If a Baby Isnt Crying After Birth Do You Slap Its Back

March 09, 2022 Post a Comment

1 Failure to breathe at birth and resuscitation

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Objectives
Assessing the infant at nativity
Neonatal resuscitation
Preventing meconium aspiration
Neonatal encephalopathy
Case studies

Objectives

When y'all have completed this unit of measurement you should exist able to:

Define failure to exhale well at birth.
Capeesh the importance of poor breathing at nascency.
List which infants are likely to need resuscitation at nascence.
Set for resuscitation.
Resuscitate an infant.
Prevent meconium aspiration.
List the dangers of hypoxia.
Diagnose and manage neonatal encephalopathy.

Assessing the infant at birth

one-1 Exercise all newborn infants breathe well at nativity?

No. Near newborn infants start to breathe well without assistance and often weep immediately subsequently birth. By 1 infinitesimal afterward commitment most infants are animate well or crying. If an infant fails to plant adequate, sustained respiration afterwards delivery (gasps simply or does non breathe at all) the infant is said to have failed to breathe well at birth. Well-nigh ten% of all newborn infants fail to breathe well and require some assistance to start breathing well after nativity.

Infants should cry or breathe well after delivery.

Failure to breathe well will event in hypoxia if the infant is not rapidly resuscitated. Therefore failure to breathe well is an important cause of neonatal decease if non managed correctly.

Note: The word 'asphyxia' causes an enormous amount of confusion equally it is used past paediatricians to indicate that the infant does not breathe well after delivery (i.east. 'neonatal asphyxia'). Withal it is besides used by obstetricians to indicate fetal hypoxia (i.e. 'intrapartum or birth asphyxia'). Therefore the word asphyxia should be avoided as it is of very piffling assistance and is difficult to define. It is all-time to only land the nature of the trouble (i.e. fetal hypoxia or failure to breathe well at birth) so that everyone understands.

1-2 What is hypoxia?

Hypoxia is divers equally likewise petty oxygen in the cells of the torso. Hypoxia may occur in the fetus or the newborn infant. If the placenta fails to provide the fetus with enough oxygen, hypoxia will result and cause fetal distress. Similarly, with failure to breathe well later delivery the infant will develop hypoxia if non correctly managed. As a event of hypoxia, earlier or subsequently delivery, the heart rate falls, fundamental cyanosis develops and the infant becomes hypotonic (floppy) and unresponsive. Most fetal hypoxia occurs during labour (i.e. intrapartum hypoxia).

Hypoxia is defined equally too footling oxygen in the cells of the body.

Annotation: The definitions of failure to exhale well and hypoxia are not the same. However, fetal hypoxia may event in poor breathing at birth while poor breathing will event in hypoxia if the infant is not rapidly resuscitated. Many infants with fetal hypoxia during labour still manage to weep well at nascency and, therefore, do not have poor animate. Hypoxaemia means likewise fiddling oxygen in the blood. It is sometimes used instead of hypoxia.

1-3 What is the Apgar score?

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

Center rate
Respiratory effort
Presence or absenteeism of cardinal and peripheral cyanosis
Muscle tone
Response to stimulation

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

Commonly the Apgar score is from 7 to 10. Infants with a score between 4 and 6 have moderate depression of their vital signs while infants with a score of 0 to 3 accept severely depressed vital signs and are at great risk of dying unless actively resuscitated.

Due to the presence of peripheral cyanosis in well-nigh infants at delivery, it is unusual for a normal infant to score 10 at 1 minute. By v minutes most infants volition have a score of ten. If the Apgar score is guessed, and non correctly assessed, too high 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 U.s.a., who described the scoring method in 1953. A way to remember the steps in the Apgar score is Advent (colour), Pulse (middle charge per unit), Grimace (response to stimulation), Action (tone) and Respiration.

1-4 When should yous decide the Apgar score?

The Apgar score should be performed on all infants at 1 minute after consummate commitment to record the infant's clinical condition after nascence. If the i minute Apgar score is beneath 7, and so the Apgar score should be repeated at v minutes to document the success or failure of the resuscitation efforts. If the 5 minute Apgar score is still depression, it should be repeated every 5 minutes until a normal Apgar score of vii or more than is accomplished. 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 baby should rather be handed to the mother. Apgar scoring is an of import manner to document the babe'south clinical condition and the response to resuscitation in the infirmary or clinical records.

