1 Care of infants at birth

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Contents

• Objectives
• Management of a normal infant at birth
• Management of an infant who does not breathe well after birth
• Resuscitation
• Management of meconium-stained infants
• Case studies

Objectives

When you have completed this unit you should be able to:

• Manage a normal infant at birth
• Promote early bonding between mother and infant
• Diagnose poor breathing at birth
• Assess an Apgar score
• Prepare for resuscitation
• Resuscitate an infant
• Prevent meconium aspiration

Management of a normal infant at birth

1-1 What care should you give a normal infant immediately after delivery?

1. Dry the infant well, especially the head, with a warm towel. Then wrap the infant in a second warm, dry towel. This will help to prevent the infant from getting cold after delivery.
2. It is not necessary to suction the nose and mouth of a normal infant who is breathing well. If the infant has a lot of secretions, turn the infant onto the side for a few minutes.
3. Assess the Apgar score at 1 minute. Only repeat at 5 minutes if the infant needs resuscitation.
4. Clamp the umbilical cord. This can be done with the infant lying on the mother’s abdomen.
5. A quick physical examination should be done to assess the infant for size, serious congenital abnormalities or other obvious clinical problems.
6. When the above have been completed, give the infant to the mother.

1-2 When is the best time to clamp the umbilical cord in infants who breathe well at birth?

It is best to wait 2 to 3 minutes before clamping the cord. Therefore, dry the infant well first and then wait before clamping the cord with surgical forceps. Drying the infant usually stimulates crying.

Delaying clamping the cord, until the infant breathes well, allows the infant to receive some extra blood from the placenta. This extra blood may help prevent iron deficiency anaemia in the first year of life. Before clamping the cord, keep the infant on the bed at the same level as the mother or place the infant on the mother’s abdomen.

The umbilical cord must be clamped or tied about 3 to 4 cm from the infant’s abdomen. The surgical forceps can then be replaced with a sterile, disposable cord clamp or a sterile cord tie.

Clamp the umbilical cord at 2 to 3 minutes after birth if the infant breathes well.

1-3 When should you give the infant to the mother?

It is important for the mother to see and hold her infant as soon as possible after delivery. If the infant appears to be normal and healthy, the infant can be given to the mother after the 1 minute Apgar score has been assessed, the cord clamped and the initial examination made. After delivery, both the infant and mother are in an alert state. The infant’s eyes are usually open and looking around.

The mother will usually hold the infant so that she can look at its face. She will talk to her infant and touch the face and hands. This initial contact between a mother and her infant is an important stage in bonding. Bonding is the emotional attachment that develops between mother and infant, and is an important step towards good parenting later. Where possible, it is important that the father also be present at the delivery so that he can be part of this important phase of the bonding process.

Give the infant to the mother as soon as possible after delivery.

1-4 When should the normal infant be put to the breast?

If possible the mother should put the infant to her breast within minutes after delivery because:

1. Studies have shown that the sooner the infant is put to the breast, the greater is the chance that the mother will successfully breastfeed.
2. Nipple stimulation, by putting the infant to the breast, may speed up the third stage of labour by stimulating the release of maternal oxytocin.
3. It reassures the mother that her infant is healthy and helps to promote bonding.

Some women want to hold and look at their infants but do not want to breastfeed soon after delivery. Their wishes should be respected. During a complicated third stage, or during the repair of an episiotomy, some mothers would rather not hold their infants.

1-5 How should the mother keep her infant warm?

When the infant is given to the mother, she should hold the infant, skin-to-skin, against her chest and cover the infant with a towel. This will keep the infant warm. Skin-to-skin care (kangaroo mother care) is important to promote bonding and breastfeeding. The infant must not be left alone in a cot.

1-6 When do you identify the infant?

Once the parents have had a chance to meet and inspect their new infant, formal identification by the mother and staff must be done. Labels with the mother’s name and folder number, together with the infant’s sex, date and time of birth are then attached to the infant’s wrist and ankle. Twins must be labelled ‘A’ and ‘B’. Once correctly identified, other routine care can then be given.

1-7 Should all infants be given vitamin K1?

