infant responds well with a cry and movement of the limbs, a score of 2 is given. However, if the response is poor, a score of 1 is given. A score of 0 is given if there is no response to stimulation.
The individual scores of the 5 criteria are now added up to give the Apgar score. The best way to learn how to perform an Apgar score accurately is to score infants with an experienced colleague. With practice the Apgar score can be accurately performed in less than a minute. Do not guess the Apgar score as this is usually higher than the correctly assessed score. Always record the Apgar score in the infant’s notes.
The individual scores and total Apgar score are recorded at 1 minute on a special form which should be attached to the infant’s notes. The score is repeated at 5 minutes if active resuscitation is required.
|1 minute||5 minutes|
|Heart rate per minute||None||0||None||0|
|Less than 100||1||Less than 100||1|
|More than 100||2||More than 100||2|
|Colour||Centrally cyanosed||0||Centrally cyanosed||0|
|Peripherally cyanosed||1||Peripherally cyanosed||1|
|Peripherally pink||2||Peripherally pink||2|
|Some flexion||1||Some flexion||1|
|Active/well flexed||2||Active/well flexed||2|
|Response to stimulation||None||0||None||0|
|Some response||1||Some response||1|
|Good response||2||Good response||2|
The infant must lie supine (back down) on a firm, flat horizontal surface. A resuscitation unit, table or bed can be used. Ideally, the working surface should be at the height of the examiner’s waist. Stand at the head of the infant. The infant’s neck should be slightly extended (in the ‘sniffing position’). Do not overextend the neck as this may obstruct the airway. If possible, a folded nappy or sheet should be placed under the infant’s shoulders to keep the head in the correct position.
If you pretend that you are offered a flower to smell, you would hold the flower in front of your nose, push your head slightly forward and slightly extend your neck. This is the position that you want the infant’s head and neck to be in as it keeps the upper airways open (and makes the vocal cords easier to see with a laryngoscope).
Figure 1A-1: The position of the head during mask ventilation
A self-inflating neonatal ventilation bag and mask is an essential piece of equipment. If possible a soft face mask with a cushioned rim should be used. A neonatal Laerdal or similar bag with moulded face masks is recommended. A ventilation bag can also be used with an endotracheal tube.
The bag and mask can be dismantled and cleaned with soap and water. Shake and then allow to dry before reassembling. The mask can best be cleaned with an alcohol swab. However, if possible, the bag and mask should be gas sterilised after use. To test the device, you should not be able to squeeze the bag if the mask is pressed against the palm of your hand.
If additional oxygen is needed, make sure that the oxygen source is switched on at 5 litres per minute to ensure an adequate flow. Humidification is not necessary. A reservoir is needed if high percentages of oxygen need to be given. A bag and mask can be used with room air alone. Remember that you can only provide supplementary oxygen via a bag and mask if the bag is regularly squeezed.
The mask must be firmly placed over the infant’s nose and face (from the tip of the chin to the top of the nose but do not cover the eyes). It is important to choose the correct size mask.
Hold the mask firmly against the infant’s face so that there are no air leaks. The mask should be held in place with the left hand while the bag is compressed at about 40 times per minute with the right hand. Use the thumb and index finger on top of the mask with middle finger under the chin. The little and ring fingers are placed under the angle of the infant’s jaw so that the jaw can be gently pulled upwards to help keep the airway open and the tongue from falling back. An inserted oral airway is not needed if mask ventilation is only given for a few minutes.
When giving bag and mask ventilation, always watch for chest movement. Squeeze the bag hard enough to move the chest with each inspiration. Good, bilateral air entry over the sides of the chest (in the axilla) should be heard if ventilation is adequate.
Most infants can be well ventilated with bag and mask if the airway is open and clear.
Figure 1A-2: A bag and mask for resuscitation
Figure 1A-3: An endotracheal tube with an introducer in place
Figure 1A-4: A laryngoscope with a small, straight blade
Figure 1A-5: The blade of the laryngoscope on the tongue
Figure 1A-6: A view of the epiglottis
Figure 1A-7: The laryngoscope is lifted upwards to see the vocal cords. Note that the tip of the blade is in the hollow just before the epiglottis.
Figure 1A-8: View of the larynx.
Figure 1A-9: Introducing the endotracheal tube.
The equipment must be checked daily to make certain that everything is present and in good working order.
A plastic intubation head model can be used to learn the method of laryngeal intubation. The correct ‘tip to lip’ distance of an endotracheal tube with oral intubation is approximately the infant’s weight plus 6 cm (e.g. 2.3 + 6 = 8.3 cm for a 2.3 kg infant).
If the heart rate remains below 60 beats per minute after adequate ventilation has been achieved for one minute, the infant should be given regular chest compressions (cardiac massage) to improve the circulation to the heart, brain and other organs.
An assistant ventilates the infant while you give chest compressions. The person giving chest compressions stands at the feet of the infant while the person ventilating the infant stands at the head. With the infant supine (back down) and the head facing away from you, place both of your hands under the infant’s chest. Both thumbs are now placed on the lower half of the infant’s sternum about 1 cm below the level of the nipples and 1 cm above the tip of the sternum. It is best to place one thumb over the other in a small infant as the sternum is very narrow. This will prevent you pushing on the infant’s ribs. Push down with both thumbs but do not squeeze the chest. This will depress the sternum about one third of the chest diameter (by about 2 cm). Keep your hands and thumbs in contact with the chest wall both when you are pushing down and while the chest is allowed to expand again. Push down on the sternum at about 90 times per minute. Continue with the cardiac massage until the infant’s heart rate increases to above 60 beats per minute.
Pressing on the sternum compresses the heart between the sternum and the spine. This squeezes blood out of the heart and into the circulation. When the sternum returns to the normal position, the heart fills again with blood. Therefore it is important that the chest be allowed time to expand fully after each compression. Repeated compression of the heart causes the blood to circulate throughout the body.
Figure 1A-10: The position of the hands when giving chest compressions.
When ventilation and chest compressions are both being given, 30 breaths and 90 chest compressions should be given each minute. This means 3 compressions to each ventilation. However, it is important to avoid giving a breath and a chest compression at the same time, especially with bag and mask ventilation.
Therefore chest compressions and breaths must be co-ordinated. This is best achieved if the person giving the chest compressions counts out aloud ‘one-and-two-and-three-and-breath-and-one-and-two-and- …’. At each number count (one-and-two-and-three) the chest is compressed and then allowed to relax. At the count of ‘breath’ the chest is not compressed but the infant is given a breath. Note that the ventilation rate is reduced to 30 breaths per minute in order to allow time for chest compressions. Once chest compressions are stopped the ventilation rate should be increased again to 40 breaths per minute.
The T-piece infant resuscitator is a very easy and safe way of ventilating a newborn infant who requires resuscitation. A blender and flow meter with an oxygen and air source are needed. As the Neopuff (manufactured by Fisher & Paykel Healthcare) is widely used in South Africa it has been chosen to explain how to provide ventilation.
Figure 1A-11: T-piece infant resuscitator.