Born to be Alive Volume Three

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By 5 minutes most infants will have a score of If the Apgar score is guessed, and not correctly assessed, too high a score is usually given. This is a common error in Apgar scoring. If the 1 minute Apgar score is below 7, then the Apgar score should be repeated at 5 minutes to document the success or failure of the resuscitation efforts. If the 5 minute Apgar score is still low, it should be repeated every 5 minutes until a normal Apgar score of 7 or more is achieved.

In many hospitals, the Apgar score is often routinely repeated at 5 minutes even if the 1 minute score was normal. This is not necessary and the infant should rather be handed to the mother. If an infant does not breathe well after being dried, it is important to start resuscitation immediately and not wait for the 1 minute Apgar score. Fetal distress due to hypoxia during labour is only one of the many causes of failure to breathe well at birth.

It is important to always try and find the cause of a low 1 minute Apgar score. If the Apgar score remains low at 5 minutes, despite good resuscitation efforts, the infant probably had fetal hypoxia before birth. Resuscitation is a series of actions taken to establish normal breathing, heart rate, colour, tone and activity in a newborn infant with depressed vital signs i. All infants who do not breathe well after delivery need immediate resuscitation.

Any infant who stops breathing or has depressed vital signs at any time after delivery or in the nursery also requires resuscitation. The following clinical situations often lead to the delivery of an infant who does not breathe well:. Remember that any infant can be born with failure to breathe well without prior warning. It is essential, therefore, to be prepared to resuscitate any newborn infant. Everyone who delivers an infant must be able to perform resuscitation. It is essential that you have all the equipment needed for basic infant resuscitation.

The equipment must be in good working order and immediately available. The equipment must be checked daily. A warm, well-lit corner of the delivery room should be available for resuscitation. A heat source, such as an overhead radiant warmer, is needed to keep the infant warm. Avoid draughts. A good light, such as an angle poise lamp, is required so that the infant can be closely observed during resuscitation.

A firm, level working area is needed. A thin foam mattress with a plastic covering can be easily cleaned. The following essential equipment must be available in all hospitals and clinics where infants are delivered:.

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Immediately after birth all infants must be thoroughly dried with a warm towel and then placed in a second warm, dry towel before they are clinically assessed. This prevents rapid heat loss due to evaporation, even in a warm room. There is no need to smack newborn infants to get them to breathe.

Never shake an infant. If the infant does not cry or breathe well in response to drying and stimulation, the umbilical cord must be cut and clamped immediately and the infant must be moved to the resuscitation area.

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Infants who are active and breathe well can stay with their mother. It is best to delay clamping their umbilical cord for 2 to 3 minutes if the infant does not need resuscitation. Then the infant should be placed in the kangaroo mother care position to keep warm. Infants who breathe well should not be routinely suctioned as this is not necessary and suctioning sometimes causes apnoea.

Infants born by Caesarean section also need not be routinely suctioned. If the infant fails to respond to the stimulation of drying, then the infant must be actively resuscitated. The most experienced person, irrespective of rank, should resuscitate the infant. However, all staff who conduct deliveries must be able to resuscitate infants. It is very helpful to have an assistant during resuscitation. Stand at the head of the infant where it is easier to carry out the steps needed in resuscitation. 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, i. Therefore the steps in neonatal resuscitation are:. If opening the airway fails to start breathing, the infant needs ventilation. Do not waste time by giving oxygen, without also applying ventilation, if the infant does not breathe.


Most infants who breathe well will have a good heart rate and soon become centrally pink. Free-flow mask oxygen alone, without ventilation, is only indicated in the few infants who breathe well with a good heart rate but remain centrally cyanosed. Even in infants who are warm and breathe well, peripheral cyanosis may take up to 10 minutes to resolve.

Ventilation is usually given with room air.

Newborn Care: 1. Failure to breathe at birth and resuscitation

However sometimes it may be necessary to give supplementary oxygen until good breathing efforts and heart rate are established. Set the flow meter at 5 litres per minute. Added oxygen can usually be stopped once the infant is centrally pink and the heart rate normal. It is very useful to have a blender and pulse oximeter so that the amount of oxygen can be monitored and controlled. Remember that a self-inflating bag and mask will not deliver oxygen unless the bag is squeezed.

A T-piece infant resuscitator is a very efficient method of ventilating a newborn infant by face mask or endotracheal tube. Oxygen : If possibly infants should be resuscitated in room air only without additional oxygen. Only if the heart rate does not increase to beats per minute or if central cyanosis remains despite adequate ventilation should oxygen be given. Oxygen should be reduced then stopped as soon as possible. Stop ventilation once the infant is pink and breathing well with a heart rate above beats per second. If the heart rate remains below 60 beats per minute in spite of effective ventilation for one minute seconds, chest compressions are needed.

A good heart rate is the best indicator of adequate ventilation. Apply chest compressions external cardiac massage at a rate of about 90 times a minute. Usually three chest compressions are followed by one ventilation a breath. One or both hands can be used to give chest compressions. Chest compressions are indicated if the heart rate is less than 60 beats per minute after one minute of adequate ventilation. When the heart rate reaches above 60 beats per minute, chest compressions can be stopped and the heart rate carefully monitored.

If the heart rate has not increased above 60 beats per minute, give adrenaline epinephrine to stimulate the heart. Adrenaline should be given intravenously, usually into the umbilical vein or a peripheral line.

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Adrenaline stimulates the myocardium and increases the heart rate. One ml of the diluted solution can then be given to term infants and 0. Adrenaline is important if the heart rate remains slow or if no heart beat can be detected. The dose can be repeated every 3 to 5 minutes if the heart rate does not increase to above 60 beats per minute.

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Do not give adrenaline subcutaneously or by intramuscular injection. Adrenaline is indicated if the heart rate is less than 60 beats per minute after one minute of chest compressions. If the infant has a good heart rate and is centrally pink, but still does not breathe, consider giving naloxone Narcan if the mother has received an opiate analgesic pethidine or morphine in the 4 hours before delivery.

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Naloxone 0. Naloxone will not help resuscitate an infant if the mother has not received an opiate analgesic during labour, or has only received a general anaesthetic, barbiturates or other sedatives. Naloxone is not a general respiratory stimulant. Never give naloxone before providing adequate ventilation. With experience and further training, additional medication e.

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:.