Newborn Care

  • Delivery of the Newborn
  • Newborn Care
  • APGAR
  • Meconium Staining
  • Newborn Resuscitation
    Time of Delivery
  • Newborn Resuscitation
    Flow Chart

Delivery of the Newborn

If delivery is determined to be imminent, follow the guidelines below. Delivery may be imminent even though the bag of waters has not broken. If the mother is not at full term, or if signs of meconium stain are present, call for ALS.

 

  1. Obtain the following information:
  2.  

    1. Due date.
    2.  

    3. Frequency of contractions.
    4.  

    5. Number of pregnancies (gravida), number of children born (para)
    6.  

    7. History of pre-term or post-term deliveries.
    8.  

    9. Sensation of the need to move bowels (delivery is imminent).
    10.  

    11. Presence of crowning (delivery is imminent).

     

  3. Administer one of the following treatments:
  4.  

  5. If no crowning is present, begin transportation in the left lateral recumbent position. If crowning is present, prepare to deliver the infant.
  6.  

  7. Administer high flow oxygen to the mother. (See Administration of Oxygen Protocol)
  8.  

  9. Assist with the delivery. (See Newborn Care Protocol)
  10.  

    1. Guide and control but do not try to stop the delivery.
    2.  

    3. Don't pull on infant or put traction on cord.
    4.  

    5. If cord is around the neck of the infant, slip it over the head. If unable to slip the cord over the head, immediately clamp the cord in two places and cut between the clamps. Continue with delivery.
    6.  

    7. Look for presence of meconium staining. (See Meconium Staining)
    8.  

    9. After completion of delivery, vigorously stimulate the infant.
    10.  

    11. Wait at least one minute before clamping the newborn’s cord.

     

  11. Provide post-partum care to the mother. After the placenta is delivered (or 5 minutes after the baby is born, whichever comes first), initiate patient transportation. Massage the fundus of the uterus after delivery of the placenta. Wrap up the delivered placenta and take it to the hospital.
  12.  

  13. Contact the receiving facility for early notification.

Newborn Care

  1. Stimulate, position and warm. Dry with towels, stimulate with gentle rubbing or heal flicks. Suction only if an obvious obstruction is seen or the neonate requires positive pressure ventilation.
  2.  

    Note – In premature infants with estimated gestational age < 30 weeks DO NOT towel dry. Instead, wrap in plastic or put infant in a plastic bag (not the head) and put on a hat if available.

     

  3. If any of the following are present, immediately start newborn resuscitation protocol.
  4.  

      Non-vigorous newborn
      Apneic or gasping
      Heart rate < 100

      If none of the above are present, continue below.

     

  5. Keep baby at the same level of the perineum for at least 1 minute. Clamp and cut the cord. Place one clamp six inches from the infant, the second clamp three inches distal from the first clamp. Cut the cord between the clamps. If cord continues to bleed, apply additional clamps.
  6.  

  7. Record the time of birth. Determine APGAR scores at one and five minutes after birth. Normal respiratory rate is 40-60/minute and pulse is 120-160/minute. See below for normal preductal oxygen saturations in the neonatal period (in the right arm.)
  8.  

  9. Contact the receiving facility for early notification. Protect newborn from hypothermia.
Targeted Preductal SpO2 After Birth
1 min
60% - 65%
2 min
65% - 70%
3 min
70% - 75%
4 min
75% - 80%
5 min
80% - 85%
10 min
85% - 95%

APGAR Scoring Chart

Meconium Staining

Presence of green amniotic fluid or green/black particulate material on face or in upper airway.

 

  1. After completion of delivery, using a catheter or bulb syringe, suction mouth and then nose of newborn ONLY if there are signs of obvious obstruction or if the baby requires positive pressure ventilation (PPV).
  2.  

  3. Wipe away any collection of meconium in the upper airway with gauze-wrapped finger.
  4.  

    BLS

     

    1. Request ALS if not already en route and initiate transport. Contact receiving facility for further orders if ALS is not on scene.

     

    ALS

     

    1. See Newborn Resuscitation Protocol.

Newborn Resuscitation at Time of Delivery

Perform the following procedures in a stepwise fashion as indicated.
Reassess after each step before proceeding to the next.

