Common for a Baby Not to Breathe When Born

1 Failure to breathe at birth and resuscitation

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Objectives
Assessing the babe at nascence
Neonatal resuscitation
Preventing meconium aspiration
Neonatal encephalopathy
Case studies

Objectives

When y'all accept completed this unit you should be able to:

Define failure to breathe well at birth.
Appreciate the importance of poor breathing at nascency.
List which infants are likely to need resuscitation at nativity.
Prepare for resuscitation.
Resuscitate an babe.
Prevent meconium aspiration.
List the dangers of hypoxia.
Diagnose and manage neonatal encephalopathy.

Assessing the infant at birth

1-one Do all newborn infants breathe well at nascence?

No. Virtually newborn infants start to breathe well without assistance and often cry immediately afterward birth. Past one infinitesimal afterward delivery most infants are animate well or crying. If an infant fails to plant adequate, sustained respiration after delivery (gasps only or does non exhale at all) the baby is said to take failed to exhale well at birth. About 10% of all newborn infants fail to breathe well and require some help to start breathing well after nascence.

Infants should cry or exhale well after delivery.

Failure to breathe well will result in hypoxia if the baby is not chop-chop resuscitated. Therefore failure to breathe well is an important cause of neonatal expiry if not managed correctly.

Note: The discussion 'asphyxia' causes an enormous amount of defoliation as it is used past paediatricians to indicate that the baby does not breathe well after commitment (i.e. 'neonatal asphyxia'). All the same it is also used by obstetricians to indicate fetal hypoxia (i.e. 'intrapartum or birth asphyxia'). Therefore the word asphyxia should exist avoided as information technology is of very little help and is difficult to define. Information technology is best to merely land the nature of the problem (i.e. fetal hypoxia or failure to exhale well at birth) and so that everyone understands.

1-2 What is hypoxia?

Hypoxia is defined as too picayune oxygen in the cells of the body. Hypoxia may occur in the fetus or the newborn baby. If the placenta fails to provide the fetus with enough oxygen, hypoxia will result and crusade fetal distress. Similarly, with failure to breathe well after commitment the babe will develop hypoxia if not correctly managed. Equally a result of hypoxia, earlier or afterward delivery, the heart rate falls, central cyanosis develops and the baby becomes hypotonic (floppy) and unresponsive. Most fetal hypoxia occurs during labour (i.e. intrapartum hypoxia).

Hypoxia is defined as too little oxygen in the cells of the trunk.

Annotation: The definitions of failure to exhale well and hypoxia are non the same. Withal, fetal hypoxia may result in poor breathing at birth while poor breathing will result in hypoxia if the infant is non rapidly resuscitated. Many infants with fetal hypoxia during labour still manage to cry well at nascence and, therefore, do non have poor animate. Hypoxaemia means too little oxygen in the blood. It is sometimes used instead of hypoxia.

1-iii What is the Apgar score?

The Apgar score is a method of assessing an infant'due south clinical status after delivery. The Apgar score is based on 5 vital signs:

Eye rate
Respiratory try
Presence or absence of central and peripheral cyanosis
Muscle tone
Response to stimulation

Each vital sign is given a score of 0 or 1 or 2. A vital sign score of 2 is normal, a score of 1 is mildly abnormal and a score of 0 is severely abnormal. The individual vital sign scores are and then totalled to give the Apgar score out of 10. The best possible Apgar score is 10 and the worst 0. An baby with a score of 0 shows no sign of life.

Unremarkably the Apgar score is from 7 to 10. Infants with a score between iv and vi have moderate low of their vital signs while infants with a score of 0 to 3 have severely depressed vital signs and are at bully risk of dying unless actively resuscitated.

Due to the presence of peripheral cyanosis in near infants at delivery, it is unusual for a normal infant to score x at 1 minute. By v minutes near infants will have a score of ten. If the Apgar score is guessed, and non correctly assessed, besides loftier a score is usually given. This is a common error in Apgar scoring.

A normal Apgar score is vii or higher.

Note: The Apgar score is named after the belatedly Dr Virginia Apgar, an anaesthetist from the USA, who described the scoring method in 1953. A way to remember the steps in the Apgar score is Appearance (color), Pulse (centre rate), Grimace (response to stimulation), Activity (tone) and Respiration.

ane-4 When should you lot determine the Apgar score?

The Apgar score should exist performed on all infants at 1 minute after complete delivery to record the infant'south clinical status afterward birth. If the 1 minute Apgar score is beneath 7, then the Apgar score should be repeated at 5 minutes to document the success or failure of the resuscitation efforts. If the five minute Apgar score is nonetheless low, it should exist repeated every 5 minutes until a normal Apgar score of 7 or more is accomplished. In many hospitals, the Apgar score is often routinely repeated at 5 minutes fifty-fifty if the i infinitesimal score was normal. This is not necessary and the infant should rather be handed to the female parent. Apgar scoring is an important way to document the infant'southward clinical condition and the response to resuscitation in the hospital or clinical records.

If an infant does non exhale well subsequently being dried, it is important to offset resuscitation immediately and not wait for the 1 minute Apgar score.

All infants should receive an Apgar score at 1 minute to document the babe'due south clinical status after delivery.

1-v What causes a low Apgar score?

