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close this bookBasic Newborn Resuscitation: A Practical Guide - Revision (WHO; 1999; 33 pages)
View the documentPREFACE
View the documentEXECUTIVE SUMMARY
View the documentINTRODUCTION
open this folder and view contents1 GUIDELINES FOR BASIC NEWBORN RESUSCITATION
close this folder2 TECHNICAL BASIS
View the documentBirth asphyxia
View the documentManagement of the newborn with birth asphyxia
View the documentPractices that are not beneficial
View the documentPrevention of infection
View the documentClamping and cutting the cord
open this folder and view contents3 EQUIPMENT AND SUPPLIES
open this folder and view contents4 DOCUMENTING RESUSCITATION
open this folder and view contents5 SPECIAL CONDITIONS
open this folder and view contents6 SPECIAL CIRCUMSTANCES
open this folder and view contents7 OPERATIONAL GUIDELINES
View the document8 GLOSSARY
View the documentREFERENCES
View the documentBACK COVER

Management of the newborn with birth asphyxia

Basic resuscitation

Regardless of the cause of birth asphyxia and how severe it is, the action - at least the initial steps - will be the same: ventilation. The main aim is to ensure oxygenation and to initiate spontaneous breathing. Effective ventilation must be established before any other steps are taken. Too often other more complicated procedures are initiated first. This can be harmful to the newborn. Anticipation, adequate preparation, timely recognition and quick and correct action are critical for the success of resuscitation.16

Anticipation of resuscitation

Resuscitation must be anticipated at every birth. Every birth attendant should be prepared and able to resuscitate since, if it is necessary, resuscitation should be initiated without delay.

Some maternal and fetal conditions that are risk factors for birth asphyxia are listed in Table 1. Good management of pregnancy and labour/delivery complications is the best means of preventing birth asphyxia. Frequent auscultation of fetal heartbeat, especially during the second stage of labour, may help to diagnose fetal distress and to predict the birth of a baby that will need resuscitation.

Adequate preparation

Some maternal and fetal risk factors for birth asphyxia are:

- maternal illnesses such as sexually
- transmitted diseases
- malaria
- eclampsia (including the treatment)
- bleeding before or during labour
- fever during labour
- maternal sedation, analgesia or anaesthesia
- prolonged rupture of membranes
- breech or other abnormal presentation
- prolonged labour
- difficult or traumatic delivery
- prolapsed cord
- meconium-stained amniotic fluid
- preterm birth
- post-term birth
- multiple birth
- congenital anomaly.

Risk factors are poor predictors of birth asphyxia. Up to half of newborns who require resuscitation have no identifiable risk factors before birth.16 Therefore it is not enough to be prepared only in cases where one or more risk factors are present.

Every birth attendant must be trained in resuscitation and must have resuscitation equipment and supplies in perfect condition (see page 16 for equipment and supplies). When no equipment is available, mouth to mouth-and-nose breathing should be done. When a newborn is expected to have severe asphyxia, a second person should be available to assist at the birth.

Assessment and timely recognition of the problem

If the newborn does not cry or breathe at all, or is gasping within 30 seconds of birth, and after being dried, the essential steps of resuscitation should be taken immediately.

The baby's cry is the most obvious sign that there is adequate ventilation after the birth. In a crying newborn the heart rate is normal. Breathing immediately after birth may be irregular but is usually still sufficient for adequate ventilation. However, gasping (occasional breaths with long pauses in between) is not sufficient.

Taking an Apgar score is not a prerequisite for resuscitation. The need for resuscitation must be recognized before the end of the first minute of life which is when the first Apgar score is taken. The most important indicator that resuscitation is needed is failure to breathe after birth so, if the baby does not breathe, resuscitation must be started immediately.

Apgar scoring has been used as a systematic tool to assess and document the clinical status of the newborn at birth, or more precisely at 1 and 5 minutes of life. The newborn is examined for five signs: breathing, heart rate, muscle tone, reflex irritability and colour (see Table 2). Determining the Apgar score correctly requires good training. The score depends not only on the severity of birth asphyxia but also on other factors such as drugs given to the mother, anaesthetics, fetal infection, fetal anomalies and prematurity.







Heart rate


Slow (<100 beats/min)

=>100 beats/min



Slow, irregular

Good, crying

Muscle tone


Some flexion

Active motion

Reflex irritability

No response


Cough, sneeze


Blue or pale

Pink body with blue extremities

Completely pink

Quick and correct action

The important steps in resuscitation are prevention of heat loss, opening the airway and positive pressure ventilation that starts within the first minute of life.

Prevention of heat loss is critical. Methods should include those that prevent the loss of heat by evaporation, radiation, conduction and convection. Each newborn should be dried first and then covered with a dry towel. The surface on which it is placed should always be warm as well as flat, firm and clean.19Drying provides sufficient stimulation of breathing in mildly depressed newborns and no further stimulation is appropriate.