 

BLS

 

  1. If infant is apneic, gasping, or has a HR < 100/min begin Positive Pressure Ventilation (PPV) with a bag-valve-mask (infant preferred) at rate of 40-60 breaths per minute for 30 seconds. (Caution: risk of barotrauma – bag only enough for chest rise and fall.). Positive pressure ventilation and thermoregulation are the most important priorities in newborn resuscitation.
  2.  

    1. Start oxygen saturation monitoring with pulse oximeter, if available.
    2.  

    3. Consider 3-lead monitoring (for purposes of obtaining heart rate)
    4.  

    5. If available, begin resuscitation with 21% oxygen.

     

  3. Reassess after 30 seconds of PPV:
  4.  

    1. If HR is < 100/min but > 60/min PPV, ensure good seal and airway position. Continue to perform PPV.
    2.  

    3. If HR < 60/min, begining chest compressions with a ratio of 3:1 compressions to breaths (90 compressions and 30 respirations per minute)
    4.  

  5. If HR >100/min, transport to closest pediatric facility with continued close monitoring
ALS

 

  1. If infant is apneic, gasping, or has a HR < 100 begin Positive Pressure Ventilation (PPV) with a bag-valve-mask (infant preferred) at rate of 40-60 breaths per minute for 30 seconds (Caution: risk of barotrauma – bag only enough for chest rise and fall.) Positive pressure ventilation and thermoregulation are the most important priorities in newborn resuscitation.
  2.  

    1. Start oxygen saturation and heart rate monitoring with pulse oximeter, if available
    2.  

    3. Consider 3-lead monitoring
    4.  

    5. If available, begin resuscitation with 21% oxygen.

     

  3. Reassess after 30 seconds of PPV:
  4.  

    1. If HR is < 100/min but > 60/min, ensure good seal and airway position. Continue to perform PPV.
    2.  

    3. If HR < 60/min begin chest compressions with a ratio of 3:1 compressions to breaths (90 compressions and 30 respirations per minute)
    4.  

      1. Reassess after additional 30 seconds of PPV and compressions. If HR < 60 BPM, administer epinephrine 0.01mg/kg of 1:10,000 IV/IO and continue compressions and ventilation.
      2.  

      3. Reassess after additional 30 seconds. If HR still < 60 bpm, administer 0.9% NS bolus 10ml/kg, slow IV push over 5-10 minutes.

     

  5. If HR does not improve despite performance of good PPV and HR does not respond thenintubate and use meconium aspirator to suction thick secretions that may be obstructing the airway (this is not necessarily meconium.)
  6.  

  7. If HR >100/min, transport to closest pediatric facility with continued close monitoring.
  8.  

  9. If HR >100/min, transport to closest pediatric facility with continued close monitoring. Protect newborn from hypothermia.
Targeted Preductal SpO2 After Birth
1 min
60% - 65%
2 min
65% - 70%
3 min
70% - 75%
4 min
75% - 80%
5 min
80% - 85%
10 min
85% - 95%

Newborn Resuscitation Flowchart

General Considerations
(From 2015 AHA Guidelines)
    Initial resuscitation steps should be completed within 60 seconds as illustrated.

    The decision to progress beyone initial steps is based on an assessment of respirations (apnea, gasping, labored, or unlabored breathing) and heart rate (>/< 100 bpm)

 

Assisting Venitlations
    Assist ventilations at a rate of 40-60 breaths per minute to maintain HR > 100
    Use 2 person BVM when possible

 

Chest Compressions
    Indicated for HR < 60 despite adequate ventilation with supplemental O2 for 30 seconds.
    2 thumbs-encircling hands technique preferred
    Allow full chest recoil
    Coordinate with ventilations so not deliverd simultaneously
    3:1 ratio for compressions to ventilations
Medications
    Epinephrine is indicated if the newborn's heart rate remains less than 60 beats/min after 30 seconds of PPV with 100% O2 AND another 60 seconds of chest compressions coordinated with PPV using 100% O2.
Intubation
    Intubation is only to be performed if all other measures listed have been attempted and the patient continues to have HR < 60 beats/min.