In that location are many causes of a low Apgar score. These include:

Fetal distress due to hypoxia before delivery (especially during labour)
Maternal general anaesthesia or recent analgesia (e.1000. morphine)
Preterm infant
Difficult or traumatic delivery
Excessive suctioning of the pharynx after delivery
Severe respiratory distress

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 attempt and observe the crusade 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 nativity.

Intrapartum hypoxia is the most important cause of failure to breathe well at birth.

Note: A base deficit of 10 or more in a sample of umbilical artery claret strongly suggests that the infant has had significant hypoxia before delivery. This is very useful data in any delivery following a diagnosis of fetal distress. It is also very useful in infants who demand resuscitation after delivery.

Neonatal resuscitation

1-6 What is neonatal resuscitation?

Resuscitation is a serial of actions taken to found normal breathing, center charge per unit, color, tone and action in a newborn infant with depressed vital signs (i.e. a low Apgar score).

ane-7 Which infants need resuscitation?

All infants who exercise not breathe well after delivery need immediate resuscitation. Therefore, it is important to formally asses an babe's breathing later delivery. Any babe who stops breathing or has depressed vital signs at whatever fourth dimension after delivery or in the plant nursery likewise requires resuscitation.

All infants who do not exhale well at nascency must be resuscitated.

1-eight Can you anticipate who will need resuscitation at nativity?

The following clinical situations ofttimes pb to the delivery of an infant who does not breathe well:

Signs of fetal distress during labour (baseline bradycardia or late decelerations)
Delivery earlier 37 weeks of gestation
Abnormal presentation of the fetus (e.chiliad. breech)
Hard or traumatic delivery (e.one thousand. forceps delivery)
General anaesthesia or recent analgesia (pethidine or morphine inside the concluding 4 hours)

Remember that whatsoever babe can be built-in with failure to exhale well without prior warning. It is essential, therefore, to be prepared to resuscitate any newborn baby. Anybody who delivers an baby must be able to perform resuscitation.

Any baby tin can fail to breathe well without warning signs during labour.

1-9 What equipment exercise yous need for basic infant resuscitation?

It is essential that you have all the equipment needed for basic babe 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 estrus source, such every bit an overhead radiant warmer, is needed to go along the infant warm. Avert draughts. A good light, such as an angle poise lamp, is required so that the baby can be closely observed during resuscitation. A house, 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:

Suction apparatus: An electric or wall vacuum suction apparatus is ideal but the vacuum pressure level should non exceed 200 cm water (i.due east. xx kPa or 200 mbar). Soft F10 cease hole suction catheters are needed. Smaller catheters (F5 and F6) with side holes are of limited employ every bit they block easily. They can exist used for an orogastric tube or for umbilical vein catheterisation. A suction bulb can also exist used to remove secretions from the infant's rima oris and olfactory organ.
Oxygen: Whenever possible a cylinder or wall source of 100% oxygen or an oxygen concentrator should exist available. Nevertheless, nearly infants can be resuscitated in room air only without oxygen. A flow meter is needed and an air-oxygen blender is very useful. A pulse oximeter (saturation monitor) is very helpful to identify infants who are hypoxic.
Ventilation bag and mask: A neonatal self-inflating ventilation bag and mask (e.g. Laerdal) must exist available to provide ventilation. A reservoir attached to the ventilation bag is needed if high concentrations of oxygen are required. Correct size face up masks with a cushioned rim are of import. A resuscitation appliance such as the T-slice infant resuscitator may likewise exist used.
Endotracheal tubes: 2.5 mm, iii.0 mm and 3.v mm straight tubes must be bachelor. Introducers are besides needed. Cuffed endotracheal or shouldered tubes must not be used in newborn infants.
Laryngoscope: A laryngoscope with a small, straight blade (size 0 and 1 blades). Spare batteries and bulbs must be kept with the laryngoscope. This is the only expensive piece of equipment that is essential for all hospitals and clinics where deliveries are washed.
Naloxone: Ampoules of naloxone (Narcan). Syringes and needles volition be needed to administer the drug.
Adrenaline 1:1000 ampoules.
Normal saline ampoules
Wall clock or wrist watch: Needed to note the time at nascency and time the Apgar scoring.
Disposable gloves. Always wear gloves when delivering or resuscitating an baby.
Stethoscope.

While a pulse oximeter is not essential it is very useful to monitor the infant'south centre rate and oxygen saturation response to resuscitation. Place the probe on the infant's correct hand.

All resuscitation equipment must be bachelor and checked every twenty-four hours.

Note: Equipment to showtime an intravenous infusion is useful for avant-garde resuscitation.

1-x How should y'all stimulate respiration immediately after birth?

Immediately after birth all infants must exist thoroughly stale with a warm towel and so placed in a 2d warm, dry towel before they are clinically assessed. This prevents rapid rut loss due to evaporation, even in a warm room. Dry the infant'due south head, body, arms and legs and wipe any blood or maternal faeces off the face,Handling and rubbing the newborn infant with a dry towel is normally all that is needed to stimulate the onset of breathing. Most infants can be stale on the mother's abdomen. In that location is no need to smack newborn infants to get them to exhale. Never shake an infant. If the infant does non cry or exhale well in response to drying and stimulation, the umbilical string must be cut and clamped immediately and the infant must be moved to the resuscitation area.

Dry to stimulate animate in all infants immediately after delivery.

