Despite seeing thousands of deliveries throughout my career, I still can’t stop myself from having joyful feelings each time whenever a newborn baby starts crying right after coming out from the birth canal.
The first cry is the sign of life, and usually, it indicates that the baby is OK. Unfortunately, a small percentage of full-term babies and more premature babies do not cry or start breathing right after birth and require some reviving measures. Those reviving measures in newborn babies are also called neonatal resuscitation efforts.
In this post, I will describe how we revive newborn babies after birth. It is aimed only to give you an idea of how we do it. If you are a health care provider, you need to obtain NRP training to gather that knowledge.
If, as a layperson, you want to learn how to resuscitate infants, children, and adults, please contact American Heart Association to find out about available courses to you, such as Basic Life Support (BLS).
You can read about the causes why babies may have problems with initiating respiratory efforts after birth in my article here.
Nothing in this post should be considered as an instruction for you on how to resuscitate a baby. I will only provide a generalized description of reviving efforts provided to newborn babies for a curious layperson!
Introduction to Neonatal Resuscitation
Neonatal resuscitation encompasses all actions that health care providers typically undertake to revive baby with compromised or absent breathing and heart function. The current recommendations for newborn resuscitation have been developed by the American Academy of Pediatrics and the American Heart Association and are available in NRP Textbook.
It is estimated that up to 10% of term and late-term babies will need external breaths (positive pressure ventilation) to support their breathing, and about 1-3 in 1000 babies will need chest compressions or medications to help the heart function.
Most babies who need CPR after birth, have compromised respiratory drive due to labor complications leading to low oxygen levels in the brain or due to prematurity. In most cases, newborns have healthy hearts. In contrast, adults who need resuscitation usually had an accident or sudden heart condition.
In general, reviving a human being involves three steps Airway, Breathing, and Circulation. Of course, depending on who the provider is, who the patient is, and what are circumstances – resuscitation efforts may need to be adjusted.
What are the steps in the resuscitation of a newborn baby?
In most situations where a baby receives CPR, CPR takes place in a hospital environment where skilled nurses and doctors are available. Usually, they will follow NRP guidelines that tell us exactly how to do it.
If a baby is breathing or crying and having a good tone within a minute after birth, usually, it means that he or she is in a good shape and does not need any significant help from us. We let obstetricians delay cord clamping and encourage the mother to hold her baby immediately so she can bond and establish breastfeeding (my article on delayed cord clamping).
If we think that baby is somewhat compromised, we may speed up cord clamping so we can take the baby to radiant warmer (a special type of bed) and proceed with the next step: stabilization and additional evaluation.
Stabilization and evaluation
During this phase, we dry baby with towels, keep it warm under radiant warmer, position its head and the neck in the most optimal pose for breathing, and open the mouth to check if the baby needs suctioning of the secretions. Rubbing the trunk, back, or extremities using towels often provides stimulation that is capable of making baby start breathing.
At the end of this phase, we need to reevaluate the baby. If there is no adequate respiratory effort or heart rate is too low, the baby will need to receive external supportive breaths.
External breaths for the baby and evaluation
We can not live without oxygen, and we can not live with too much carbon dioxide in our bodies. Therefore, if a newborn baby is not breathing adequately, we have to start breathing for the baby by providing “Positive pressure ventilation.”
Positive pressure ventilation can be provided in three ways:
- using bag and mask
- after intubation
- using LM airway
The word “positive pressure” means that we have to provide external pressure using a certain volume of gas with oxygen in order to facilitate lung expansion. We can do that using different sacs or bags inflated with gases or utilizing machines. After the lungs are expanded, the expiratory phase is passive. Stretched chest wall and lungs retract on its own and push air out.
The three methods of providing Positive Pressure Ventilation (PPV) differ in their effectiveness and level of complexity; therefore, one may be easier to apply than the other.
While we apply PPV via the “Bag and Mask” method, we place a mask tightly over the baby’s face, covering nose and mouth. Then, using the attached bag, we push air into the baby’s lungs. The significant advantage of this method is that it is easy. Almost any health care provider will know how to do it. However, it may lead to too much air entering the stomach. Also, some providers have a hard time maintaining a proper seal between the mask and face.
