Summary

In study session VI you have learnt

• All babies require immediate assessment at birth and to be dried and covered and kept warm, preferably by skin-to-skin contact with the mother
• Around 10% of babies require assistance to start breathing and 1% require more extensive resuscitation - this figure may be higher in areas where prolonged labour or late presentation are common
• The prime responsibility of the anesthetist during a caesarean section is the care of the mother, but the knowledge and skills of the anaesthetist may be invaluable in resuscitation of the newborn
• The essential drugs and equipments for resuscitation should be routinely available and checked every day
• Formal assessment of the newborn is traditionally described using the Apgar score. The score is used to describe the status of the baby at one minute and the response to resuscitation when reassessed at 5 minutes.
• Resuscitation of the baby should start immediately if required after delivery, and should not be delayed until the 1-minute score is assessed. A score of 3 critically low and a score of 7-10 at 5 minutes is normal. A baby who scores less than 7 at 5 minutes should be reassessed every 5 minutes up to 20 minutes. A score of less than 3 at 10, 15 and 20 minutes predicts poor outcome
• 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.
• All newborn babies should be dried, the cord securely clamped, and the baby covered in dry towels to keep warm. The color, tone, breathing and heart rate should be assessed rapidly
• 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.
• If the baby is not breathing effectively by 90 seconds, give 5 inflation breaths with a self-inflating bag to aerate the lungs..
• 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 remains slow (<60 beats/min) or is absent despite adequate ventilation of the lungs, chest compressions may be required.
• If the heart rate fails to respond to effective ventilation, chest compressions may be required.
• 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.
• If the baby has been severely hypoxic, ventilation and compressions may not be adequate to restore the circulation; drugs may be required..
• Meconium aspiration syndrome is a serious cause of morbidity and mortality in babies with fetal distress..
• If a baby is born through thick meconium and is unresponsive or is not vigorous at birth, the mouth should be inspected and suctioned to clear the meconium. If there is an individual who is skilled at intubation, the baby may be intubated to clear the larynx and trachea prior to initiating ventilation.
• It has been shown that newborn infants may be resuscitated effective with either air or 100% oxygen; the most important intervention is to aerate the lungs to allow gas exchange to occur.
• High concentrations of oxygen should be avoided if possible, particularly in preterm infants.
• Resuscitation should be stopped if there are no signs of life after 10 minutes of adequate and continuous resuscitation and the baby should be given to the mother to hold if she wishes.
• If the Apgar score remains less than 3 after 20 minutes the chance of death or severe brain damage is extremely high and it may be justifiable to stop resuscitation efforts.
• All infants who have been resuscitated require careful monitoring for at least four hours after delivery. The oxygen saturation should be monitored, particularly where there has been meconium; supplementary oxygen or ventilator support may be required (CPAP or positive pressure ventilation).
• The baby should be kept warm, ideally in skin-to-skin contact with the mother. Overheating should be avoided..
• Newborn infants should be encouraged to breast-feed within the hour; babies who have been severely hypoxic may require supplementary oral or intravenous fluids.