Infants who are active and breathe well can stay with their mother. Information technology is best to delay clamping their umbilical cord for 2 to iii minutes if the infant does non need resuscitation. And so the infant should be placed in the kangaroo female parent care position to continue warm. Infants who breathe well should non be routinely suctioned every bit this is not necessary and suctioning sometimes causes apnoea. Infants born past Caesarean section also need not be routinely suctioned. Even so, the babe's oral fissure can be wiped with a clean towel if at that place are excessive secretions.

Information technology is not necessary to routinely suction the mouth and nose of infants after delivery.

1-11 How exercise you lot resuscitate an baby?

If the infant fails to respond to the stimulation of drying, then the infant must exist actively resuscitated. The about experienced person, irrespective of rank, should resuscitate the infant. However, all staff who conduct deliveries must be able to resuscitate infants. Information technology is very helpful to have an assistant during resuscitation. Stand at the head of the babe where it is easier to carry out the steps needed in resuscitation.

There are 4 main steps in the bones resuscitation of a newborn babe. They tin be easily remembered past thinking of the kickoff 4 messages of the alphabet, i.east. 'ABCD': Airway – Animate – Circulation – Drugs. Therefore the steps in neonatal resuscitation are:

Airway: Open the airway.
Breathing: Commencement the infant breathing by providing adequate ventilation.
Circulation: Obtain a skillful heart rate and circulation with breast compressions.
Drugs: Give adrenaline to stimulate the heart and naloxone to opposite pethidine and morphine.

1-12 How should you lot open the airway?

Position the caput correctly by placing the infant on his back and so putting the baby'south caput in the neutral position with the neck slightly extended. Do not flex or overextend the neck. It is of import to position the caput correctly to open up the airway before starting mask ventilation.
Gently clear the throat. The infant may be unable to exhale because the airway is blocked past meconium or blood. Therefore, gently suction the back of the mouth and throat with a soft terminate-pigsty F10 catheter. Excessive suctioning, especially if too deep in the region of the song cords, may event in apnoea and bradycardia by stimulating the vagal nervus. This tin can be prevented by holding the catheter 5 cm from the tip when suctioning the infant's pharynx. Exercise not suction the nose before suctioning the rima oris or throat as this often causes the baby to gasp and inhale fungus and blood. Never hold an infant upside down to clear secretions. Suctioning clear liquor from the airways is probably non needed. Remember to keep the infant warm. Opening the airway will often allow the infant to start breathing. Gently rubbing the baby'due south back may help stimulate animate.

If opening the airway fails to start animate, the infant needs ventilation. Practise not waste time by giving oxygen, without also applying ventilation, if the infant does not exhale.

If an infant fails to breathe well afterwards nascence, ventilation should be started as soon as possible only preferably within 1 minute ('The golden minute'). The Apgar score should exist adamant at 1 to assess the babe'due south clinical condition.

Infants needing ventilation include:

Any babe who is not breathing at all, is animate poorly or gasping
Any babe who has central cyanosis
Whatsoever infant who has a center rate below 100 per minute

Ventilation is indicated if the infant does not breathe well.

Nearly infants who breathe well volition have a good heart rate and soon become centrally pink. Gratis-flow mask oxygen alone, without ventilation, is simply indicated in the few infants who breathe well with a good center rate but remain centrally cyanosed. Even in infants who are warm and breathe well, peripheral cyanosis may have upwards to 10 minutes to resolve.

1-13 How can you lot start the babe breathing past providing adequate ventilation?

Keep the infant warm: Under a radiant heater if bachelor. Good lighting is important. Infants nether 28 weeks can be placed in a clean plastic pocketbook to preclude hypothermia.
Mask ventilation: If the infant fails to breathe adequately despite opening the airway, some grade of artificial ventilation (animate) is required. Near all infants (90%) who do not breathe on their own can be adequately ventilated with a purse and mask. The mask must be held firmly over the infant'due south nose and mouth only non over the eyes. Brand sure the caput is in the right position and the airway is open up. It is very important to position and hold the mask correctly. Do not merely printing the mask onto the face.
Even if animate is not started, most infants can be kept alive with face mask ventilation until help arrives. Intubation and ventilation are only needed if adequate chest movement cannot be accomplished with correct mask ventilation. Proficient bag and mask ventilation is the virtually important step in resuscitation of an babe. Ventilate the infant at about forty breaths per minute. If mask ventilation is needed for more than a few minutes, it is useful to pass a F8 orogastric tube to prevent abdominal amplification.
Intubation and ventilation: An alternate method of ventilation is via an endotracheal tube. Although information technology is ordinarily non needed, all staff who frequently deliver infants should acquire this simple technique. Infants who fail to respond to mask ventilation must be intubated. Ventilate the infant at a rate of well-nigh 40 breaths a infinitesimal. Make sure that the baby's chest moves well with each jiff and that good air entry is heard over both sides of the chest. Abdominal amplification or air entry heard over the abdomen suggests that the oesophagus has been intubated in error. Mouth-to-rima oris ventilation and straight mouth suction should exist avoided unless it is an emergency, as the infant'southward mother may be HIV positive.

Most infants can exist adequately ventilated with a bag and mask in room air.

Ventilation is usually given with room air. Nevertheless sometimes it may be necessary to requite supplementary oxygen until good breathing efforts and heart charge per unit are established. Set the flow meter at 5 litres per minute. Added oxygen can usually exist stopped once the baby is centrally pink and the center rate normal. Information technology is very useful to accept a blender and pulse oximeter and then that the amount of oxygen tin be monitored and controlled.

