What are the 5 initial steps of newborn care?

What is neonatal resuscitation?

Neonatal resuscitation is a series of emergency procedures performed by a doctor to support newborn babies who are not breathing, are gasping or have a weak heartbeat at birth. These skills allow a doctor to save the lives of newborn babies.

The chances of a baby needing resuscitation are high in case of 

• Twins
• Preterm or small babies
• Mothers with infection or bleeding during pregnancy
• Prolonged labor

Globally, about one-quarter of all newborn deaths are caused by lack of oxygen (asphyxia) at birth, which can be prevented by effective and rapid resuscitation.

What are the necessities for neonatal resuscitation?

As the need for resuscitation is often unexpected, before every delivery a nurse will have on hand

• A warm labor room with good light sources to assess the baby
• Equipment
  • An Ambu bag with a baby-sized mask
  • Stethoscope
  • Clock 
  • Clean ties
  • Scissors
  • Clean towels 

What are the steps in neonatal resuscitation?

The first 60 seconds after delivery are the most critical. The doctor will quickly assess and start resuscitation for the baby with

• Abnormal breathing or poor cry
• Floppy baby
• Blue or pale lips and tongue
• Low heart rate ( less than 100 beats/minute)

The doctor will follow the steps below and they will have about 30 seconds to achieve a response from one step before deciding on another intervention.

• Keeping the baby warm
  • Immediately after birth, the baby will be wrapped in a dry, warm towel and rubbed gently, which may stimulate some babies to breathe.
  • The baby’s back and soles of feet may be rubbed gently for five seconds to stimulate breathing.
  • The baby is dried with warmed towels or blankets to avoid lowering of body heat, which may cause complications including death, especially in small preterm babies.
• Clearing the airway
  • The doctor will clear the airway by sucking mouth secretions with a bulb syringe quickly within five seconds.
  • The doctor will remove thick meconium (if present) using a wide port tube.
• Clamping and cutting the cord: If the baby is breathing adequately, then the doctor will
  • Keep the baby at the same height as the placenta or below the placenta until the cord is clamped to enhance blood transfusion.
  • Clamp the cord approximately one to three minutes after birth to minimize anemia (low red blood cells in the blood).
  • Return the baby to the mother for skin-to-skin contact to keep the baby warm.
• Opening the airway for breathing: If the baby is still not breathing, to open the airways
  • They will be kept on a flat surface on their back.
  • Their head will be kept in a neutral position (parallel to the surface).
  • A two to three centimeter thick folded towel will be placed beneath their shoulders.
• Keeping the baby breathing: If the baby still does not breathe with a low heart rate (less than 100 beats/minute), then the doctor will
  • Place a mask over the baby’s mouth and nose, connecting it with an Ambu bag.
  • Provide five inflation breaths by slowly squeezing the bag.
  • Provide a two- to three-second long breath by counting out loud to allow accurate rhythm.
  • Inspect the baby’s chest movement.
  • Reassess the inflation and listen to the heart rate (normal is greater than 100 beats/minute) and check whether the baby is breathing.
  • Repeat the maneuver if the baby is still not responding or use jaw thrust alone by himself or with the help of another attendant to open the airway.
  • Return the baby to the mother for breastfeeding and skin-to-skin contact if the baby starts breathing.
  • Monitor the baby further for six hours.

           Infants who continuously have a heart rate higher than 100 beats/minute and adequate respiratory effort but who remain blue around the lips and tips should receive blow-by oxygen aided by oxygen tubing or a mask under expert guidance.

• Chest compression: Rarely, some babies may need chest compressions if the heart rate is absent or low (less than 60 beats/minute) and not responding to being resuscitated with an Ambu bag. Then the doctor will
  • Hold the baby’s chest with two hands while placing the thumbs below the nipples.
  • Press the baby’s chest with their thumbs quickly. Another method in smaller babies is using the index and middle fingers to gentle press over the breastbone.
  • Make sure there is time for the chest to recoil.
  • Provide three chest compressions to one breath with the help of an attendant.
  • Continue chest compression until the baby’s heart rate gets to normal.
  • Check for responses by listening to the baby's heart rate every 30 seconds to one minute and see chest movements with each breath, after each intervention.

When should a doctor stop resuscitation?

In the majority of cases, the above steps are enough to save a baby. Even after this if there is no improvement, infants may require tracheal intubation if endotracheal (ET) administration of medications is desired, congenital diaphragmatic hernia is suspected or there is a prolonged need for assisted ventilation. Such measures are only done in a neonatal intensive care unit (NICU) supervised by an experienced doctor. These decisions should be made by the parents and clinician. Each country's guidelines vary as to when a doctor should stop resuscitation attempts (from 10 to 20 minutes after birth).

Medically Reviewed on 11/13/2020

References

Medscape Medical Reference Medecins Sans Frontieres

NICE UK Guidelines

The successful transition of a fetus, which is immersed in amniotic fluid and totally dependent on the placenta for nutrition and oxygen, to a crying, air-breathing baby is a source of wonder. Healthy newborns (age birth to 1 month) and infants (age 1 month to 1 year) need good care to ensure their normal development and continued health.

Immediately after the normal delivery of a baby Overview of Labor and Delivery Although each labor and delivery is different, most follow a general pattern. Therefore, an expectant mother can have a general idea of what changes will occur in her body to enable her to deliver... read more , the doctor or nurse gently clears mucus and other material from the mouth, nose, and throat with a suction bulb. The newborn is then able to take a breath. Two clamps are placed on the newborn's umbilical cord, side by side, and the umbilical cord is then cut between the clamps. The newborn is dried and laid carefully on the mother's abdomen with skin-to-skin contact or on a sterile, warm blanket. Not all deliveries follow a standard pattern. For example, some women need to have a cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery of a baby by incision through a woman’s abdomen and uterus. In the United States, up to 30% of deliveries are cesarean. Doctors use a cesarean delivery... read more

Keeping the newborn warm is critical. As soon as possible, the newborn is wrapped in lightweight clothing (swaddled), and the head is covered to reduce the loss of body heat. A few drops of an antibiotic, such as erythromycin, tetracycline, or silver nitrate or, in some countries, povidone iodine, are placed into the eyes to prevent infection from any harmful organisms that the newborn may have had contact with during delivery.

Immediately after a normal birth, the parents are encouraged to hold their newborn. Some experts believe that early physical contact with the newborn helps establish bonding. However, parents can bond well with their newborn even when the first hours are not spent together. The mother and newborn usually recover together in the delivery room. If the delivery is in a birth center, the mother, father or mother's partner, and newborn remain together in the same room. Mothers who are breastfeeding put their newborn to their breast within the first 30 minutes after delivery. Breastfeeding stimulates oxytocin, a hormone that helps the mother's womb to heal and promotes development of the milk supply. Once transported to the nursery, newborns are placed on their back in a small crib and kept warm. Because all babies are born with low levels of vitamin K, a doctor or nurse gives an injection of vitamin K to prevent bleeding (hemorrhagic disease of the newborn).

About 6 hours or more after birth, newborns are bathed. The nurse tries not to wash off the whitish greasy material (vernix caseosa) that covers most of the newborn's skin because this material helps protect against infection.