Yes. It is important that all infants be given 1 mg of vitamin K1 (0.1 ml of Konakion) by intramuscular injection into the anterolateral aspect of the mid-thigh after delivery. Never give the Konakion into the buttock as it may damage nerves or blood vessels that are just under the skin in infants. Konakion will prevent haemorrhagic disease of the newborn. Be very careful not to give the infant the mother’s oxytocin (Syntocinon) in error. To avoid this mistake, some hospitals give Konakion in the nursery and not in the labour ward. Do not use oral Konakion.

All infants must be given intramuscular vitamin K1 after delivery.

1-8 Should antibiotic ointment be placed in the infant’s eyes?

Yes, it is advisable to place chloromycetin ointment routinely into both eyes to prevent Gonococcal conjunctivitis as an infant’s eyes may become infected when the infant passes through the cervix and vagina. This is particularly important if gonorrhoea is common in that community. Many women with Gonococcal infection have no symptoms.

1-9 Should all infants be weighed and measured?

Yes, it is important to measure the infant’s weight and head circumference after birth. The parents are usually anxious to know the infant’s weight. The infant’s length is usually not recorded, as it is very difficult to measure accurately. Weighing all infants helps to identify low-birth-weight infants (less than 2500 g) who may need special care.

1-10 What care and management should be documented?

Accurate notes should be made after the infant has been delivered. It is important to document the following observations and procedures:

1. Apgar score
2. Any action taken to resuscitate the infant
3. Any abnormality or clinical problem noticed
4. Identification of the infant
5. Whether the infant is male or female
6. Administration of Konakion
7. Whether prophylactic eye ointment was given
8. Birth weight and head circumference

1-11 Should the infant stay with the mother after delivery?

Yes. If the mother and infant are well, they should not be separated. The infant should be kept skin-to-skin on the mother’s chest, as this is the best way to keep an infant warm. The infant can stay with the mother in the labour ward and should be transferred with her to the postnatal ward. If the infant is cared for by the mother, the staff will be relieved of this additional duty.

The mother and infant should remain together after delivery, if both are well.

1-12 Should the infant be bathed after delivery?

There is no need to bath an infant immediately after delivery. It is much better if the infant stays with the mother and is only bathed later. Vernix protects the infant’s skin and helps to prevent skin infection.

Management of an infant who does not breathe well after birth

1-13 When does a normal infant start breathing after delivery?

A normal, healthy newborn infant usually starts to breathe immediately after birth. Sometimes gentle stimulation, such as drying, is needed before the infant breathes well. After drying the infant should be breathing well or crying.

1-14 What is neonatal asphyxia?

If an infant does not breathe well by 1 minute after birth, the infant was said to have neonatal asphyxia (asphyxia neonatorum). This is outdated terminology that is best not used as it is confusing. Simply say the infant does not breathe well after birth.

Infants should breathe well by 1 minute after delivery.

1-15 What important clinical signs should be looked for in the infant after delivery?

There are 5 important clinical signs, which should be present after birth. These are called vital signs:

1. Breathing
2. Heart rate
3. Colour
4. Tone
5. Response

The most important sign is breathing.

Breathing is the most important sign after birth.

1-16 What is the Apgar score?

The Apgar score uses the 5 vital signs at birth to give a score, which is very useful in assessing and documenting an infant’s condition after delivery. It is not necessary to wait for the 1 minute Apgar score before deciding which infants need resuscitation. The Apgar score is named after Virginia Apgar, who described the score in 1953.

1-17 How is the Apgar score measured?

Each of the 5 vital signs is given a score of 0, 1 or 2. If the sign is normal a score of 2 is given. Mildly abnormal signs are given a score of 1. If the vital sign is very abnormal a score of 0 is given.

The scores for each vital sign are then added together to give the Apgar score out of 10. The best possible Apgar score is 10 and the worst is 0.

1-18 How should you assess an infant’s breathing after birth?

Look at the infant’s chest movements. Both sides of the chest should move well when the infant breathes. A normal infant will cry or take at least 40 breaths a minute.

If the infant breathes well or cries, a score of 2 is given. If there is poor or irregular breathing, or the infant only gives an occasional gasp, a score of 1 is given. A score of 0 is given if the infant makes no attempt to breathe.