Remember that a cocky-inflating bag and mask will not evangelize oxygen unless the bag is squeezed. A reservoir is needed to provide an infant with 100% oxygen.

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 100 beats per minute or if central cyanosis remains despite adequate ventilation should oxygen be given. Oxygen should be reduced and so stopped as soon as possible.

Adequate ventilation is the most of import stride in newborn resuscitation.

In one case adequate ventilation has been given for one minute, the infant's breathing, color and heart rate must be assessed. Cease ventilation once the infant is pink and animate well with a centre rate above 100 beats per second. If the heart charge per unit remains below sixty beats per minute in spite of constructive ventilation for i minute seconds, chest compressions are needed. A good eye rate is the best indicator of acceptable ventilation.

A adept heart rate is the all-time indicator of adequate ventilation.

Annotation: Using oxygen rather than room air in neonatal resuscitation may increase the risk of neonatal encephalopathy. Many experts concur that room air should be used unless good ventilation does not correct the bradycardia and fundamental cyanosis.

ane-xiv How should y'all obtain a adept heart rate with breast compressions?

Apply chest compressions (external cardiac massage) at a charge per unit of about 90 times a minute. Usually three breast compressions are followed by one ventilation (a breath). One or both hands can be used to give chest compressions.

Breast compressions are indicated if the heart charge per unit is less than sixty beats per minute after one minute of adequate ventilation.

Once both constructive ventilation and chest compressions have been given for one infinitesimal, again appraise the baby's breathing, colour and heart rate. When the heart rate reaches in a higher place 60 beats per minute, chest compressions can be stopped and the center rate advisedly monitored. If the heart charge per unit has not increased above 60 beats per minute, give adrenaline (epinephrine) to stimulate the heart.

i-fifteen How should yous give adrenaline to stimulate the heart?

Adrenaline 1:10 000 should exist given intravenously, normally into the umbilical vein or a peripheral line. Adrenaline stimulates the myocardium and increases the heart rate. 1 ml of adrenaline 1:1000 must beginning be diluted with 9 ml normal saline to requite a i:10 000 solution. One ml of the diluted solution tin can then be given to term infants and 0.5 ml to preterm infants (recommended dose is 0.25 ml/kg of diluted adrenaline). Adrenaline is important if the heart rate remains dull or if no heart vanquish tin exist detected. The dose can be repeated every 3 to five minutes if the heart rate does not increase to above 60 beats per minute. Practice not give adrenaline subcutaneously or by intramuscular injection.

Adrenaline is indicated if the centre rate is less than sixty beats per minute subsequently 1 minute of chest compressions.

Note: i:1000 adrenaline gives 1 mg/ml. Therefore 1 ml of i:10 000 adrenaline gives 0.1 mg while 0.five ml gives 0.05 mg. A dose of 0.25 ml/kg of one:ten 000 adrenaline gives 0.025 mg/kg. Information technology has been suggested that 0.five ml/kg may be given via an endotracheal tube if it is not possible to admission an intravenous road.

If the baby has a good heart rate and is centrally pink, but still does non breathe, consider giving naloxone (Narcan) if the mother has received an opiate analgesic (pethidine or morphine) in the 4 hours before delivery.

1-xvi How can yous give naloxone to reverse pethidine or morphine?

If the mother has received either pethidine or morphine during the iv 60 minutes menstruum before commitment, the babe's poor animate may be due to narcotic depression. If then, the depressing effect of the maternal analgesia on the infant'southward respiration tin can be rapidly reversed with naloxone (1 ml ampoule contains 0.4 mg naloxone). Naloxone 0.1 mg/kg (i.east. 0.25 ml/kg) can exist given by intramuscular injection into the anterolateral aspect of the thigh. Naloxone will not help resuscitate an infant if the mother has non received an opiate analgesic during labour, or has only received a general anaesthetic, barbiturates or other sedatives. Naloxone is not a full general respiratory stimulant. Never requite naloxone before providing adequate ventilation.

Naloxone must but be used after adequate ventilation has been provided.

Note

Intramuscular naloxone may accept a few minutes to reverse the effects of opiates but acts for a longer time. Flumazenil (Anexate) volition opposite the depressant effect of benzodiazepines such every bit diazepam (Valium).

With experience and further training, additional medication (e.g. dopamine) can exist given to back up the blood pressure and circulation if the above steps fail to resuscitate the infant:

If the infant remains shocked with poor peripheral perfusion despite all other attempts at resuscitation, a plasma volume expander such as normal saline tin can be given intravenously via an umbilical vein catheter or peripheral line. The required volume is usually ten ml/kg over 10 minutes. If needed this can exist repeated once unless in that location has been severe blood loss.
Simply give actress glucose intravenously if the blood glucose concentration is low when measured with a reagent strip. Practice non routinely requite glucose during resuscitation. Ordinarily a ten% glucose solution is adequate to correct whatever hypoglycaemia.

one-17 How can you lot assess whether resuscitation is successful?