If an infant does not breathe well after being dried, it is of import to start resuscitation immediately and not wait for the 1 minute Apgar score.

All infants should receive an Apgar score at 1 infinitesimal to document the infant'south clinical condition later on delivery.

i-5 What causes a depression Apgar score?

There are many causes of a low Apgar score. These include:

Fetal distress due to hypoxia before delivery (especially during labour)
Maternal full general anaesthesia or contempo analgesia (east.g. morphine)
Preterm infant
Hard or traumatic commitment
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 nascency.

It is important to always try and find the cause of a depression 1 minute Apgar score. If the Apgar score remains low at 5 minutes, despite good resuscitation efforts, the infant probably had fetal hypoxia before nascency.

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

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

Neonatal resuscitation

1-6 What is neonatal resuscitation?

Resuscitation is a serial of actions taken to found normal breathing, heart rate, colour, tone and activity in a newborn infant with depressed vital signs (i.due east. a depression Apgar score).

1-7 Which infants need resuscitation?

All infants who exercise not breathe well afterwards delivery need firsthand resuscitation. Therefore, information technology is of import to formally asses an baby'southward breathing later delivery. Any infant who stops breathing or has depressed vital signs at whatever fourth dimension later on delivery or in the nursery likewise requires resuscitation.

All infants who practise not breathe well at birth must be resuscitated.

1-8 Can you anticipate who will demand resuscitation at nascency?

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

Signs of fetal distress during labour (baseline bradycardia or late decelerations)
Delivery before 37 weeks of gestation
Abnormal presentation of the fetus (e.g. breech)
Difficult or traumatic commitment (e.g. forceps commitment)
General anaesthesia or recent analgesia (pethidine or morphine within the last 4 hours)

Think that any babe tin exist built-in 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.

Any babe tin fail to breathe well without alarm signs during labour.

1-9 What equipment do you need for basic infant resuscitation?

It is essential that y'all have all the equipment needed for basic infant resuscitation. The equipment must be in good working order and immediately bachelor. The equipment must exist checked daily.

A warm, well-lit corner of the delivery room should be available for resuscitation. A heat source, such every bit an overhead radiant warmer, is needed to keep the babe warm. Avoid draughts. A practiced low-cal, such every bit an angle poise lamp, is required so that the infant can exist closely observed during resuscitation. A firm, level working area is needed. A thin foam mattress with a plastic roofing can be easily cleaned.

The following essential equipment must exist available in all hospitals and clinics where infants are delivered:

Suction appliance: An electric or wall vacuum suction appliance is ideal but the vacuum pressure should not exceed 200 cm water (i.e. xx kPa or 200 mbar). Soft F10 end pigsty suction catheters are needed. Smaller catheters (F5 and F6) with side holes are of limited use as they block easily. They can be used for an orogastric tube or for umbilical vein catheterisation. A suction bulb can also be used to remove secretions from the infant'south mouth and nose.
Oxygen: Whenever possible a cylinder or wall source of 100% oxygen or an oxygen concentrator should be bachelor. However, near infants tin 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 place infants who are hypoxic.
Ventilation bag and mask: A neonatal self-inflating ventilation bag and mask (e.thou. Laerdal) must be available to provide ventilation. A reservoir fastened to the ventilation bag is needed if loftier concentrations of oxygen are required. Correct size confront masks with a cushioned rim are important. A resuscitation appliance such every bit the T-slice infant resuscitator may also be used.
Endotracheal tubes: 2.5 mm, three.0 mm and 3.5 mm straight tubes must exist available. Introducers are besides needed. Cuffed endotracheal or shouldered tubes must not exist used in newborn infants.
Laryngoscope: A laryngoscope with a small, straight bract (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 done.
Naloxone: Ampoules of naloxone (Narcan). Syringes and needles volition be needed to administrate the drug.
Adrenaline 1:one thousand ampoules.
Normal saline ampoules
Wall clock or wrist scout: Needed to note the time at birth 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 middle rate and oxygen saturation response to resuscitation. Place the probe on the infant's right hand.

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

Note: Equipment to beginning an intravenous infusion is useful for advanced resuscitation.

1-10 How should you stimulate respiration immediately after nascency?