1-19 How should you count an infant’s heart rate after birth?

Feel the base of the umbilical cord or listen to the infant’s heart with a stethoscope to count the heart (pulse) rate. It is often very difficult to feel peripheral pulses immediately after birth. The average heart rate of a normal infant is 140 with a range of 120 to 160 beats per minute. It saves time to count the heart rate for 30 seconds and then multiply the rate by 2 to give the heart rate per minute. A wall clock is useful when counting the heart rate.

If the heart rate is above 100 per minute a score of 2 is given. A score of 1 is given if a heartbeat is present but the rate is slower than 100 per minute, while a score of 0 is given if no heartbeat can be heard or umbilical pulse felt.

1-20 How should you assess an infant’s colour after birth?

Look at the infant’s tongue and also at the hands and feet. The tongue should always be pink. It is not helpful to look at the colour of the lips or mucous membranes. If the tongue is blue the infant has central cyanosis. This shows that important organs like the brain are not getting enough oxygen. Almost all newborn infants have peripheral cyanosis with blue hands and feet immediately after delivery. This is normal and within minutes the hands and feet should become pink. A pink tongue indicates that enough oxygen is reaching the brain.

If the hands and feet are pink, a score of 2 is given. If the tongue is pink, but the hands and feet are still blue, a score of 1 is given. When the tongue, hands and feet are all blue, a score of 0 is given.

1-21 How should you assess an infant’s tone after birth?

Normal infants should have good muscle tone at birth and move their arms and legs actively. They should not lie still. Normally the arms and legs are flexed and held above the body, with the knees held together, in a term infant.

If the infant moves well, a score of 2 is given. If there is only some movement, and the arms and legs are not pulled up against the body or lifted off the surface, a score of 1 is given. A score of 0 is given if the infant is completely limp and does not move at all.

1-22 How should you assess an infant’s response to stimulation after birth?

If you handle or gently stimulate the infant there should be a good response. Usually the infant moves a lot or cries. The best method of stimulation is to dry the infant well with a towel. Smacking the infant or flicking the feet is not recommended.

If the infant responds well to stimulation and cries or moves a lot a score of 2 is given. If there is only some response a score of 1 is given while a score of 0 is given if the infant does not respond to stimulation at all.

Table 1-1: Calculating an Apgar score

	1 Minute		5 Minutes
Respiratory rate	Absent	0	Absent	0
	Weak or irregular	1	Weak or irregular	1
Heart rate per minute	None	0	None	0
	Less than 100	1	Less than 100	1
	More than 100	2	More than 100	2
	Good or cries	2	Good or cries	2
Colour	Centrally cyanosed	0	Centrally cyanosed	0
	Peripherally cyanosed	1	Peripherally cyanosed	1
	Peripherally pink	2	Peripherally pink	2
Muscle tone	Limp	0	Limp	0
	Some flexion	1	Some flexion	1
	Active and well flexed	2	Active and well flexed	2
Response to stimulation	None	0	None	0
	Some response	1	Some response	1
	Good response	2	Good response	2
TOTAL SCORE:		/10		/10

1-23 When should the Apgar score be measured?

All infants should have their Apgar score measured at 1 minute after delivery. The 1 minute Apgar score is a good method of measuring the infant’s general condition after birth. If the Apgar score is normal, the score usually does not need to be repeated at 5 minutes. However, in many clinics and hospitals the Apgar score is still repeated routinely at 5 minutes. Unfortunately many of these normal infants are needlessly removed from their mother’s skin-to-skin care to have the 5 minute Apgar score determined.

However, if the 1 minute Apgar score is low, the score must be repeated at 5 minutes and every 5 minutes thereafter while the infant is being resuscitated. This gives a very good assessment of the success or failure of the attempts at resuscitation. With successful resuscitation the Apgar score will increase to normal.

1-24 What is a normal Apgar score?

The Apgar score at 1 minute should be 7 or more out of a possible 10. As almost all infants have blue hands and feet immediately after birth, a 1 minute Apgar score of 10 is rare. The Apgar score at 5 minutes, and thereafter, should also be 7 or more.

