Inform the mother - explain to her quickly what the problem is and what you are going to do. Tell her to watch for vaginal bleeding - if she starts bleeding she should tell you.
Figure 2: Correct position of the head for ventilation
Open the airway
Position the newborn by moving it from the mother's abdomen to a dry, clean and, if possible, warm surface next to her. Put the baby on its back. Position the head so that it is slightly extended (Figure 2). A folded piece of cloth under the shoulders may help accomplish this. Clear the airway by suctioning first the mouth and then the nose (Figure 3). Be especially thorough if there is blood or meconium in the baby's mouth and/or nose. The newborn may start breathing because suctioning provides additional stimulation. If so, no immediate further action is needed. If there is still no breathing, start ventilating.
Figure 3: Suctioning the mouth and nose
Select the appropriate mask (size 1 for a normal weight newborn, size 0 for a small newborn). Reposition the newborn - make sure that the neck is slightly extended. Place the mask on the newborn's face, so that it covers the chin, mouth and nose (Figure 4). Form a seal between the mask and the infant's face. Squeeze the bag with two fingers only or with the whole hand, depending on the size of the bag and manufacturer’s instructions. Check the seal by ventilating two or three times and observing for the rise of the chest (Figure 5).
If the chest is not rising, the most probable obstacles are inappropriate head position, poor seal between the mask and the face, insufficient ventilation pressure or mucus, blood or meconium in the airway. The corrective steps are repositioning of the newborn's head, repositioning of the face mask, increased ventilation pressure by pressing the bag with the whole hand; exactly how much to press will depend on the size of the bag and further suctioning of the upper airway. The first ventilations require higher inflation pressure than later ventilation.
Figure 4: Fitting the face mask
Figure 5: Ventilation with bag and mask
Once a seal is ensured and chest movement is present, ventilate the newborn with a frequency of around 40 breaths per minute, the range being 30-60 (better more than less). After effectively ventilating for about 1 minute, stop briefly but do not remove the mask and bag and look for spontaneous breathing. If there is none or it is weak, continue ventilating until spontaneous cry/breathing begins. Observe the chest for an easy rise and fall. Hold the head in the correct position to keep the airway open during ventilation and keep a tight seal between the mask and the face. Continue ventilating. If the chest is rising, ventilation pressure is most probably adequate.
If the newborn starts crying, stop ventilating but do not leave the newborn. Observe breathing when it stops crying; if breathing is normal - 30-60/min - and there is no chest or costal indrawing and no grunting for one minute, no further resuscitation is needed. Tie the cord and cut it (if not done earlier). Put the newborn skin-to-skin on the mother's chest to prevent heat loss.
If breathing is slow (frequency of breathing is <30), or if there is severe indrawing, continue ventilating and ask for arrangement for referral if possible. A newborn will benefit from transfer only if it is properly ventilated and kept warm during transport. Two people are needed for the transport of the newborn that requires ventilation: one will ventilate while the other will assist with other tasks. If possible, transfer for the mother should be arranged.
If there is no gasping or breathing at all after 20 minutes of ventilation, stop ventilating. If there was gasping but no spontaneous breathing after 30 minutes of ventilation, stop ventilating.
After resuscitation check the mother, ensure that she is not bleeding or having convulsions. Explain to her what you did and what happened because of your action.
Resuscitation practices that are not effective or are harmful
- routine aspiration (suction) of the baby's mouth and nose as soon as the head is born, or later when the amniotic fluid has been clear;
- routine aspiration (suction) of the baby's stomach at birth;
- stimulation of the newborn by slapping or by flicking the soles of its feet;
- postural drainage, and slapping the back;
- squeezing the chest to remove secretions from the airway;
- routine giving of sodium bicarbonate to newborns who are not breathing;
- intubation by an unskilled person.