Most infants born at term and without specific indicators of high risk during pregnancy do not need resuscitation. Almost all those who do can be resuscitated by simple methods using bag and mask ventilation. A small number of term infants and the many extremely preterm infants require resuscitation involving endotracheal intubation. Thus, while having equipment for resuscitation ready, the first task of the attendant is to decide whether resuscitation is required or not.
Assignment of American Pediatric Gross Assessment Record (APGAR) scores as described in Table 11.3 can
Table 11.3 Clinical evaluation of the newborn infant (Apgar scoring method)
Heart rate Respiratory effort Muscle tone Reflex irritability (response to stimulation of sole of foot) Colour
Absent Slow (below 100 beats/min) Over 100 beats/min
Absent Weak Good; strong cry
Limp Some flexion of extremities Active motion; extremities well flexed
No response Grimace Cry
Blue; pale Body pink; extremities blue Completely pink
The Apgar score is obtained by assigning the value of 0,1 or 2 to each of five signs and summing the result.
be helpful. These scores are conventionally determined at 1 and 5 min and describe cardiorespiratory and neurological depression. There are many causes of depression at birth, and low Apgar scores are neither evidence of birth asphyxia, nor, except in extreme circumstances, a guide to neurological prognosis. Nevertheless, a low Apgar score signifies a problem that needs explanation and management.
It is helpful to commence a time clock at the moment of delivery and some attendants aspirate the nasal passages immediately after delivery to remove fluid and debris from the pharynx and exclude choanal atresia, although many believed this to be excessive for low-risk births.
In an infant who breathes immediately on delivery, it takes minutes for the cerebral oxygenation concentration to reach normal extrauterine levels and there is no reason to believe that a short period of apnoea at birth causes significant injury. At least three quarters of normal term infants breathe within a minute of delivery and most of the rest have breathed before 3 min. The low-risk newborn can thus be safely given immediately to the mother, while drying with a warm towel, which should then be discarded, and the baby then covered in dry warm towels to allow skin-to-skin contact with the mother. The infant can then be observed, and failure to breath by 30 s should persuade the attendant that resuscitation might be needed. Initially drying, or blowing cold air or oxygen over the face may stimulate respiration. If this fails then resuscitation is appropriate. In many units preterm babies are placed directly in plastic bags without drying. If the bag covers the whole baby except the face better thermal control is achieved and hypothermia, which is known to significantly increase mortality and morbidity, can be prevented.
In infants who have taken a first breath, mask ventilation is highly effective provided the right equipment is used. The mask must be soft so as to form a seal around the airway. Pressurized air or oxygen is provided either by a compressible bag or an interruptible pressurized gas source; both should have a valve which releases pressure at 30 cm of water. After the airway has been adequately cleared by suction, the mask is positioned over the nose and mouth with the baby lying prone and the bag squeezed (or gas provided) to deliver several long inspiratory breaths followed by regular ventilation at a rate of 30-40 breaths/min. In many cases ventilating with air is as effective as using oxygen. This technique requires practice and obstetricians and midwives should maintain their skills, if necessary, using an appropriate resuscitation dummy.
The best guide to successful resuscitation is the baby's heartbeat. This can be determined in most cases by feeling the umbilical cord or the femoral pulsation, or can be heard through a stethoscope over the chest. A heart rate above 120 usually signifies adequate oxygenation, but a heart rate below this implies a need for more effective therapy. The heart rate provides a more immediate and accurate guide to the baby's state than respiratory effort or skin colour and, especially for the occasional or inexperienced resuscitator, is the best short-term measure of success or failure.
The Resuscitation Council UK course in Neonatal Life Support (NLS) teaches and assesses basic neonatal resuscitation practice (www.resus.org.uk).
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The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.