A 1 minute Apgar score of 4 to 6 is moderately abnormal while a score of 0 to 3 is severely abnormal.

A low 5 minute Apgar score is worrying as it suggests that the infant is not responding well to resuscitation. The longer the score remains low, the greater is the risk of death or brain damage.

The Apgar score should be 7 or more at 1 minute.

1-25 What are the important causes of poor breathing and a low Apgar score?

1. Fetal hypoxia
2. Maternal general anaesthesia
3. Maternal sedation or analgesia with pethidine or morphine given within the last 4 hours
4. Excessive suctioning of the infant’s mouth and throat
5. Delivery of a low-birth-weight infant
6. Difficult or traumatic delivery
7. Severe respiratory distress

1-26 What is hypoxia?

Hypoxia is defined as too little oxygen reaching the cells of the body. If the infant fails to breathe well after delivery the infant will develop hypoxia. As a result of hypoxia, the infant’s heart rate falls, breathing is poor, central cyanosis develops and the infant becomes hypotonic (floppy) and unresponsive. Failure to breathe, if not correctly managed, will lead to hypoxia and possible brain damage or death.

1-27 What is fetal hypoxia?

If the placenta fails to provide the fetus with enough oxygen during labour, fetal hypoxia will result. Fetal hypoxia presents with meconium-stained amniotic fluid and late fetal heart rate decelerations or baseline bradycardia. These are the signs of fetal distress. Therefore, fetal hypoxia results in fetal distress. As hypoxia may damage or kill the fetus, it is very important that each infant is well monitored during labour so that any signs of fetal distress can be detected as soon as possible, so that the correct management can be given.

Fetal hypoxia is an important cause of failure to breathe at birth.

1-28 Do all hypoxic infants fail to breathe at birth?

No. Failure to breathe well and fetal hypoxia are not the same, although severe fetal hypoxia usually results in poor breathing after delivery. Some infants with mild fetal hypoxia breathe well after birth. There are also many causes of poor breathing other than fetal hypoxia. Therefore, some infants have poor breathing even though they have not had fetal hypoxia.

1-29 Can failure to breathe at birth be prevented?

Good management during labour and the early detection of fetal distress are the best methods of preventing failure to breathe at birth. However, sometimes failure to breathe cannot be predicted or prevented.

1-30 How is failure to breathe managed?

Failure to breathe or poor breathing is corrected by resuscitating the newborn infant. Only about 10% of newborn infants fail to breathe well and, therefore, need resuscitation.

Resuscitation

1-31 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.

The international Helping Babies Breathe programme has improved the way infants are resuscitated. Their method is used in this book.

1-32 Which infants need resuscitation?

All infants who do not breathe well after delivery, or have a 1 minute Apgar score below 7, need resuscitation. However do not wait until 1 minute before starting 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 who do not breathe well after delivery need resuscitation.

1-33 Can you anticipate which infants will need resuscitation at birth?

No. While any of the conditions which cause failure to breathe well may result in the infant needing resuscitation, poor breathing cannot always be predicted before delivery. Remember that any infant can be born with failure to breathe 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 failure to breathe at birth without warning signs during labour and delivery.

1-34 What is needed to resuscitate a newborn infant?

1. A suitable, warm area with good lighting
2. The correct, clean and functioning equipment
3. The knowledge and skills

1-35 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 25 °C.

A warm, well-lit corner of the delivery room is ideal for resuscitation. A heat source, such as an overhead radiant warmer or wall heater, is needed to keep the infant warm. A good light, such as an angle-poise lamp, is essential so that the infant can be closely observed during resuscitation. A firm, flat surface at waist height is best for resuscitating an infant. There is no need to have the infant lying head down, and the neck must not be overextended. It is very useful to have warm towels to dry the infant.

1-36 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.