The four steps in resuscitation are followed step by step until the 3 most important vital signs of the Apgar score have returned to normal:

A pulse rate higher up 100 beats per minute. Easily assessed past palpating the base of the umbilical cord or listening to the chest with a stethoscope. A good eye rate is the best indicator of adequate ventilation and oxygenation during resuscitation. It is useful to count the number of heart beats in fifteen seconds and and so multiply by 4 to give beats per minute.
A expert cry or good breathing efforts (not just gasping). This assures adequate animate. A good cry usually indicates that the infant has been successfully resuscitated.
A pink natural language. This indicates a good oxygen supply to the encephalon. Practice not rely on the colour of the lips or buccal mucosa.

one-18 When is farther resuscitation hopeless?

Every effort should be made to resuscitate all infants that show any sign of life at delivery unless the babe's gestational historic period, weight or astringent congenital disorders signal a very poor hazard of survival. The Apgar scores at ane and 5 minutes are not a practiced indicator of the likelihood of hypoxic brain damage or the possibility of an unsuccessful resuscitation. If the Apgar score remains depression afterwards 5 minutes, efforts at resuscitation must exist continued. It is important to keep repeating the Apgar score every 5 minutes until the score is normal or resuscitation is abased.

If the infant has not started to breathe, or only gives occasional gasps past 20 minutes, the risk of death or brain damage is extremely high. The exception is when the babe is sedated past maternal drugs. It is preferable if an experienced person decides when to abandon farther attempts at resuscitation. Resuscitation tin also be stopped if in that location are no signs of life (no heart beat) after 10 minutes.

Note: Some people merits that resuscitating infants with failure to breathe is contra-indicated as they survive with brain impairment. Enquiry has indicated that this claim is not correct equally many infants that exercise non exhale at nascence, that are aggressively resuscitated and survive, recover completely.

1-xix What mail service-resuscitation care is needed?

Infants that offset animate as soon as mask and bag ventilation is provided can be observed with their mothers. However infants who require more than prolonged ventilation must be advisedly observed in the newborn nursery for at least 4 hours later on delivery. Their temperature, pulse and respiratory rate, colour and activity should be recorded and their blood glucose concentration checked. Proceed these infants warm and provide fluid and energy either intravenously or orally. Commonly these infants are observed in a airtight incubator. Do not bath the infant until the infant has fully recovered.

If the baby has signs of respiratory difficulty, or is centrally cyanosed in room air after resuscitation, information technology is essential to provide oxygen while the infant is existence moved to the nursery. Some infants may even require ventilation during ship.

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

Preventing meconium aspiration

1-20 Does the meconium-stained infant need special care?

Yeah. All infants that have meconium-stained amniotic fluid (liquor) need special care to reduce the risk of severe meconium aspiration after delivery. Whenever possible all these at-risk infants should be identified before delivery, especially infants with thick meconium in the amniotic fluid.

Note: Good intrapartum care will help to prevent fetal distress and meconium-stained liquor.

1-21 Why does the meconium-stained infant need special care?

As a event of hypoxia before delivery, the fetus may pass meconium. Some hypoxic fetuses will too brand gasping movements which can suck meconium into the upper airways together with amniotic fluid. Fortunately well-nigh of the meconium is unable to accomplish the fluid-filled alveoli of the fetus. Only after delivery, when the babe inhales air, does meconium enter the small airways and alveoli.

Meconium contains enzymes from the fetal pancreas that can cause severe lung harm and even death if inhaled into the alveoli later on delivery. Meconium too obstructs the airways. This results in respiratory distress due to meconium inhalation. Meconium aspiration syndrome remains a common problem is many developing countries.

Note: Meconium often burns the infant'south skin and digests away the babe'southward eyelashes! Therefore, imagine the damage meconium can cause to the fragile lining of the bronchi and alveoli.

one-22 How tin you reduce the risk of meconium aspiration during delivery?

Many cases of meconium aspiration syndrome can exist prevented with the right intendance of the baby during delivery. A suction apparatus and a F10 end-pigsty 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.

Later delivery of the head, the shoulders should be held back and the mother asked to pant to forbid delivery of the trunk. The infant'south face is then turned toward the assistant and so that the mouth and pharynx tin can be well suctioned. Merely when no more meconium can be cleared, should the infant be completely delivered. The aforementioned procedure should exist followed if a meconium-stained infant is delivered past Caesarean section. Suctioning should not take more than than 30 seconds.

Some infants develop apnoea and bradycardia every bit a issue of the suctioning and, therefore, may demand mask ventilation for a few minutes after delivery.

Meconium-stained infants must exist suctioned earlier delivery of the shoulders.

Note: A recent study in adult countries where astringent meconium aspiration is uncommon suggests that suctioning meconium-stained infants at commitment is not needed. However, these findings probably exercise not utilize to services where monitoring in labour is poor, intrapartum hypoxia is an important cause of neonatal death, Caesarean section rates are low and severe meconium aspiration syndrome is mutual. A meconium aspirator, which attaches between the endotracheal tube and bag, is very useful.

1-23 How tin can you reduce the risk of meconium aspiration after delivery?

No further suctioning is needed if the infant was well suctioned during delivery and cries well at birth. The oral cavity can exist wiped with a towel and meconium can exist removed from the pare during routine drying.