Neonatal bag and mask that can be used for CPR
Intubation is a procedure during which we place a small plastic tube in the baby’s trachea (windpipe) and connect that tube to a resuscitation bag or ventilator to provide external breaths. It is a somewhat complicated procedure, even for experienced providers. Whenever a baby is extremely sick, or we expect that resuscitation will be needed for a long time, it is desirable to use this method of ventilation. It avoids problems with inflating the stomach with too much air.
LM airway is a device that is build of a small mask attached to a plastic breathing tube. The device can be inserted through the baby’s mouth until resistance is felt. After insertion, the mask is supposed to cover entry to the trachea (windpipe). Again, we connect the breathing tube to a bag or ventilator and can provide external breaths for the baby. Providing PPV using the LM airway is easier than intubation, but still, it requires some experience from the provider.
If we decided to start Positive Pressure Ventilation for the baby, after some time, we need to evaluate the response. We can do it by listening to the baby’s heart, checking pulse on the umbilical cord, and by placing the baby on the monitors. Doctors can use cardiorespiratory monitors and pulse oximeter monitors (pulse oximeter tells us the heart rate and percentage of hemoglobin attached to oxygen).
If the baby’s heart rate is absent or too slow despite providing appropriate ventilation for the baby, we need to proceed to the next step: chest compressions.
Chest compressions and evaluation
Chest compressions in a baby are done by placing fingers in the middle of the chest on the lower third of the sternum and compressing chest rhythmically with an approximate frequency of 90 per minute.
Chest compressions squeeze the heart, pushing out blood to main arteries and coronary arteries, thus providing critically needed oxygen to the heart, brain, and other organs. We always hope that restoration of blood flow and oxygen supply will allow the heart and brain to recover, and spontaneous heart function and breathing can come back.
As with previous steps and actions, we have to keep evaluating the baby’s condition and response to the treatment. If spontaneous heart rhythm has not been restored, we have to proceed to the next step, which is the administration of medication and fluids.
Administration of fluids and evaluation
Medications during the resuscitation should be given intravenously. It is challenging to insert a needle or catheter in the baby’s vein due to low blood pressure. To speed up the process and increase the success rate of the resuscitation, we can place a special plastic catheter into the baby’s blood vessel located in an umbilical cord (Procedure is called: placement of an umbilical venous catheter).
If done by an experienced provider, the procedure is almost always successful and can be done within only a few minutes.
Once we obtained venous access, we can give Epinephrine, which is a medication that helps to restore heart function. We can also administer intravenous fluids to maintain better circulation and support blood pressure.
When are resuscitation efforts stopped?
We stop resuscitation efforts after we successfully restored heart rate in a baby, and the baby’s vital signs are stable. We can also stop it if, in our opinion, further continuation of it would be futile. Some experts suggest that if we could not revive a baby after 10-15 minutes of correctly done CPR, we can consider stopping it.
Babies who survived resuscitation will most likely be sick and will require admission to NICU for monitoring and subsequent treatment. If you are interested to know more about people, equipment, and procedures performed in NICU, you can read my article on this subject here.
What questions to ask if your baby received CPR after birth?
- Why did my baby need resuscitation?
- What were Apgar scores assigned to my baby? My article explaining the Apgar score.
- Did you have to put a breathing tube to provide artificial ventilation?
- Did you have to provide chest compressions?
- Did you have to give medications to stimulate heart?
- How long it took for my baby to have a normal heart rate?
- How long it took for my baby to have normal oxygen levels?
- Do you think that my baby may be at increased risk of having developmental problems in the future?
- Do you think that my baby should be treated with Hypothermia to decrease the risk of neurodevelopmental problems?
- What kind of monitoring and treatment will my baby need now?
This article is only for general information purposes. It should not be viewed as any medical advice. There is a chance that information here may be inaccurate. It would be best if you always discussed all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.