Newborn Not Breathing at Birth: Resuscitation with Limited Equipment
A term baby is born at a health post after an uncomplicated labour. The midwife is alone with one assistant. The baby is dried and stimulated, and at 30 seconds the baby is not breathing, is limp, and has a heart rate of about 60 beats/min by auscultation. The skin is centrally cyanotic. There is a self-inflating bag with a 250 mL size and a term mask, a suction bulb, and a clock. There is no pulse oximeter and no blended oxygen; only room air and a cylinder of oxygen without a blender are available. The assistant has never helped with a resuscitation.
1. List your actions in order for the next 60 seconds, and explain the choice of ventilation technique and oxygen.
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Actions in order:
- Call for help and assign the assistant a clear task: note the time and prepare to record. Say exactly what you need ("hold the mask, watch the chest, tell me the time").
- Position the head in a neutral sniffing position and clear the airway only if secretions are obstructing; routine suction is not needed.
- Start positive pressure ventilation with the self-inflating bag and term mask. Use room air. The heart rate is below 100 and the baby is not breathing, so ventilation is the single most important action. Room air is recommended for term babies; if oxygen is used without a blender, it should not be given as free-flowing high concentration to a term baby, because hyperoxia is harmful. Use room air and escalate only per protocol if there is no response.
- Give inflation breaths: 5 breaths, each lasting 2-3 seconds, watching for chest rise. If the chest does not rise, reposition the head, check the mask seal, and consider two-person technique with a jaw thrust.
- Then ventilate at 40-60 breaths per minute and reassess the heart rate after 30 seconds of effective ventilation.
Key principle: the most common reason a newborn does not improve is ineffective ventilation. Rate of chest rise and heart rate response tell you whether the technique is working. Do not start chest compressions until the heart rate has been reassessed after effective ventilation.
2. After 30 seconds of effective ventilation the heart rate is still about 60 beats/min. What do you do next, and how do you involve the untrained assistant safely?
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Next step: the heart rate is below 60 despite effective ventilation, so start chest compressions while continuing ventilation. Use the two-thumb technique encircling the chest, compressing the lower third of the sternum to about one-third of the chest depth, at a ratio of 3 compressions to 1 breath, giving 90 compressions and 30 breaths per minute. Reassess the heart rate every 60 seconds, and stop compressions when the heart rate is above 60.
Involving the assistant:
- Give one task at a time and demonstrate it. "You hold the mask with both hands and watch the chest; I will squeeze the bag and do compressions." Or, if the assistant can count, ask them to call out the compression count while you ventilate.
- The assistant should not be asked to do compressions and ventilation simultaneously; the two-person technique is safer.
- Ask the assistant to note the time of each intervention and the heart rate at each check, and to fetch the oxygen cylinder and any additional help.
Escalation: if the heart rate remains below 60 after compressions and effective ventilation, continue and call for emergency transport to a facility with neonatal intensive care. Do not stop resuscitation prematurely; a newborn who does not respond may need prolonged support, and stopping is a decision made with senior input and documented. Keep the baby warm throughout, and record times, interventions, and responses.