Sequence of Actions in Newborn Resuscitation

Sequence of Actions in Newborn Resuscitation

The sequence of actions required in caring for all newborns includes drying, warmth and assessment, followed by the consideration of airway, Breathing, Circulation and Drugs.

Initial Care and Assessment

All newborn babies should be dried, the cord securely clamped, and the baby covered in dry towels to keep warm. Preterm babies (<30 weeks gestational age) should be wrapped in a clean clear plastic bag with the face exposed, and placed under a radiant heater to keep warm. The color, tone, breathing and heart rate should be assessed rapidly:

• Healthy newborn. Good tone, cries within a few seconds, good heart rate (120-150 beats/min), may be blue initially but turns pink within 90 seconds.
• Newborn in need of assistance. Blue at birth, less good tone, may have a slow heart rate (< 100 beats/min), may not have established breathing by 90-120 seconds
• Ill newborn, pale, floppy, not breathing, slow or very slow heart rate.

The heart rate is best assessed using a stethoscope, or if this is not available, by feeling the pulsations in the umbilical cord.

Airway

The airway should be opened by placing the baby on his back in the 'neutral' position. Avoid flexion of the neck or overextension, both of which will obstruct the airway.

The airway may be cleared if necessary by gentle suction, but avoid deep suction of the pharynx as this will cause apnoea or bradycardia secondary to vagal reflexes. Do not suction the nose first as this will cause the baby to gasp and inhale mucous and blood from the pharaynx. An infant who is floppy may require chin lift' of 'jaw thrust' to open the airway. Remember, the priority is to open the airway quickly and for the baby to start breathing, not for extensive suctioning of the airway.

Breathing

If the baby is not breathing effectively by 90 seconds, give 5 inflation breaths with a self-inflating bag to aerate the lungs. 'Inflation breaths' are defined as sustained breaths of 2-3 seconds up to a pressure of about 30cm of water pressure.

Reassess the heart rate- if ventilation of the lungs is effective the heart rate should increase and should be maintained above 100 beats/min. Continue low pressure ventilation at a rate of 30 - 40 breaths/min until the baby starts to breath for himself at a rate of > 30 breaths/min. intubation may be considered if skilled personnel are available; a size 1 laryngeal mask may be considered as an alternative if tracheal intubation is not available. Remember, bag and mask ventilation is as effective as ventilation via a tracheal tube.

If the heart rate does not increase, reposition the airway and reattempt ventilation - the chest should move with each ventilated breath. Consider or pharyngeal suction, an oropharyngeal airway with two hands and the face mask, the second to squeeze the bag.

If the heart rate remains slow (<60 beats/min) or is absent despite adequate ventilation of the lungs, chest compressions may be required.

Chest Compression

If the heart rate fails to respond to effective ventilation, chest compressions may be required. The most effective way to compress the chest in a newborn infant is to place the hands around the chest, with the fingers over the spine at the back and the 2 thumbs pressing on the lower third of the sternum.

The chest should be compressed by approximately one third of the depth of the chest, at a compression rate of approximately 100/min and a ratio of 3 compressions to one breath.

Drugs

If the baby has been severely hypoxic, ventilation and compressions may not be adequate to restore the circulation; drugs may be required. However, drugs are not the first line treatment and will be ineffective unless the baby is adequately ventilated (+/-chest compressions if required).

The recommended drugs and doses are described in Table 20.2. They may be delivered via an umbilical venous catheter or a peripheral vein - flush the cannula with 0.9% saline after drugs are given.

If there is a history suggestive of blood loss from the baby, or the baby is shocked with poor peripheral perfusion, a bolus of 10 ml.kg 0.9% saline should be given and may be repeated if required.

Naloxone is not recommended as one of the drugs of resuscitation, but may be given in a dose of 100mcg/kg IM after ventilation and circulation have been established, if the mother has received opioid analgesia in the 4 hours prior to delivery.

Table 6.2 Drugs Used in Resuscitation of the Newborn