The following essential equipment must be available in the delivery room:

1. Suction apparatus: An electric or wall vacuum suction apparatus is ideal but the vacuum pressure should not exceed 200 cm water. Soft F 10 end-hole suction catheters are needed. A simple mouth suction apparatus (mucus extractor) can also be used. It consists of 2 soft plastic catheters attached to a 20 ml plastic container. Although it is effective, there is a small risk that the staff could become infected with HIV if the secretions get into the mouth of the person suctioning the infant.
2. Oxygen: Whenever possible, a cylinder or wall source of 100% oxygen should be available. Some rural clinics use an oxygen concentrator. However, oxygen is not essential for resuscitation.
3. Self-inflating bag and mask: A simple neonatal self-inflating bag and mask, e.g. Laerdal, must be available to provide mask ventilation. Direct mouth-to-mouth resuscitation is dangerous due to the risk of the health worker becoming infected with HIV.
4. Naloxone: Ampoules of naloxone (Narcan 0.4 mg in 1 ml). Small syringes and needles will be needed to administer the drug.
5. Wall clock or watch: To time the assessment of the Apgar score.

Although not essential for basic resuscitation, it is very useful to have an infant laryngoscope and endotracheal tubes so that infants who fail to breathe can be intubated, if bag and mask ventilation is not adequate. Everyone who regularly resuscitates newborn infants should learn how to intubate them.

1-37 How should you stimulate respiration immediately after birth?

After birth, all infants must be quickly dried with a warm towel and then wrapped in a second warm, dry towel. 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.

1-38 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.

1-39 Which infants should be suctioned after delivery?

1. Infants who do not breathe well after drying
2. Meconium-stained infants

1-40 When should you start to resuscitate an infant?

If the infant does not breathe well and fails to respond to the stimulation of drying, then the infant must be actively resuscitated. Usually the umbilical cord is clamped before the infant is moved to a suitable place for resuscitation. Do not wait for a low 1 minute Apgar score before starting resuscitation. The aim is to get all infants breathing well or start ventilation by 1 minute after delivery – the ‘golden minute’.

All infants should be breathing well or receiving ventilation by 1 minute after delivery.

1-41 Can resuscitation of an infant with no breathing result in survival without 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 failure to breathe die. Therefore, it is better to give good resuscitation early to all infants who do not breathe 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.

1-42 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.

1-43 How do you resuscitate an infant?

After drying the infant, it is usually necessary to cut and clamp the cord and then move the infant to a suitable resuscitation area.

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, ‘ABCD’:

1. Airway
2. Breathing
3. Circulation
4. Drugs

Progress from step to step until the infant is breathing well.

Step 1: Open the airway

Gently clear the throat if needed. The infant may be unable to breathe because the airway is blocked by mucus or blood. Therefore, if the infant fails to breathe after drying and 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.

If wall suction or a suction machine is not available, a mucus extractor can be used to suction the infant’s mouth and throat. Because of the small risk of HIV infection, wall suction or a suction machine is best.

Correctly position the head. The upper airway (pharynx) can be opened by placing the infant’s head in the correct position. With the infant lying on its back on a flat surface, slightly extend the neck so that the face is pointing towards the ceiling. Do not overextend the neck.

If the infant is not breathing well after the airway has been suctioned and the head correctly positioned, move on to step 2.

Step 2: Start the infant breathing

If after opening the airway the infant is still not breathing, mask and bag ventilation must be started immediately. 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 neonatal bag and mask (e.g. Laerdal). Ventilation is the most important part of resuscitation and 90% of infants will start to breathe with mask and bag ventilation. It is very important that the infant’s chest moves well when ventilated. Usually mask and bag ventilation is given with room air. Giving mask oxygen alone often does not help.

Ventilation is more important than oxygen.

Step 3: Obtain a good circulation

If the heart rate or umbilical cord pulse remains below 60 beats per minute after effective ventilation has been given for 1 minute, apply chest compressions at about 90 times a minute. Always ensure good ventilation before starting chest compressions as most infants can be resuscitated with good mask ventilation alone. Therefore chest compressions are usually not needed in basic neonatal resuscitation.

Mask and bag ventilation is the most important step in resuscitating an infant.

Step 4: Drugs to reverse pethidine and morphine

If the mother has received either pethidine or morphine for pain during the 4-hour period before delivery, the infant’s poor breathing may be due to the drug. If so, the respiratory depression caused by the drug can be reversed with naloxone (a 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. Intramuscular naloxone takes a few minutes before it starts to act. Naloxone is rarely needed.