Immediately after birth all infants must exist thoroughly dried with a warm towel and then placed in a second warm, dry out towel before they are clinically assessed. This prevents rapid heat loss due to evaporation, fifty-fifty in a warm room. Dry out the infant'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 usually all that is needed to stimulate the onset of breathing. Well-nigh infants can be stale on the mother'due south abdomen. At that place is no need to smack newborn infants to get them to exhale. Never shake an babe. If the babe 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 expanse.

Dry to stimulate animate in all infants immediately after delivery.

Infants who are agile and breathe well tin can stay with their female parent. It is best to delay clamping their umbilical cord for 2 to iii minutes if the infant does not need resuscitation. And then the infant should be placed in the kangaroo mother intendance position to proceed warm. Infants who breathe well should not be routinely suctioned equally this is non necessary and suctioning sometimes causes apnoea. Infants born past Caesarean section also demand non exist routinely suctioned. All the same, the infant'southward rima oris can be wiped with a clean towel if there are excessive secretions.

It is not necessary to routinely suction the oral fissure and nose of infants after delivery.

1-eleven How do you lot resuscitate an infant?

If the infant fails to reply to the stimulation of drying, then the babe must be actively resuscitated. The almost 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 caput of the infant where it is easier to carry out the steps needed in resuscitation.

There are iv 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.e. 'ABCD': Airway – Breathing – Apportionment – Drugs. Therefore the steps in neonatal resuscitation are:

Airway: Open up the airway.
Breathing: Start the infant breathing by providing acceptable ventilation.
Circulation: Obtain a good center rate and apportionment with chest compressions.
Drugs: Requite adrenaline to stimulate the heart and naloxone to contrary pethidine and morphine.

i-12 How should you lot open the airway?

Position the caput correctly by placing the infant on his back and then putting the babe's head in the neutral position with the cervix slightly extended. Exercise not flex or overextend the neck. It is important to position the head correctly to open the airway before starting mask ventilation.
Gently articulate the throat. The babe may be unable to breathe because the airway is blocked by meconium or claret. Therefore, gently suction the dorsum of the oral fissure and pharynx with a soft end-hole F10 catheter. Excessive suctioning, especially if besides deep in the region of the vocal cords, may outcome in apnoea and bradycardia by stimulating the vagal nerve. This can be prevented by holding the catheter five cm from the tip when suctioning the baby's throat. Exercise not suction the nose before suctioning the mouth or pharynx as this often causes the infant to gasp and inhale mucus and blood. Never hold an baby upside down to clear secretions. Suctioning articulate liquor from the airways is probably not needed. Remember to keep the infant warm. Opening the airway will often permit the infant to offset animate. Gently rubbing the infant'southward dorsum may help stimulate breathing.

If opening the airway fails to start breathing, the babe needs ventilation. Do not waste matter fourth dimension by giving oxygen, without as well applying ventilation, if the baby does not exhale.

If an infant fails to exhale well afterward birth, ventilation should exist started as soon as possible but preferably within one minute ('The golden minute'). The Apgar score should be determined at i to assess the infant'due south clinical condition.

Infants needing ventilation include:

Any infant who is not breathing at all, is breathing poorly or gasping
Any infant who has primal cyanosis
Any babe who has a heart rate below 100 per minute

Ventilation is indicated if the infant does not exhale well.

Most infants who exhale well volition accept a good heart rate and presently go centrally pinkish. Complimentary-flow mask oxygen alone, without ventilation, is simply indicated in the few infants who exhale 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.

1-13 How tin yous start the baby animate past providing adequate ventilation?