If a meconium-covered babe needs resuscitation, it is better to intubate the babe immediately to clear the airways. Once intubated, direct suction can exist applied to the endotracheal tube. Withdraw the endotracheal tube slowly while applying suction. Repeat intubation and suction until no more meconium is obtained. This aggressive method of suctioning is very successful in preventing severe meconium aspiration. Alternatively the pharynx tin can also be suctioned under straight vision using a laryngoscope, before ventilation is started. Exercise non use bag and mask ventilation before adequately suctioning meconium-stained infants as this can blow meconium from the pharynx into the lungs.

Meconium-stained infants who require resuscitation need suctioning before starting ventilation.

1-24 What care should you requite to meconium-stained infants in the nursery?

All heavily meconium-stained infants should be observed in the nursery for a few hours after delivery as they may prove signs of hypoxic damage or meconium aspiration syndrome. Most meconium-stained infants take swallowed meconium before commitment. Meconium is a very irritant substance and causes meconium gastritis. This may effect in repeated vomits of meconium-stained fungus.
Infants with lightly meconium-stained amniotic fluid who appear well subsequently delivery can be kept with their mothers.

Meconium gastritis may be prevented past washing out the tum with normal saline or ii% sodium bicarbonate (mix 4% sodium bicarbonate with an equal volume of sterile h2o). V ml of normal saline or 2% sodium bicarbonate is repeated injected into the stomach via a nasogastric tube and then aspirated until the gastric aspirate is clear. Only heavily meconium-stained infants should accept a breadbasket washout on inflow in the plant nursery. This should be followed past a feed of colostrum. Routine tum washouts in all preterm infants or infants born by Caesarean department are not needed. A stomach washout is besides not needed if there is only lightly meconium-stained amniotic fluid.

Meconium-stained infants do not need to be washed or bathed immediately after commitment but should be carefully wiped with a warm towel.

Notation: Colostrum contains phagocytic cells that ingest any meconium that remains in the stomach. This reduces the adventure of farther vomiting.

A tummy washout is only needed if the babe is covered with thick meconium.

Neonatal encephalopathy

1-25 What is the danger of hypoxia earlier or later on delivery?

If the cells of the fetus or newborn infant practise not receive enough oxygen, many organs may be damaged. This may result in either:

Transient impairment which will recover completely after delivery
Permanent damage that will not recover fully after nascence
Death of the fetus or newborn baby

ane-26 What organs are normally damaged by hypoxia?

The brain needs a lot of oxygen and, therefore, is very sensitive to hypoxia either before or afterward delivery.
The kidneys may be damaged, resulting in haematuria, proteinuria and decreased urine output for the beginning few days afterward delivery. Occasionally renal failure may effect.
The heart may be damaged causing heart failure. This presents with hepatomegaly, respiratory distress and poor peripheral perfusion.
The gut may be damaged causing necrotising enterocolitis.
The lungs may exist damaged resulting in respiratory distress with pulmonary artery spasm (persistent pulmonary hypertension).

Note: At the onset of hypoxia, blood is shunted away from the kidneys, gut and lungs to protect the brain and heart. This may cause ischaemic damage to these organs. The increased blood flow to the brain may cause intraventricular haemorrhage in preterm infants. With severe, prolonged hypoxia, cardiac output eventually falls and as a result the brain and myocardium may besides suffer ischaemic damage.

Fetal hypoxia may crusade encephalon damage.

1-27 What damage is done to the encephalon by hypoxia?

Dissimilar types of brain damage can occur depending on the gestational age of the fetus and the severity of the hypoxia:

In term infants and infants near to term, hypoxia and ischaemia of the encephalon during labour presents in the first 72 hours every bit neonatal encephalopathy (hypoxic ischaemic encephalopathy). This clinical diagnosis is common especially where monitoring and care of the fetus during labour is poor.
In preterm infants, hypoxia earlier delivery may impairment minor claret vessels around the ventricles of the encephalon causing an intraventricular haemorrhage. The haemorrhage can damage the surrounding brain. An intraventricular haemorrhage usually presents within the starting time 2 days after commitment. A balmy bleeding is usually asymptomatic merely a severe bleeding causes apnoea, shock and death. The clinical diagnosis of intraventricular haemorrhage can exist confirmed with ultrasonography of the brain.
Hypoxia may cause decreased blood flow which results in infarction (death) of part of the brain. In preterm infants this usually causes spastic diplegia (spastic weakness of both legs). In term infants hypoxia usually causes convulsions, mental retardation and cognitive palsy.
Hypoxia may also crusade blindness, deafness or learning and behaviour problems at school.

1-28 What are the clinical signs of neonatal encephalopathy?

Contradistinct level of consciousness. Either depressed level of consciousness with poor feeding, or staring with increased irritability.
Altered tone. Either increased tone or decreased tone (hypotonia).
Poor feeding or abnormal breathing with apnoea.
Fits (convulsions) or aberrant movements.
Aberrant reflexes due east.g. no or poor Moro reflex.

Most infants with neonatal encephalopathy bear abnormally in the first 12 hours after delivery. Most, but non all, cases of neonatal encephalopathy are due to intrapartum hypoxia (hypoxia during labour or but before commitment). Hypoglycaemia, meningitis and encephalon haemorrhage can also requite neonatal encephalopathy.

Note: A number of scoring methods (eastward.g. the Thompson score) are available to assess the severity of neonatal encephalopathy on a daily basis for the get-go two weeks of life. This can help to predict the issue. Infants with a normal score on day vii will probably recover completely.

Neonatal encephalopathy presents with abnormal neurological signs shortly after nascency.

