10.2 Neonatal resuscitation

10% of newborns need help breathing properly at birth; this help comes in the form of tactile stimulation and/or airway clearing.

For half of them, these procedures are not sufficient, and if the newborn is not breathing or is gasping despite stimulation/suction, ventilation is needed as of the first minute of life.
A small percentage of ventilated newborns will require more advanced resuscitation.

The birth attendant in charge of the delivery is also responsible for the newborn. S/he should start resuscitation immediately then, if necessary, call for help.

 Anticipate the potential need for resuscitation at every birth. The necessary equipment should be ready at hand and ready for use.

Hypothermia compromises resuscitation. Resuscitation should be done in a heated room, if possible under a warming lamp.

10.2.1 Basic resuscitation

For more information, refer to the Helping Babies Breathe training course.

Steps 1 to 6 should be performed in the first minute of life.

1 - Check for meconium
• If the amniotic fluid is meconium-stained but the infant is breathing spontaneously and is tonic: suction is not indicated; simply wipe the face.
• If the amniotic fluid is meconium-stained and the infant is not breathing well or is hypotonic: quickly but gently suction the mouth, preferably with a suction bulb (Penguin).

2 - Stimulate the infant by drying
Tactile stimulation can trigger spontaneous breathing. It is done by drying the infant vigorously, but not roughly. Effective respiratory effort should begin within 5 seconds. If not, stop the stimulation; the infant requires additional care.

3 - Clamp and cut the cord

4 - Position the infant’s head
Lay the infant on the back with the head in a neutral position (Figure 10.1); avoid flexion or hyperextension of the neck, as this can obstruct the airway.

Figure 10.1 - Head position for clearing the airway

5 - Clear the airway (only in the rare cases where there are copious secretions)
Suction the mouth gently – i.e., not too deeply (maximum depth 2 cm from the lips) – and quickly (maximum duration 5 seconds) with a bulb syringe.

6 - Stimulate the infant
Rub the back and the soles of the feet (do not shake, slap or hang the infant by the feet). If effective respiratory effort has not begun after 5 seconds: stop the stimulation; the infant requires ventilation.

7 - Perform bag-mask ventilation (room air)
Fit the mask to the infant’s face covering nose and mouth. Press firmly to prevent air leaks. Hold it with one hand, with the thumb on one side and the index and middle fingers on the other (Figures 10.2 and 10.3).
With the other hand, squeeze the bag at a rate of 30 to 50 compressions per minute for 60 seconds.
Ventilation is effective if the chest rises and falls.
Note: excessive ventilation pressure can cause pneumothorax.

Figure 10.2 - Mask position

Figure 10.3 - Manual ventilation

If the chest fails to rise:
– Check the connection between the bag and the mask;
– Correct the position of the mask on the face;
– Correct the head position.

Check every minute for spontaneous respiratory effort (look for chest movement); do not take the mask off the infant’s face to check for spontaneous breathing.
Continue manual ventilation until there is spontaneous respiratory effort.

If oxygen is available: connect the ambu bag to an oxygen reservoir after 1 to 2 minutes of ventilation, setting it at a 2 litres/minute flow rate. Ventilation is a priority and should not be interrupted to connect the oxygen (have an assistant connect the oxygen).

Stop resuscitation if the infant has no heart rate after 10 minutes or if the heart rate is < 60/minute of effective manual ventilation.
If the infant has a heart rate > 60/minute, but does not breathe spontaneously, manual ventilation can be continued. However, resuscitation should be stopped if the infant does not breathe spontaneously within 30 minutes.

Record all procedures on the monitoring sheet.

10.2.2 After resuscitation

Check the infant’s immediate needs: blood glucose, head position, oxygen saturation, temperature and assessment for signs of sepsis.

Perform a retroactive Apgar score assessment (Section 10.1.3), and record the results on the monitoring sheet.
If the Apgar score was ≤ 4 at 1 minute or ≤ 6 at 5 minutes, or if the infant was ventilated with a mask for 2 minutes or more:
– Hospitalise in a neonatal care unit (keep the mother and infant together if possible).
– If transfer is not possible, keep the infant under observation for at least 24 hours. Monitor every 2 hours: look for danger signs (Section 10.3.1) and monitor vital signs. Ensure routine care (Section 10.1). Begin breastfeeding as soon as possible.

If the infant is floppy, has no sucking reflex or exhibits other neurological problems (e.g. seizures), check blood glucose. If blood glucose cannot be checked, start presumptive treatment for hypoglycaemia (Section 10.3.5).

If oxygen saturation is low or there are signs of respiratory distress, see Section 10.3.2.

In the event of seizures:
– Check blood glucose and/or treat for hypoglycaemia.
– If the infant continues to have seizures after receiving glucose, administer a loading dose of phenobarbital (20 mg/kg) by slow IV infusion (dilute the required dose of phenobarbital in 20 ml of 0.9% sodium chloride and administer over 30 minutes). Never administer phenobarbital as a rapid, undiluted direct IV injection. If intravenous access cannot be obtained, administer the same dose of phenobarbital (undiluted) by IM injection.
– Precaution should be taken when administering phenobarbital; there is a risk of respiratory depression: monitor the infant closely; have ventilation equipment at hand.
– If seizures persist after 30 minutes, give a second dose of phenobarbital (10 mg/kg) by slow IV infusion over 30 minutes as above. If IV access cannot be obtained, administer the second dose (10 mg/kg) of phenobarbital undiluted by IM injection 60 minutes minimum after the first IM dose.
– In any cases, monitor the infant closely for at least 6 hours.
– For recurrent seizures, administer phenobarbital PO: 5 mg/kg/day for 5 days.