Keep the infant warm: Under a radiant heater if available. Good lighting is important. Infants nether 28 weeks tin exist placed in a clean plastic bag to prevent hypothermia.
Mask ventilation: If the baby fails to breathe adequately despite opening the airway, some form of artificial ventilation (animate) is required. Almost all infants (xc%) who practise non breathe on their own can be fairly ventilated with a handbag and mask. The mask must be held firmly over the babe'south nose and mouth but non over the eyes. Make certain the head is in the correct position and the airway is open. It is very important to position and concur the mask correctly. Do non simply press the mask onto the face.
Even if breathing is not started, nigh infants can be kept live with face mask ventilation until aid arrives. Intubation and ventilation are only needed if adequate chest movement cannot be achieved with correct mask ventilation. Practiced pocketbook and mask ventilation is the nearly of import pace in resuscitation of an infant. Ventilate the infant at about 40 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 distension.
Intubation and ventilation: An alternate method of ventilation is via an endotracheal tube. Although information technology is usually not needed, all staff who often deliver infants should acquire this unproblematic technique. Infants who neglect to answer to mask ventilation must be intubated. Ventilate the infant at a charge per unit of about xl breaths a minute. Make sure that the baby'due south chest moves well with each breath and that good air entry is heard over both sides of the chest. Intestinal distension or air entry heard over the belly suggests that the oesophagus has been intubated in error. Rima oris-to-oral cavity ventilation and straight mouth suction should be avoided unless it is an emergency, as the babe's mother may be HIV positive.

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

Ventilation is commonly given with room air. However sometimes it may be necessary to give supplementary oxygen until good breathing efforts and heart rate are established. Fix the flow meter at v litres per minute. Added oxygen can normally be stopped once the infant is centrally pink and the heart charge per unit normal. It is very useful to have a blender and pulse oximeter then that the amount of oxygen can be monitored and controlled.

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

A T-slice baby resuscitator is a very efficient method of ventilating a newborn infant by face mask or endotracheal tube.

Oxygen: If possibly infants should exist resuscitated in room air just without additional oxygen. Only if the eye 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 then stopped equally soon as possible.

Adequate ventilation is the most important footstep in newborn resuscitation.

One time adequate ventilation has been given for one minute, the baby's breathing, color and heart rate must be assessed. Cease ventilation once the infant is pink and breathing well with a heart charge per unit above 100 beats per 2d. If the middle rate remains beneath 60 beats per minute in spite of effective ventilation for one minute seconds, breast compressions are needed. A good centre charge per unit is the best indicator of adequate ventilation.

A good middle charge per unit is the all-time indicator of adequate ventilation.

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

1-14 How should you lot obtain a proficient centre charge per unit with chest compressions?

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

Chest compressions are indicated if the centre charge per unit is less than 60 beats per minute later on one minute of adequate ventilation.

In one case both effective ventilation and breast compressions take been given for one minute, again appraise the baby'southward breathing, color and centre charge per unit. When the heart charge per unit reaches above threescore beats per infinitesimal, chest compressions tin can be stopped and the heart rate advisedly monitored. If the heart rate has non increased above 60 beats per infinitesimal, give adrenaline (epinephrine) to stimulate the center.

one-fifteen How should you give adrenaline to stimulate the heart?

Adrenaline one:10 000 should be given intravenously, ordinarily into the umbilical vein or a peripheral line. Adrenaline stimulates the myocardium and increases the eye rate. i ml of adrenaline ane:thou must first be diluted with 9 ml normal saline to requite a ane:10 000 solution. One ml of the diluted solution can then be given to term infants and 0.five ml to preterm infants (recommended dose is 0.25 ml/kg of diluted adrenaline). Adrenaline is of import if the centre rate remains boring or if no heart beat tin can be detected. The dose tin be repeated every 3 to 5 minutes if the centre rate does not increase to to a higher place threescore beats per minute. Practice not give adrenaline subcutaneously or by intramuscular injection.

Adrenaline is indicated if the eye rate is less than 60 beats per minute afterward one infinitesimal of breast compressions.

Note: one:1000 adrenaline gives 1 mg/ml. Therefore 1 ml of 1:10 000 adrenaline gives 0.one mg while 0.five ml gives 0.05 mg. A dose of 0.25 ml/kg of 1:10 000 adrenaline gives 0.025 mg/kg. Information technology has been suggested that 0.5 ml/kg may be given via an endotracheal tube if it is not possible to access an intravenous route.

If the infant has a expert heart rate and is centrally pinkish, just still does not breathe, consider giving naloxone (Narcan) if the mother has received an opiate analgesic (pethidine or morphine) in the 4 hours before commitment.

1-16 How can you give naloxone to reverse pethidine or morphine?

If the female parent has received either pethidine or morphine during the four hour period before delivery, the infant'southward poor animate may be due to narcotic depression. If so, the depressing upshot of the maternal analgesia on the infant's respiration can be rapidly reversed with naloxone (ane ml ampoule contains 0.4 mg naloxone). Naloxone 0.1 mg/kg (i.e. 0.25 ml/kg) tin can be given by intramuscular injection into the anterolateral aspect of the thigh. 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 earlier providing adequate ventilation.