1-29 What are the results of neonatal encephalopathy?

The encephalopathy may recover completely and the child develops unremarkably. This is mutual with balmy encephalopathy when the infant appears normal past seven days of age.
The encephalopathy may recover slowly and the kid survives just has permanent brain impairment with cerebral palsy or mental disability or both. This is often seen when the signs of neonatal encephalopathy have non disappeared past seven days of life.
The encephalopathy may get worse and the infant dies during the start few days.

i-30 What is the management of an babe with neonatal encephalopathy?

Prevent severe hypoxia, if possible, by good monitoring and intendance in labour and active resuscitation after delivery if needed. Once the hypoxic and ischaemic encephalon harm is done, there is trivial that can repair this.

Infants with neonatal encephalopathy should be given general supportive care to prevent hypoglycaemia or farther hypoxia. If possible they should exist referred to a level 2 or three hospital.
Information technology is very of import that they practise not become as well hot as this may brand the brain harm worse. Their abdominal skin temperature should not be allowed to increase above 35.5°C and axillary temperature higher up 36°C.
Fluid intake is normally restricted to 60 ml/kg daily for the first 3 days to assist prevent cognitive oedema.
Fits are controlled with a single dose of xx mg/kg intravenous phenobarbitone given slowly over ten minutes.
Ventilation may be needed.
Monitor the vital signs and await out for hypoxic harm to other organs.
Survivors must exist followed upward for signs of neurodevelopmental filibuster or cerebral palsy.

Note: Recent exciting studies show that the extent of brain damage in infants with moderate encephalopathy can be reduced if the infants are cooled for the first 72 hours after delivery. This procedure promises some hope to many of these infants.

Example report 1

Subsequently a normal pregnancy, an infant is born past constituent caesarian department nether full general anaesthesia. Immediately after delivery the infant is dried and placed under an overhead radiant warmer. He is not breathing and resuscitation is started. At 1 minute after birth the babe has a heart rate of lxxx beats per minute, gives irregular gasps, has bluish hands and feet just a pink tongue, has some muscle tone only does not answer when dried. Resuscitation is started and at five minutes the infant has a center charge per unit of 120 beats per minute and is breathing well. The natural language is pink only the hands and feet are still bluish. The infant moves actively and cries well.

1. What is the infant'due south Apgar score at 1 infinitesimal?

The Apgar score at one minute is four: eye rate=1, respiration=i, colour=1, tone=one, response=0.

2. Why does this infant crave resuscitation?

Because he is not animate well after being dried. The diagnosis of failure to breathe well is supported past the low Apgar score at one minute.

3. What is the probable crusade of the failure to breathe?

The full general anaesthetic. Both the intravenous drugs and the anaesthetic gases cantankerous the placenta and may sedate the fetus. These sedated infants ordinarily respond chop-chop to resuscitation.

iv. What is the most important pace in resuscitating this infant?

If respiration cannot be stimulated past drying the infant, then ventilation must be started. Most infants can be adequately ventilated with a bag and mask. If practiced chest movement cannot be obtained with mask ventilation, the babe must exist intubated and ventilated.

5. What is this baby's Apgar score at 5 minutes?

The Apgar score at 5 minutes is 9: center rate=ii, breathing=two, color=1, tone=2, response=two. This indicates that the infant has responded well to resuscitation. Bluish hands and feet (peripheral cyanosis) at 5 minutes are common.

6. Why is this infant very unlikely to have suffered brain impairment due to hypoxia?

Because at that place is no history of fetal distress to bespeak that this babe had been hypoxic earlier delivery. The rapid response to resuscitation also suggests that in that location was no fetal hypoxia. In that location is also no good reason why the fetus should be hypoxic as the mother has had an elective Caesarean department and was non in labour. Most fetal hypoxia occurs during labour.

vii. What should be the direction of this baby afterward resuscitation?

The infant should be kept warm and be transferred to the nursery for observation for a few hours.

Example study 2

Afterward fetal distress has been diagnosed, an infant is delivered past a difficult vacuum extraction. At delivery the infant is covered with thick meconium. The infant starts to gasp. Only and then are the mouth and pharynx suctioned for the first time. The Apgar score at 1 minute is 3. The infant is given face mask oxygen and by 5 minutes the Apgar score is half-dozen. By fifteen minutes the infant is agile and crying well. It is decided to bath the infant and give a breadbasket washout in the labour ward before transferring both female parent and infant to the postnatal ward.

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

Hypoxia resulting in fetal distress, as indicated by the passage of meconium before commitment. The difficult delivery by vacuum extraction probably resulted in failure to exhale well and a depression Apgar score, while inhaled meconium may accept blocked the airway.

ii. What mistake was made with the management of this babe?

The infant's rima oris and pharynx should have been well suctioned earlier the shoulders were delivered. This volition unremarkably prevent severe meconium aspiration as the airway is cleared of meconium earlier the infant starts to breathe.

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

A large catheter (F10) must be used as a small catheter will block with meconium. The catheter should take a hole at the cease and non just at the side.

iv. Should this infant be given a bath and tum washout in the labour ward later on it starts to breathe spontaneously?

No. A bath should not be done until the baby has been stable for a number of hours in the nursery. As at that place was thick meconium, the infant should be given a stomach washout with normal saline or two% sodium bicarbonate in the nursery followed by a breastfeed.

v. What 2 complications is this infant at high risk of?