Naloxone will not help resuscitate an infant if the mother has not received a narcotic analgesic such as pethidine or morphine during labour, or has received a non-opioid general anaesthetic, barbiturates or other sedatives.

1-44 When do you give oxygen to an infant?

Oxygen is given if the infant is centrally cyanosed with a slow heart rate in spite of good bag and mask ventilation for 1 minute. Usually wall oxygen is used. Otherwise an oxygen cylinder or an oxygen concentrator is needed. Oxygen is best given by mask and bag ventilation. It is safer to use room air for resuscitation and only give oxygen if the central cyanosis is not corrected by mask ventilation.

Room air is safer than oxygen for most resuscitations.

1-45 How should you use a self-inflating bag and mask to ventilate an infant?

1. The position of the infant: The infant must lie face up on a flat surface. The infant’s neck should be slightly extended. Do not over extend the neck. The infant’s face should look towards the ceiling. Infants should be wrapped in a warm towel or placed in a plastic bag to prevent heat loss during resuscitation.
2. The apparatus: A number of bag and mask sets are suitable (e.g. Laerdal). Make sure that both the bag and mask are designed for newborn infants. If required, the bag should be attached to an oxygen source providing 5 litres per minute. It is important that the correct size mask is used.
3. The position of the mask: The mask must be placed over the infant’s mouth and nose, but not eyes. Hold the mask tightly against the face so that there are no air leaks.
4. Using the self-inflation bag: The mask should be held in place with the left hand while the bag is squeezed at about 40 breaths per minute with the right hand. If the little and ring finger of the left hand are placed under the angle of the jaw, the jaw can be gently pulled upwards to keep the tongue from falling back. The position of the mask is the same with all types of bag. When giving mask and bag ventilation, watch the movement of the chest. Squeeze the bag hard enough to move the chest with each inspiration. Continue giving mask and bag ventilation at about 40 breaths per minute until the infant starts to cry or breathes well. A small percentage of infants will not respond to mask ventilation and need intubation and ventilation.

The technique of good bag and mask ventilation is best learned with a training mannequin (doll).

1-46 How do you give chest 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 90 times a minute. Pressing on the sternum squeezes blood out of the heart and causes blood to circulate to the lungs and body.

It takes two people to both mask ventilate and give cardiac massage. An assistant should ventilate the infant while you give chest compressions. After every third push on the sternum the assistant should squeeze the bag to give 1 breath for every 3 chest compressions. Continue chest compressions until the infant’s heart rate increases to 100 or more beats per minute. If you are resuscitating an infant on your own, good mask ventilation is more important than chest compressions.

1-47 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:

1. A heart or pulse rate above 100 beats per minute. Easily assessed by palpating the base of the umbilical cord or listening to the chest with a stethoscope.
2. A good cry or good breathing efforts. This assures adequate breathing. Crying is the best indicator of good breathing.
3. A pink tongue. This indicates a good oxygen supply to the brain. Do not rely on the colour of the lips.

With good resuscitation the Apgar score at 5 minutes should be 7 or more. This suggests that the infant did not suffer severe hypoxia before delivery.

1-48 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 death. 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 at resuscitation.

Resuscitation will not save all infants who do not breathe at birth, but it will help most.

1-49 What post-resuscitation care is needed?

Infants who begin breathing as soon as mask ventilation is started can be given to the mother.

All infants that require resuscitation with more than a few minutes with bag and mask ventilation must be carefully observed for at least 6 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.

Careful notes must be made describing the infant’s condition at birth, the resuscitation needed and the probable cause of failure to breathe at birth after delivery.

1-50 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 is being resuscitated.

1-51 How is the resuscitation equipment cleaned?

It is important 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 must be sterilised.

Management of meconium-stained infants

1-52 Does the meconium-stained infant need special care?

Yes. All infants that are meconium stained at birth need special care to reduce the risk of severe meconium aspiration. Whenever possible, all these at-risk infants should be identified before delivery by noting that the amniotic fluid is meconium stained.

1-53 Why is the meconium-stained infant at risk of meconium aspiration?

As a result of fetal hypoxia, the fetus may make gasping movements and pass meconium. Before delivery, meconium in the amniotic fluid can be sucked into the upper airways. Fortunately most of the meconium is unable to reach the fluid-filled lungs of the fetus. Only after delivery, when the infant inhales air, does meconium usually enter the lungs.