Naloxone must only be used later on adequate ventilation has been provided.

Annotation

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 feel and further training, additional medication (e.g. dopamine) can be given to support the blood pressure level and circulation if the above steps neglect to resuscitate the infant:

If the babe 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 10 ml/kg over ten minutes. If needed this tin be 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. Do non routinely give glucose during resuscitation. Usually a 10% glucose solution is adequate to correct any hypoglycaemia.

1-17 How can you assess whether resuscitation is successful?

The 4 steps in resuscitation are followed stride by footstep until the 3 well-nigh important vital signs of the Apgar score accept returned to normal:

A 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. A good eye charge per unit is the best indicator of adequate ventilation and oxygenation during resuscitation. It is useful to count the number of center beats in 15 seconds and and so multiply by iv to requite beats per minute.
A good cry or skillful animate efforts (not merely gasping). This assures adequate animate. A good cry commonly indicates that the baby has been successfully resuscitated.
A pinkish tongue. This indicates a skilful oxygen supply to the encephalon. Do non rely on the colour of the lips or buccal mucosa.

1-xviii When is further resuscitation hopeless?

Every effort should be made to resuscitate all infants that show whatever sign of life at delivery unless the infant's gestational historic period, weight or severe built disorders indicate a very poor adventure of survival. The Apgar scores at 1 and 5 minutes are non a practiced indicator of the likelihood of hypoxic encephalon impairment or the possibility of an unsuccessful resuscitation. If the Apgar score remains low after 5 minutes, efforts at resuscitation must be continued. It is of import to go on 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 simply gives occasional gasps past xx minutes, the chance of death or brain damage is extremely loftier. The exception is when the infant is sedated by maternal drugs. It is preferable if an experienced person decides when to abandon further attempts at resuscitation. Resuscitation can also be stopped if there are no signs of life (no centre beat) later ten minutes.

Note: Some people claim that resuscitating infants with failure to breathe is contra-indicated as they survive with brain damage. Research has indicated that this claim is not correct equally many infants that do non breathe at birth, that are aggressively resuscitated and survive, recover completely.

i-19 What postal service-resuscitation intendance is needed?

Infants that start breathing as presently every bit mask and bag ventilation is provided can exist observed with their mothers. Withal infants who crave more prolonged ventilation must exist carefully observed in the newborn nursery for at least 4 hours after delivery. Their temperature, pulse and respiratory rate, color and activity should be recorded and their blood glucose concentration checked. Keep these infants warm and provide fluid and energy either intravenously or orally. Usually these infants are observed in a closed incubator. Exercise not bath the baby until the baby has fully recovered.

If the babe has signs of respiratory difficulty, or is centrally cyanosed in room air after resuscitation, it is essential to provide oxygen while the baby is being moved to the plant nursery. Some infants may even require ventilation during send.

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

Preventing meconium aspiration

ane-20 Does the meconium-stained babe need special care?

Yes. 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 commitment, peculiarly infants with thick meconium in the amniotic fluid.

Note: Expert intrapartum care will assist to prevent fetal distress and meconium-stained liquor.

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

As a effect of hypoxia earlier delivery, the fetus may pass meconium. Some hypoxic fetuses will as well brand gasping movements which can suck meconium into the upper airways together with amniotic fluid. Fortunately most of the meconium is unable to reach 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 tin crusade severe lung damage and even death if inhaled into the alveoli after delivery. Meconium also obstructs the airways. This results in respiratory distress due to meconium inhalation. Meconium aspiration syndrome remains a mutual problem is many developing countries.

Note: Meconium often burns the baby's skin and digests abroad the infant's eyelashes! Therefore, imagine the harm meconium tin 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 be prevented with the correct care of the infant during delivery. A suction apparatus and a F10 end-hole catheter must be ready at the bedside. If possible, the person conducting the commitment should have an assistant to suction the babe's mouth when the head delivers.