Resuscitation should be started immediately. There is no evidence that hypothermia helps to initiate breathing or reduces damage due to birth asphyxia.13,14

To open the airway in a baby that is not breathing, the newborn must be positioned on its back, with the neck slightly extended (Figure 2, page 6). The upper airway (the mouth and nose) should be suctioned to remove fluid if stained with blood or meconium (Figure 3, page 7). Suctioning must be thorough but gentle and quick. It may create additional stimulation for breathing.

When the amniotic fluid is stained with meconium, there is no evidence that suctioning the nostrils and oropharynx before the chest is delivered and before umbilical circulation is interrupted has any important effect on the incidence of severe meconium aspiration syndrome.13 Nevertheless it is practised widely. However, women take different positions for delivery and suctioning before the whole baby is delivered may not be without risk in some positions.

Positive pressure ventilation is the most important aspect of newborn resuscitation for ensuring adequate ventilation of the lungs, oxygenation of vital organs such as heart and brain, and initiation of spontaneous breathing. Ventilation can almost always be initiated using a bag and mask (it is rarely necessary to intubate) and room air.11,15,20 To open the lungs the ventilation pressure required is 30-40 cm of water; later around 20 cm is sufficient for ventilating healthy lungs. Sometimes the initial (opening) pressure could be as high as 50-70 cm of water. Approximately 40 breaths per minute are required.16 Only a soft mask provides a good seal with the newborn's face to in achieve this pressure.21 Adequacy of ventilation is assessed by observing the chest movements (Figure 5, page 8). The best indication of adequate pressure is the chest rising and falling easily with ventilation. If two skilled birth attendants are present, the one who is not ventilating can auscultate the lungs for breathing sounds and heart rate.

The above are the essential first steps of any resuscitation. They will, according to experience, establish spontaneous breathing in more than three-quarters of newborns with birth asphyxia.22

Advanced resuscitation

A small proportion of infants fail to respond to ventilation with the bag and mask. This happens infrequently but, when it does, additional decisions must be made and actions taken. Advanced procedures can be introduced in a health care institution if the following criteria are met: (a) trained staff with the necessary equipment and supplies are available; (b) at least two skilled persons are available to carry out the resuscitation; (c) there are sufficient deliveries for the skill to be maintained; and (d) the institution has the capacity to care for or to transfer newborns who suffer severe birth asphyxia since they are expected to have problems after being resuscitated. Guidelines and training materials on advanced newborn resuscitation are available from universities and professional organizations. Below is a brief outline of the procedures.

Endotracheal intubation

This has been shown to provide more effective ventilation in severely depressed/ill newborns. It is more convenient for prolonged resuscitation but is also a more complicated procedure that requires good training. Endotracheal intubation is needed only rarely and can be dangerous if performed by untrained staff. Potential hazards include cardiac arrhythmias, laryngospasms and pulmonary artery vasospasm13,14 Usually only newborns that are severely ill will require endotracheal intubation.

Tracheal suction by a skilled resuscitator has been shown to reduce morbidity among depressed infants born with meconium in the pharynx.13,14 However, it requires a highly experienced person to do it without causing damage. Despite its potential benefit, tracheal suction is not recommended unless the resuscitator is very skilled, because of the severe hazards associated with it (hypoxia, bradycardia).14


Additional oxygen is not necessary for basic resuscitation 10,23,24 although it has been considered so by some practitioners. Oxygen is not available at all places and at all times. It is also expensive.25 Moreover, new evidence from a controlled trial shows that most newborns can be successfully resuscitated without additional oxygen.11,24 Research also suggests that high oxygen concentration may not be beneficial in most circumstances.26 However, when the newborn's colour does not improve despite effective ventilation, oxygen should be given if available. An increased concentration of oxygen is needed for severe lung problems such as meconium aspiration and immature lung, or when the baby does not become pink despite adequate ventilation.

Chest compressions

Chest compressions are not recommended for basic newborn resuscitation. There is no need to assess the heartbeat before starting ventilation. Slow heartbeat is usually caused by lack of oxygen, and in most newborns the heart rate will improve as soon as effective ventilation is established. Effective ventilation should be established before chest compressions are started.

It has been shown that it is more difficult to assess the heart rate reliably in newborns than in older children, especially by feeling the beat (pulse) through the chest wall or over big arteries. Therefore a person without experience is highly likely to make a mistake in assessing the heart rate in a newborn.27 Assessing the heart rate without the necessary skill and equipment is a waste of time, and a wrongly assessed pulse may lead to wrong decisions.

However, in newborns with persistent bradycardia (heart rate <80/min and falling) despite adequate ventilation, chest compressions may be life-saving by ensuring adequate circulation.28 A higher mean arterial pressure was observed using the method in which the hands encircle the chest compared to the two-finger method of compressing the sternum.16 Two people are needed for effective chest compression and ventilation. Before the decision is taken that chest compressions are necessary, the heart rate must be assessed correctly.


Drugs are seldom needed to stimulate the heart, to increase tissue perfusion and to restore acid-base balance. They may be required in newborns who do not respond to adequate ventilation with 100% oxygen and chest compressions. Narcotic antagonists and plasma expanders have limited indications in newborn resuscitation.14

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