Meconium contains enzymes from the fetal pancreas that can cause severe lung damage and even death if inhaled into the lungs at delivery. Meconium also obstructs the airways. Meconium aspiration may result in respiratory distress after delivery.

Meconium often burns the infant’s skin and digests away the infant’s eye lashes, and can cause severe damage to the delicate lining of the lungs.

1-54 How can you prevent meconium aspiration at delivery?

Before delivery of all meconium-stained infants, a suction apparatus and a F 10 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 breathe fast and not to push. This should prevent delivery of the trunk. The infant’s face is then turned to the side so that the mouth and throat can be well suctioned. The nose can be suctioned after the mouth and throat. The infant should be completely delivered only when no more meconium can be cleared from the mouth and throat.

If the infant cries well after delivery, no further resuscitation or suctioning is needed. However, some infants develop apnoea and bradycardia as a result of the suctioning and, therefore, need ventilation after delivery. If a meconium-stained infant needs ventilation, the throat should again be suctioned before ventilation is started.

This aggressive method of suctioning is very successful in preventing severe meconium aspiration in meconium-stained infants.

The mouth and throat of all meconium-stained infants must be suctioned before the shoulders are delivered.

When a meconium-stained infant is delivered by Caesarean section, the mouth and throat must similarly be suctioned with a F 10 end-hole catheter, before the shoulders are delivered from the uterus. After complete delivery, move the infant immediately to the resuscitation table. If the infant does not breathe well, further suctioning is needed before stimulating respiration or starting ventilation.

1-55 What care should you give to meconium-stained infants after birth?

All meconium-stained infants should be observed for a few hours after delivery as they may show signs of meconium aspiration. Most meconium-stained infants have also swallowed meconium before delivery. Meconium is an irritant and causes meconium gastritis. This results in repeated vomits of meconium-stained mucus.

If the infant vomits meconium wash out the stomach with 2% sodium bicarbonate (mix 4% sodium bicarbonate with an equal volume of sterile water). Five millilitres of 2% sodium bicarbonate is repeatedly injected into the stomach via a nasogastric tube and then aspirated until the gastric aspirate is clear. This should be followed by a feed of colostrum. Only heavily meconium-stained infants should have a stomach washout on arrival in the nursery. Routine stomach washouts in infants with mildly meconium-stained amniotic fluid are not needed.

Case study 1

An infant is delivered by spontaneous vertex delivery at term. Immediately after birth the infant cries well and appears normal. The cord is clamped and cut after the infant is dried. The infant has a lot of vernix. As the infant appears healthy and the mother has no vaginal discharge, chloromycetin ointment is not put in the infant’s eyes. The infant is placed in a cot beside the mother.

1. When should the infant be given to the mother?

As soon as the infant is dried the 1 minute Apgar score is determined, the cord is cut and a brief examination indicates that the infant is a normal, healthy term infant. The mother should give her infant skin-to-skin care after birth. The infant should not be left in a cot. The father should also be present to share this exciting moment.

2. When should the mother be encouraged to put the infant to her breast?

As soon as she wants to. This is usually after she has had a chance to have a good look at her infant. There are advantages to putting the infant to the breast soon after delivery.

3. Should the vernix be washed off immediately after delivery?

Infants should not be bathed straight after delivery, as they often get cold, and vernix should not be removed as it helps protect the infant’s skin from infection. It would be better to bath the infant later, in the mother’s presence, when most of the vernix will have cleared.

4. Do you agree that this well infant does not need chloromycetin eye ointment?

No. All infants should be given chloromycetin eye ointment, especially if gonorrhoea is common in the community. Gonococcal infection may be asymptomatic in the mother.

5. Should the infant stay with the mother after delivery?

Yes, if possible the mother and her infant should not be separated after delivery.

Case study 2

After a normal pregnancy, an infant is born by spontaneous vertex delivery. There are no signs of fetal distress during labour. The mother received pethidine 2 hours before delivery. Immediately after delivery the infant is dried and placed under an overhead radiant warmer. There is no spontaneous breathing. 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 to stimulation. After the 1 minute Apgar score the infant is ventilated with bag and mask for 3 minutes. 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.