After delivery of the head, the shoulders should be held dorsum and the female parent asked to pant to forbid delivery of the trunk. The infant'south face up is and then turned toward the assistant and then that the mouth and pharynx can exist well suctioned. Only when no more than meconium can exist cleared, should the infant exist completely delivered. The aforementioned process should be followed if a meconium-stained infant is delivered by Caesarean section. Suctioning should non take more than 30 seconds.

Some infants develop apnoea and bradycardia as a result of the suctioning and, therefore, may need mask ventilation for a few minutes after commitment.

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

Note: A recent study in developed countries where severe meconium aspiration is uncommon suggests that suctioning meconium-stained infants at commitment is not needed. Notwithstanding, these findings probably do non apply 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 common. A meconium aspirator, which attaches betwixt the endotracheal tube and bag, is very useful.

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

No further suctioning is needed if the baby was well suctioned during commitment and cries well at nativity. The mouth can be wiped with a towel and meconium can be removed from the peel during routine drying.

If a meconium-covered infant needs resuscitation, information technology is meliorate to intubate the babe immediately to clear the airways. In one case intubated, direct suction tin be applied to the endotracheal tube. Withdraw the endotracheal tube slowly while applying suction. Echo 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 can also exist suctioned under direct vision using a laryngoscope, before ventilation is started. Do not use bag and mask ventilation before adequately suctioning meconium-stained infants as this can blow meconium from the throat into the lungs.

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

i-24 What care should you give to meconium-stained infants in the nursery?

All heavily meconium-stained infants should exist observed in the nursery for a few hours subsequently commitment as they may show signs of hypoxic harm or meconium aspiration syndrome. Well-nigh meconium-stained infants have swallowed meconium before commitment. Meconium is a very irritant substance and causes meconium gastritis. This may result in repeated vomits of meconium-stained mucus.
Infants with lightly meconium-stained amniotic fluid who appear well after delivery can exist kept with their mothers.

Meconium gastritis may exist prevented by washing out the tum with normal saline or 2% sodium bicarbonate (mix 4% sodium bicarbonate with an equal book of sterile water). Five ml of normal saline or ii% 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 have a tummy washout on arrival in the nursery. This should be followed past a feed of colostrum. Routine stomach washouts in all preterm infants or infants born by Caesarean section are non needed. A tum washout is also not needed if there is only lightly meconium-stained amniotic fluid.

Meconium-stained infants exercise not need to exist washed or bathed immediately later delivery but should be advisedly wiped with a warm towel.

Note: Colostrum contains phagocytic cells that ingest any meconium that remains in the tummy. This reduces the chance of further vomiting.

A stomach washout is only needed if the infant is covered with thick meconium.

Neonatal encephalopathy

one-25 What is the danger of hypoxia before or after delivery?

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

Transient harm which will recover completely after delivery
Permanent damage that volition non recover fully after nativity
Death of the fetus or newborn infant

1-26 What organs are normally damaged by hypoxia?

The brain needs a lot of oxygen and, therefore, is very sensitive to hypoxia either earlier or afterward delivery.
The kidneys may be damaged, resulting in haematuria, proteinuria and decreased urine output for the beginning few days later on delivery. Occasionally renal failure may result.
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 avenue 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 crusade ischaemic damage to these organs. The increased blood flow to the brain may crusade intraventricular haemorrhage in preterm infants. With severe, prolonged hypoxia, cardiac output somewhen falls and as a result the brain and myocardium may besides suffer ischaemic harm.

Fetal hypoxia may cause brain impairment.

1-27 What harm is done to the brain past hypoxia?

Different 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 nearly to term, hypoxia and ischaemia of the brain during labour presents in the first 72 hours as neonatal encephalopathy (hypoxic ischaemic encephalopathy). This clinical diagnosis is common especially where monitoring and intendance of the fetus during labour is poor.
In preterm infants, hypoxia before delivery may harm small blood vessels around the ventricles of the brain causing an intraventricular haemorrhage. The haemorrhage can damage the surrounding encephalon. An intraventricular haemorrhage usually presents within the start ii days after delivery. A mild bleeding is commonly asymptomatic merely a severe haemorrhage causes apnoea, shock and death. The clinical diagnosis of intraventricular haemorrhage can be confirmed with ultrasonography of the brain.
Hypoxia may cause decreased claret menses which results in infarction (death) of part of the brain. In preterm infants this ordinarily causes spastic diplegia (spastic weakness of both legs). In term infants hypoxia usually causes convulsions, mental retardation and cognitive palsy.
Hypoxia may also cause incomprehension, deafness or learning and behaviour issues at school.

