It's 9:22 p.m., and the delivery went well. It was a cephalic delivery (head first), and mom had no complications. The baby, however, isn't doing so well. Initial assessment reveals a flaccid (limp) newborn with acrocyanosis, which means the newborn has blue extremities and a pink core. New baby Damien will need to be resuscitated.
A neonate, sometimes referred to as a newborn, is a baby from birth to 28 days old.(1) Although the majority of newborns don't require resuscitation, the American Heart Association (AHA) reports that about 10% will require some assistance to begin breathing; however, only about 1% will require extensive resuscitation.(2) It's been suggested that these numbers may be higher in the out-of-hospital setting because of unpredicted events, such as early labor, which may warrant a 9-1-1 call.
Resuscitating newborns begins with the basics. As soon as the head has been delivered, suction the mouth and then the nose, using a bulb syringe. Meconium, or the baby's first stool, usually occurs within the first 24 hours after birth and may appear during birth. If meconium is on the child’s face, then be more aggressive with suctioning to avoid aspiration, which may cause complications. Be sure to report this finding to the receiving hospital because it may alter the newborn's initial care.
When a child is born, they're wet and will become cold quickly. As their temperature drops, their oxygen demand increases.(3 )They're slippery too, so be careful. Dry the child, and at the same time gently rub its back and extremities. The newborn should begin to cry within a few seconds of delivery, and if they don’t respond to warming and stimulation, you must assess breathing and pulse rate. As a child becomes hypoxic, their heart rate can decrease, resulting in bradycardia (slow heart), which is abnormal.
A newborn's heart rate should be between 100 to 160 beats per minute (bpm). Slow heart rates are usually remedied by providing oxygen and assisting with ventilations. Use a small mask or oxygen tubing and flow oxygen at 1 to 2 liters per minute, holding the tube or mask to the side of the child's face. If the child's heart rate does not increase, then begin to ventilate. If the child's heart rate remains less than 60 bpm, or if assisting ventilations don't increase the heart rate to above 100 bpm, you must begin CPR. CPR should be performed by encircling your hands around the chest, using your thumbs for compression. Compress the newborn's chest approximately one third of their anterior-posterior diameter using a compression to ventilation ratio of 3:1.
If the child does not respond to CPR and ventilation, ALS intervention, including advanced airway management and drug administration, may be required. If it is allowed within your scope of practice, establish an IV. Epinephrine at a dose of 0.01mg/kg of a 1:10,000 solution can be administered to help with the bradycardia.
Newborns may not respond to resuscitation for several reasons. Always consider reversible causes. Blood glucose levels should be evaluated, and if low (and allowed in your scope of practice), administer dextrose 10%, dose of 2–4mL/kg IV push. If the mother had an opiate, such as morphine or heroin in her system, the newborn will also have them in their system. If this is the case, consider administering narcan 0.1mg/kg. Other causes adversely affecting the newborn in early extra-uterine life may be congenital in nature, meaning they're born with an abnormality, such as a heart defect. Most likely, congenital abnormalities won't be identifiable in the prehospital setting, so it's a wise idea to rapidly transport the child to the closest, most appropriate receiving hospital continuing resuscitation attempts.
At the one minute and five minute marks, you should attempt to obtain an APGAR score. APGAR evaluates the following: A-appearance, P-pulse, G-grimace, A-activity and R-respirations. A total of 10 points is possible, as each category is scored with values from zero to two. A child born with a score of less than six, for example, will require some form of resuscitation. Scores of seven up to 10 are considered good to excellent. After appropriate resuscitation, newborns with low APGAR scores at one minute will have higher scores at five minutes. However, do not delay or impede resuscitation attempts in order to obtain an APGAR score.
Baby Damien responds well to being stimulated and receiving blow-by oxygen. He soon begins to cry and actively move his arms. His pulse rate is 160 and respirations are 50 per minute. He scores a perfect APGAR of 10 at 5 minutes. Welcome to the world, baby Damien.
1. Venes R, editor. Tabor’s Cyclopedic Medical Dictionary, 20th Edition. F.A. Davis. Philadelphia. 2005.
3. Dieckmann, R, editor. Pediatric Education for Prehospital Professionals 2nd Edition. American Academy of Pediatrics. Jones & Bartlett. 2005.