1A Skills: Neonatal resuscitation
- Assessing the Apgar score
- Giving mask ventilation
- Tracheal intubation
- Chest compressions
- Use a T-piece infant resuscitator
When you have completed this skills chapter you should be able to:
- Perform an Apgar score.
- Mask ventilate an infant.
- Intubate an infant.
- Give chest compressions.
Assessing the Apgar score
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.
1-a Counting the heart rate
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.
1-b Assessing the respiratory effort
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.
1-c Determining the presence or absence of cyanosis
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.
1-d Assessing muscle tone
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.
1-e Determining the response to stimulation
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.
1-f The final Apgar score
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|
Giving mask ventilation
1-g Position of the infant
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
1-h Bag and 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.
- A T-piece infant resuscitator can be used to provide positive pressure ventilation. The percentage oxygen, flow rate and inflation pressure can be controlled.
1-i Position of the mask
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.
1-j Equipment needed for intubation
- A firm, level surface on which to place the infant
- A good light so that you can see the infant
- A source of heat, such as an overhead heater or a warm room, so that the infant does not get cold. The body of the infant can be slid into a plastic bag to reduce heat loss.
- A source of oxygen, a flow meter and plastic tubing. An air/oxygen blender is useful to control the concentration of oxygen provided, if mechanical air is available. Usually a flow of 5 litres is used.
- Endotracheal tubes: 2.5, 3.0 and 3.5 mm (internal diameter). Straight tubes are safer and therefore should be used rather than shouldered tubes. A 2.5 mm tube is best for infants below 200 g; a 3.0 mm tube for infants 1000 to 2000 g; and a 3.5 mm tube for infants larger than 2000 g. Sometimes tubes are cut to 15 cm before use. Make sure that the connector has been inserted into the top of the endotracheal tube.
- A ventilation bag and face mask (e.g. Laerdal). A reservoir enables 100% oxygen to be given if needed.
- Introducers for the endotracheal tubes. Before intubating an infant, the introducer should be placed into the endotracheal tube. Make sure that the end of the introducer does not stick out beyond the tip of the endotracheal tube. It is important to bend a wire introducer at the top of the tube so that it does not slip out beyond the tip of the tube. With the introducer in place, bend the tip of the endotracheal tube slightly upward.
- A laryngoscope handle with small straight blades, size 0 (for small infants) and size 1 (for big infants). The blades must be cleaned or sterilised after use.
- Spare batteries
- Spare bulbs
- Suction apparatus and tubing. The suction pressure most not exceed 200 cm water (20 kPa or 200 mbar).
- Suction catheters, sizes F5 and F6. A size F5 catheter will pass down a 2.5 mm endotracheal tube while a F6 catheter will pass down a 3.0 mm tube.
- A small stethoscope
- A saturation monitor is very useful but not essential.
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
The equipment must be checked daily to make certain that everything is present and in good working order.
1-k Look for the vocal cords with the laryngoscope
- Pull the laryngoscope blade into a 90 degree position so that the light is switched on. Make sure that the bulb is tightly screwed in and that the correct blade is used.
- Hold the laryngoscope in your left hand (even if you are right handed).
- With the infant lying supine (back down), and the infant’s head towards you in the correct position for mask ventilation, place the blade into the infant’s mouth. Always keep the base of the blade to the left of the mouth with the tip of the blade in the midline of the tongue. Throughout the procedure the tip of the blade must always remain in the midline. See Figure 1A-5.
Figure 1A-5: The blade of the laryngoscope on the tongue
- Slowly move the tip of the blade along the back of the tongue until you can see the infant’s epiglottis. The epiglottis is about 1 cm long and is in the midline. It hangs down from the wall of the pharynx to cover the opening of the larynx (the glottis). If your view is obstructed by mucus, suction the pharynx with a catheter held in your right hand.
- Place the tip of the laryngoscope blade in the hollow just before the epiglottis (i.e. the vallecula). The epiglottis must always remain in view. One of the commonest mistakes is to push the blade in too far, beyond the epiglottis. It is important to initially look for the epiglottis rather than the vocal cords. See Figure 1A-6.
Figure 1A-6: A view of the epiglottis
- Now use the laryngoscope to lift the epiglottis out of the way so that the vocal cords and glottis can be seen. It is important to lift the laryngoscope upwards and not to pull the handle back towards you, as this may damage the infant’s upper gum. Slight downward pressure on the infant’s throat with the little finger of your left hand may make the vocal cords and glottis easier to see. This is called cricoid pressure. See Figure 1A-7.
