Non-vigorous term newborn with thick meconium at a planned home birth

First 60 seconds

1. Dry and stimulate: dry the baby thoroughly with a warm towel, including the back and head, and discard the wet towel. This prevents heat loss and provides tactile stimulation. The baby has only had a quick face wipe, so proper drying has not yet been done.
2. Warm and position: place the baby under a radiant warmer if available, or use skin-to-skin with the mother covered by warm towels, and position the head in a neutral alignment to open the airway.
3. Assess tone, breathing, and heart rate: the baby is limp, pale, and not breathing, with a heart rate of 50 beats/min. This is a non-vigorous baby.
4. Airway: do not perform routine suction for meconium. Suction only if there is visible obstruction or the airway is blocked. Routine intubation or suctioning of a non-vigorous baby is not recommended in this setting and is not possible here.
5. Call for help: the second midwife should confirm the ambulance is coming and prepare the bag-mask device.

Why The priority is to establish effective ventilation. The baby’s heart rate is below 60 beats/min, but chest compressions are not the first step; effective inflation breaths must be given first. The baby is term, so air is the appropriate gas, and no oxygen is available. I would document the time and the interventions.

Assessment After the initial drying and positioning, I would give five inflation breaths using the bag-mask device with a good seal, watching for chest movement. Each breath should be sustained for 2–3 seconds. I would then reassess the heart rate and breathing.

• If the heart rate is rising above 60 beats/min and breathing is starting, I would continue to support breathing and keep the baby warm.
• If the heart rate remains below 60 beats/min after five effective inflation breaths, I would start chest compressions at a ratio of 3 compressions to 1 inflation, with 90 compressions and 30 inflations per minute.
• I would reassess the heart rate every 30 seconds and check that the chest is moving with each inflation. If it is not, I would reposition the head, check the mask seal, and consider whether the airway is obstructed.

Reasoning The heart rate is the best indicator of response in newborn resuscitation. Compressions are indicated when the heart rate is below 60 beats/min despite effective ventilation. I would not use the Apgar score to guide resuscitation; it is a retrospective assessment, not a treatment algorithm. I would keep the baby warm throughout and document the time of each intervention.

Telling the parents I would speak clearly and calmly while continuing to resuscitate: ‘Your baby is not breathing well on his own, so we are helping him breathe with a mask. His heart rate is low, and we are doing everything we can. The ambulance is coming to take him to the special care baby unit.’ I would avoid blaming anyone and avoid false reassurance. I would explain each step briefly as I do it and ask the second midwife to stay with Lena if possible.

Preparing for transfer

• Keep the baby warm with towels, a hat, and cover during transfer.
• Continue breathing support and, if needed, compressions until the ambulance crew arrives.
• Give the crew a structured handover: time of birth, meconium, heart rate at birth and now, interventions given, response, temperature, and maternal history.
• Take the notes, the placenta if delivered, and any documents.
• Pre-alert the receiving neonatal unit so they can prepare.
• Document the timeline, the parents’ questions, and the advice given.

I would also ask the second midwife to stay with Lena during transfer if the ambulance crew can accommodate her, and I would ensure the parents know where the baby is being taken and when they can follow.