This infant may develop meconium aspiration syndrome as meconium was probably inhaled into the lungs after birth. The infant may also suffer brain damage or harm to other organs due to hypoxia causing fetal distress during labour.

half dozen. What does an Apgar score of half dozen at 5 minutes suggest?

Information technology suggests that the infant has not been correctly resuscitated. This babe needed intubation and suctioning followed by ventilation, and not just face mask oxygen.

Case study iii

A woman with an abruptio placentae delivers at 32 weeks. Before delivery the fetal middle rate was only 80 beats per infinitesimal. The babe appeared dead at nascency but was intubated and ventilated. Chest compressions were as well given, and the heart rate remained slow afterward ventilation was started. The one infinitesimal Apgar score was 2. Despite further efforts at resuscitation, the Apgar score at v, 10, fifteen and 20 minutes remained two.

1. What is the likely cause of the infant's poor status at nativity?

Fetal distress acquired by fetal hypoxia. Abruptio placentae (placental separation earlier delivery) is a mutual crusade of severe hypoxia and fetal distress.

2. Why is it possible to successfully resuscitate some infants that appear expressionless at birth?

If a fetal heart is heard just before commitment but the infant appears dead at birth, the duration of cardiac arrest has but been a few minutes. With ventilation and breast compressions, it is possible to resuscitate some of these infants. Many of the survivors practice not suffer brain damage.

3. What is the significance of the depression Apgar scores at 5, 10, 15 and twenty minutes?

Prolonged failure to answer well to practiced resuscitation suggests that the babe will die due to astringent hypoxic damage to the brain and heart.

4. Which 5 organs are likely to exist damaged by severe hypoxia?

The brain, heart, kidneys, gut and lungs.

5. What is neonatal encephalopathy?

Aberrant neurological behaviour of a term or most term newborn infant within hours of birth. The important features of neonatal encephalopathy are altered level of consciousness, abnormal muscle tone, poor feeding and breathing, depressed reflexes and convulsions. Neonatal encephalopathy is usually due to intrapartum hypoxia.

vi. When should attempts at resuscitation be stopped?

If there is no heart vanquish after ten minutes or no attempt at breathing afterwards 20 minutes.

Example study 4

After a normal labour and delivery at term, an babe cries well at nascence. No maternal analgesia was needed and the amniotic fluid was not meconium stained. The infant is well suctioned after delivery as this is the routine practice in the dispensary. Immediately after suctioning the infant stops breathing and becomes cyanosed. The 1 minute Apgar score is non washed. The medical officer tries unsuccessfully for v minutes to intubate the baby. When an intramuscular injection of naloxone fails to stimulate respiration, further attempts at resuscitation are abandoned. The infant is centrally cyanosed, has a eye rate of 50 beats per minute and starts to gasp at 5 minutes. Face mask oxygen was given and eventually the infant cried weakly. No ane at the dispensary had been trained in bones neonatal resuscitation.

1. What was the beginning mistake that was fabricated in managing this infant?

The infant's mouth and pharynx should not have been suctioned as there was no clinical indication. The infant breathed well after delivery and was not meconium stained. Normal infants must not be routinely suctioned. Suctioning clear liquor from the mouth and pharynx before starting ventilation is probably not needed. The 1 minute Apgar score should have been done to certificate the infant's clinical condition at this time.

two. Why did the infant stop breathing and get cyanosed?

Excessive, deep suctioning often causes apnoea. This is why routine suctioning has been stopped.

3. How should this baby accept been resuscitated?

The head and neck should have been correctly positioned to open the airway. Then bag and mask ventilation should take been given. With this basic resuscitation, the babe would almost certainly have started to exhale normally and cry. The infant became more and more than hypoxic while attempts were made to intubate the trachea. The Apgar should as well take been done at 5 minutes and every 5 minutes thereafter to record the status of the infant during the resuscitation attempt.

4. What is the value of giving naloxone to infants who exhale poorly at nativity?

Naloxone is useful in reversing respiratory low in the newborn baby if the mother had received pethidine or morphine during the 4 hours before delivery. In that location was no indication for giving naloxone in this infant as the female parent had non received whatsoever analgesia. Naloxone is not a respiratory stimulant.

5. Should attempts at resuscitation take been abandoned before v minutes?

No. Attempts should be continued for at least twenty minutes. An urgent telephone call to the referral hospital could have provided the correct advice needed. Some infants with poor breathing at birth will eventually starting time gasping spontaneously even if the correct resuscitation is not given. However, during the catamenia of inadequate resuscitation the baby becomes progressively more hypoxic. This tin can effect in brain damage.

6. Who should exist trained to requite basic resuscitation to newborn infants?

All the medical and nursing staff who deliver infants or care for them at delivery. Often information technology cannot be predicted during labour which infants will not exhale well and need resuscitation. Clinics and hospitals should not deliver infants if they do not have the correct equipment and are not able to provide proficient resuscitation.

seven. Should this infant have received chest compressions?

Just if the heart rate remained below threescore per minute after lx seconds of constructive ventilation. With early purse and mask ventilation the center rate would almost certainly take increased and the cyanosis disappeared.

Come across Figure one-i, the important steps in basic newborn resuscitation.

Figure 1-1: The important steps in basic newborn resuscitation.

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