- The larynx (vocal cords and glottis) is a triangular structure and, therefore, is easy to recognise. The two sides of the triangle are formed by the vocal cords. The vocal cords tend to move apart when the infant breathes out. If the cords are in spasm against one another, they can be separated by gently squeezing the infant’s chest. The most important step in intubation is to get a good view of the vocal cords. The opening between the vocal cords is the glottis. This is where the endotracheal tube must be inserted. See Figure 1A-8.
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.
1-l Introducing the endotracheal tube
- Take the endotracheal tube, with the introducer in place, in your right hand and insert it towards the larynx from the right side of the mouth. This will allow you to keep the vocal cords in view all the time. Push the first 1 to 2 cm of the endotracheal tube between the vocal cords and into the glottis (to the black ‘vocal cord line’). Always make sure that you can see the vocal cords clearly, otherwise you will push the tube into the oesophagus. Make sure that you do not push the tube in too far. Once the tube is correctly in place, the laryngoscope can be removed. Your left hand can now be used to hold the endotracheal tube in place. It is helpful to hold the endotracheal tube tightly against the infant’s hard palate. Note the length of the endotracheal tube at the infant’s lip.
- Remove the introducer with your right hand while the endotracheal tube is held in position with your left hand. Make sure that the endotracheal tube does not slip out of the larynx. See Figure 1A-9.
- Attach the connector at the end of the endotracheal tube to the ventilation bag and ventilate the infant at about 40 breaths per minute using your right hand. Usually the face mask is removed before the ventilation bag is attached to the connector of the endotracheal tube.
- Listen to both sides of the chest and watch the chest movement:
- The chest should move well with each inspiration and air should be heard to enter both sides equally when the chest is examined with a stethoscope. Misting of the inside of the endotracheal tube during expiration is a helpful sign that the tube is in the trachea and not the oesophagus.
- If the air entry is good on the right side but poor on the left side of the chest, then the endotracheal tube has been pushed in too far and has entered the right bronchus. Slowly pull the endotracheal tube back until good air entry is heard over the right chest.
- If the endotracheal tube has been placed into the oesophagus by mistake, then the air entry will be poor on both sides of the chest and the chest movement will also be poor. In addition, the stomach will become distended with air and air entry will be well heard over the abdomen. The tube must be removed and be replaced correctly.
- If the infant cannot be intubated within 20 seconds of attempting, remove the laryngoscope and mask ventilate for a minute to allow the infant to recover. Then try again. If a second attempt also fails, give mask ventilation and call for help.
- Once the infant has started to breathe well, the heart rate is above 100 beats per minute and the tongue is pink, the endotracheal tube can be pulled out.
- The laryngoscope and blade must be cleaned after use.
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).
Figure 1A-9: Introducing the endotracheal tube.
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.
1-m Giving chest compressions
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.
- The main aim of chest compressions is to perfuse the coronary arteries. This takes place when the compression on the chest is released (i.e. during diastole). Therefore, do not give chest compressions too fast.
1-n Co-ordinating ventilation with 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.
T-piece infant resuscitator
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.
1-o Setting up a T-piece infant resuscitator
- Attach the inflow supply pipe from the blender to the inflow port on the Neopuff
- Attach the outflow pipe with a T-piece to the outlet port
- Switch the blender to room air
1-p Setting the pressures on a T-piece infant resuscitator
- By twisting, remove the cover over the maximum pressure relief valve
- Turn the maximum pressure relief knob clockwise to fully open the value
- Now turn the inspiratory pressure control knob clockwise to fully open the value
- Turn up the flow on the flow meter to 10 litres per minute. The manometer should read zero.
- Block both ends of the T-piece and the manometer should show a pressure of about 70 cm water
- With the T-piece still blocked at both ends turn the maximum pressure relief knob counterclockwise to reduce the pressure to 30 cm water. The cover of this value can now be twisted back into place to hide the knob and prevent accidental adjustments.
- With both ends of the T-piece still blocked turn the inspiratory pressure control knob counterclockwise until the monitor shows a pressure of 20 cm water
- Block only the mask end of the T-piece and set the PEEP on the monitor to 5 cm water by rotating the ring at the top end of the T-piece
1-q Operating the T-piece infant resuscitator
- Attach the T-piece to the face mask and apply the mask correctly over the infant’s face
- Block the T-piece with your finger or thumb for less than a second to inflate the infant’s chest
- Release your finger or thumb and the infant will exhale
- By blocking and releasing the T-piece repeatedly you should ventilate the infant at about 60 breaths per minute
- It is important that during inspiration the T-piece is not blocked by your finger or thumb for too long
- If needed the T-piece can be attached to an endotracheal tube instead of a face mask