1. When should resuscitation be started?

As soon as possible. Do not wait until the 1 minute Apgar score before starting resuscitation.

2. What is the probable cause of the failure to breathe spontaneously?

Sedation due to the maternal pethidine given 2 hours before delivery. These sedated infants usually respond rapidly to resuscitation. If not, naloxone can be given to reverse the sedative effect of the pethidine.

3. What should be the first two steps in resuscitating this infant?

If respiration cannot be stimulated by drying the infant then the following two steps must be taken:

1. Open the airway by gently suctioning the throat and positioning the head.
2. Bag and mask ventilation must be started.

4. Should oxygen be given?

Room air is usually adequate for resuscitation unless the infant remains centrally cyanosed.

5. What is the infant’s Apgar score at 1 minute?

The Apgar score at 1 minute is 4: respiration=1, heart rate=1, colour=1, tone=1, response=0.

6. What is this infant’s Apgar score at 5 minutes?

The Apgar score at 5 minutes is 9: breathing=2, heart rate=2, colour=1, tone=2, response=2. This indicates that the infant has responded well to resuscitation.

7. Why is this infant very unlikely to have suffered brain damage due to hypoxia?

Because there is no history of fetal distress to indicate that this infant had been hypoxic before delivery and the infant responded well to resuscitation.

8. What should be the management of this infant after resuscitation?

The infant should be kept warm and be transferred to the nursery for observation. As soon as the infant is active and sucking well it should given to the mother to breastfeed.

Case study 3

A woman with an abruptio placentae delivers at 32 weeks in a clinic. Before delivery the fetal heart rate was only 80 beats per minute. The infant does not breathe, has a 1 minute Apgar score of 1 and is ventilated with bag and mask. Cardiac massage is also given. With further efforts at resuscitation, the Apgar score at 5 minutes is 5 and at 10 minutes is 9.

1. What is the probable cause of failure to breathe in this infant?

Fetal distress caused by hypoxia. Abruptio placentae (placental separation before delivery) is a common cause of fetal distress.

2. What is the significance of the Apgar scores at 5 and 10 minutes?

The good response indicates that the resuscitation is successful. If the Apgar score is still low at 5 minutes it is important to repeat the score every 5 minutes. The normal score at 10 minutes indicates the infant’s response to the resuscitation.

3. Is this child at high risk of brain damage due to hypoxia?

The good response to resuscitation suggests that this infant will not have brain damage due to fetal hypoxia.

4. When should all attempts at resuscitation be abandoned?

If the Apgar score remains low at 20 minutes, attempts at resuscitation may be stopped.

Case study 4

After fetal distress has been diagnosed, an infant is delivered vaginally after a long second stage of labour. At delivery the infant is covered with thick meconium. The infant starts to gasp when the umbilical cord is clamped. Only then are the mouth and throat suctioned for the first time. The Apgar score at 1 minute is 3. By 5 minutes the Apgar score is 6.

1. What are the probable causes of gasping and the low 1 minute Apgar score?

Fetal distress, as indicated by the passage of meconium before delivery. The prolonged second stage may have caused fetal hypoxia. Inhaled meconium may have blocked the airway and prevented the infant from breathing.

2. What mistake was made with the management of this infant?

The infant’s mouth and throat should have been well suctioned before the shoulders were delivered. This should reduce the risk of severe meconium aspiration as the airway is cleared of meconium before the infant starts to breathe.

3. What size catheter would you have used to suction this infant’s mouth and throat?

A large catheter (F 10) must be used as a small catheter will block with meconium.

4. Should this infant be given a bath and stomach washout in the labour ward after it starts to breathe spontaneously?

No. These should not be done until the infant has been stable for a number of hours in the nursery.

5. What two complications is this infant at high risk of?

This infant may develop meconium aspiration syndrome as it probably inhaled meconium into its lungs after birth. It may also suffer brain damage due to hypoxia causing fetal distress during labour. The poor response to resuscitation suggests that some brain damage may be present. It would be important to repeat the Apgar score every 5 minutes until 20 minutes after delivery.