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

Altered 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 abnormal movements.
Abnormal reflexes e.g. no or poor Moro reflex.

Well-nigh infants with neonatal encephalopathy behave abnormally in the commencement 12 hours afterwards delivery. Most, but not all, cases of neonatal encephalopathy are due to intrapartum hypoxia (hypoxia during labour or just earlier commitment). Hypoglycaemia, meningitis and brain bleeding can as well give neonatal encephalopathy.

Note: A number of scoring methods (e.chiliad. the Thompson score) are available to assess the severity of neonatal encephalopathy on a daily basis for the commencement two weeks of life. This can help to predict the upshot. Infants with a normal score on day 7 will probably recover completely.

Neonatal encephalopathy presents with abnormal neurological signs before long after birth.

one-29 What are the results of neonatal encephalopathy?

The encephalopathy may recover completely and the kid develops normally. This is common with balmy encephalopathy when the infant appears normal by 7 days of age.
The encephalopathy may recover slowly and the child survives only has permanent encephalon damage with cerebral palsy or mental disability or both. This is often seen when the signs of neonatal encephalopathy accept not disappeared past 7 days of life.
The encephalopathy may become worse and the infant dies during the first few days.

1-30 What is the direction of an baby with neonatal encephalopathy?

Preclude severe hypoxia, if possible, by good monitoring and care in labour and active resuscitation later on delivery if needed. Once the hypoxic and ischaemic brain damage is done, in that location is trivial that can repair this.

Infants with neonatal encephalopathy should be given full general supportive intendance to foreclose hypoglycaemia or farther hypoxia. If possible they should exist referred to a level 2 or three hospital.
It is very important that they practise not become likewise hot as this may brand the encephalon damage worse. Their abdominal skin temperature should not be allowed to increase above 35.five°C and axillary temperature above 36°C.
Fluid intake is commonly restricted to 60 ml/kg daily for the showtime iii days to assistance prevent cognitive oedema.
Fits are controlled with a single dose of 20 mg/kg intravenous phenobarbitone given slowly over ten minutes.
Ventilation may be needed.
Monitor the vital signs and look out for hypoxic damage to other organs.
Survivors must be followed up for signs of neurodevelopmental delay or cerebral palsy.

Note: Recent exciting studies testify that the extent of brain harm in infants with moderate encephalopathy tin 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.

Case written report one

Later a normal pregnancy, an babe is born by elective caesarian department nether general anaesthesia. Immediately afterwards delivery the infant is dried and placed under an overhead radiant warmer. He is not animate and resuscitation is started. At 1 minute after birth the infant has a center charge per unit of 80 beats per minute, gives irregular gasps, has blue hands and feet just a pinkish tongue, has some muscle tone merely does not respond when dried. Resuscitation is started and at v minutes the infant has a middle rate of 120 beats per minute and is breathing well. The natural language is pinkish but the hands and feet are still bluish. The babe moves actively and cries well.

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

The Apgar score at 1 minute is 4: center rate=1, respiration=ane, color=1, tone=ane, response=0.

two. Why does this infant require resuscitation?

Because he is non breathing well after being stale. The diagnosis of failure to breathe well is supported past the low Apgar score at 1 minute.

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

The general anaesthetic. Both the intravenous drugs and the anaesthetic gases cross the placenta and may sedate the fetus. These sedated infants commonly respond apace to resuscitation.

four. What is the most important step in resuscitating this baby?

If respiration cannot be stimulated past drying the infant, then ventilation must be started. Most infants can be adequately ventilated with a handbag and mask. If good chest motion cannot be obtained with mask ventilation, the infant must be intubated and ventilated.

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

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

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

Because in that location is no history of fetal distress to signal that this infant had been hypoxic earlier delivery. The rapid response to resuscitation also suggests that there was no fetal hypoxia. There is also no practiced reason why the fetus should be hypoxic as the mother has had an elective Caesarean section and was not in labour. Nigh fetal hypoxia occurs during labour.

seven. What should be the management of this infant later resuscitation?

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

Case written report two

After fetal distress has been diagnosed, an infant is delivered past a difficult vacuum extraction. At delivery the babe is covered with thick meconium. The infant starts to gasp. Simply so are the rima oris and pharynx suctioned for the first time. The Apgar score at one minute is 3. The babe is given face mask oxygen and by v minutes the Apgar score is 6. By 15 minutes the infant is active and crying well. It is decided to bath the babe and give a stomach washout in the labour ward before transferring both mother and infant to the postnatal ward.

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

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

ii. What error was made with the direction of this infant?

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

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

A large catheter (F10) must be used every bit a pocket-size catheter will block with meconium. The catheter should have a hole at the end and not just at the side.

4. Should this babe be given a bath and tum washout in the labour ward later on information technology starts to breathe spontaneously?

No. A bath should not be done until the infant has been stable for a number of hours in the nursery. Every bit there was thick meconium, the infant should exist given a stomach washout with normal saline or ii% sodium bicarbonate in the nursery followed by a breastfeed.

five. What 2 complications is this baby at high risk of?

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

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

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

Example written report 3

A woman with an abruptio placentae delivers at 32 weeks. Before delivery the fetal heart charge per unit was only fourscore beats per minute. The infant appeared dead at nativity merely was intubated and ventilated. Breast compressions were too given, and the centre rate remained slow after ventilation was started. The i minute Apgar score was 2. Despite further efforts at resuscitation, the Apgar score at 5, ten, 15 and 20 minutes remained 2.

one. What is the likely cause of the babe'due south poor condition at birth?

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

2. Why is information technology possible to successfully resuscitate some infants that appear dead at nascency?

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

3. What is the significance of the low Apgar scores at 5, 10, fifteen and 20 minutes?

Prolonged failure to reply well to proficient resuscitation suggests that the infant will die due to severe hypoxic damage to the brain and center.

4. Which v organs are likely to be damaged past severe hypoxia?

The encephalon, heart, kidneys, gut and lungs.

five. What is neonatal encephalopathy?

Abnormal neurological behaviour of a term or near term newborn infant within hours of birth. The of import features of neonatal encephalopathy are contradistinct level of consciousness, aberrant muscle tone, poor feeding and breathing, depressed reflexes and convulsions. Neonatal encephalopathy is commonly due to intrapartum hypoxia.

half-dozen. When should attempts at resuscitation exist stopped?

If there is no eye beat after 10 minutes or no endeavor at animate after 20 minutes.

Case written report 4

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

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

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

two. Why did the baby end breathing and become cyanosed?

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

three. How should this infant have been resuscitated?

The head and neck should accept been correctly positioned to open the airway. Then purse and mask ventilation should take been given. With this basic resuscitation, the infant would almost certainly have started to breathe normally and weep. The infant became more and more than hypoxic while attempts were made to intubate the trachea. The Apgar should also have been done at 5 minutes and every v minutes thereafter to tape the condition of the infant during the resuscitation endeavour.

4. What is the value of giving naloxone to infants who breathe poorly at birth?

Naloxone is useful in reversing respiratory depression in the newborn infant if the mother had received pethidine or morphine during the 4 hours before delivery. There was no indication for giving naloxone in this infant as the mother had not received any analgesia. Naloxone is not a respiratory stimulant.

5. Should attempts at resuscitation have been abased earlier five minutes?

No. Attempts should exist continued for at to the lowest degree 20 minutes. An urgent telephone call to the referral hospital could have provided the correct advice needed. Some infants with poor breathing at nativity will eventually start gasping spontaneously even if the correct resuscitation is not given. However, during the period of inadequate resuscitation the infant becomes progressively more hypoxic. This can consequence in brain damage.

half-dozen. Who should exist trained to give bones resuscitation to newborn infants?

All the medical and nursing staff who deliver infants or care for them at commitment. Often it cannot be predicted during labour which infants volition non exhale well and need resuscitation. Clinics and hospitals should not deliver infants if they practice non have the correct equipment and are non able to provide good resuscitation.

7. Should this baby accept received chest compressions?

But if the center charge per unit remained below sixty per minute after 60 seconds of constructive ventilation. With early on bag and mask ventilation the center rate would well-nigh certainly take increased and the cyanosis disappeared.

Meet Figure 1-1, the important steps in basic newborn resuscitation.

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

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Source: https://bettercare.co.za/learn/newborn-care/text/01.html