Neonatal Resuscitation at the Peripheral Clinic

THE low APGAR baby delivered in a clinic presents the midwife with a formidable problem. The problem arises from the fact that clinics generally are poorly equipped for major resuscitation of the newborn. The problem is further compounded by the fact that the baby with a low APGAR score travels very badly. He becomes hypothermic easily, and is likely to die if moved in a cold ambulance without oxygen or adequate heating. Then too, midwives are generally poorly trained for the task o f resuscitating babies suffering from severe asphyxia neonatorum, because they received their training in hospitals with the basic assumption that a medical officer is always in the background ready to take over the management of such problems. Finally, accep­ tance by the community o f clinic-based obstetric services is largely dependent upon the clinics' achieving a nil perinatal mortality rate. The delivery o f a gasping newborn who dies in the midwife’s hands can do great damage to the reputation of the service.


INTRODUCTION
T HE low APGAR baby delivered in a clinic presents the m idwife with a form idable problem.The problem arises from the fact that clinics generally are poorly equipped for m ajor resuscitation o f the new born.The problem is further com pounded by the fact that the baby with a low APGAR score travels very badly.He becom es hypothermic easily, and is likely to die if m oved in a cold ambulance without oxygen or adequate heating.Then too, midwives are generally poorly trained for the task o f resuscitating babies suffering from severe asphyxia neonatorum , because they received their training in hospitals with the basic assumption that a medical officer is always in the background ready to take over the m anagem ent of such problem s.Finally, accep tance by the com m unity o f clinic-based obstetric services is largely dependent upon the clinics' achieving a nil perinatal mortality rate.The delivery o f a gasping newborn who dies in the m idw ife's hands can do great dam age to the reputation of the service.

THE IM PO RTA N CE O F A N TEN A TA L SCREENING
The three im portant causes o f fetal distress and therefore asphyxia neonatorum , are hypoxia, excessive head com pres sion.and intra-uterine infection, see Figs.I and II.A high proportion of patients in whom these three factors operate, can be detected during the antenatal period, and thus selected for hospital delivery.
For exam ple, placental insufficiency, and therefore fetal distress, is predictably more common in pregnancies com plicated by hypertension, diabetes, postm aturity, an tepartum haem orrhage, and intra-uterine growth retardation.The elderly prim ipara and the patient o f more than 40 years o f age also show a higher incidence o f placental insufficiency.
Excessive head com pression occurs in patients in whom there is cephalopelvic disproportion because the pelvis is small or the baby is o f excessive size.
M eticulous history-taking and thoughtful examination o f the antenatal patient at each visit, as well as careful pelvic assessm ent, and assessm ent o f fetal size from 36 weeks onw ards, should enable the midwife to detect all such pa tients and select them for hospital delivery.
Fetal distress due to syphilitic damage to the placenta can largely be prevented by doing the W assermann reaction in every antenatal patient and treating positive reactors with penicillin.Patients in whom other causes o f recurrent intra uterine infection (e.g.toxoplasm osis) produce fetal com promise can usually be detected by careful history-taking.All patients who have two or more first trim ester abortions, a previous unexplained stillbirth or neonatal death, a previous m id-trim ester abortion, or recurrent prem ature labours, should be referred as early as possible in the antenatal period for investigation, antenatal care from the hospital and hospi tal delivery.
Experience has shown that careful selection o f patients in this way greatly reduces the incidence o f asphyxiated births in the clinic.

THE IM PORTANCE OF INTRAPARTUM M O N ITO R ING
If the midwife is to avoid delivering asphyxiated babies in aclinic, it is essential that she should detect any signs o f fetal compromise as early as possible in the labour, in order that the patient can be tim eously transferred to the base hospital.The signs of fetal com prom ise which she can use, are fetal heart changes, meconium staining of the liquor amnii, and excessive moulding o f the fetal skull together with other signs o f cephalopelvic disproportion.
This really does mean that the fetal heart in labour must be monitored half hourly, before, during and after contractions.Such m onitoring must be given a high priority by the midwife whose duties in a busy clinic may involve her in attending to patients with m inor ailments as well as looking after the patients in the labour ward.
It also means that the liquor amnii should be looked at in early labour.Any patient who has passed from the passive phase o f labour i.e. her cervix is 4 or more centimetres dilated, should have the membranes ruptured, in order to inspect the liquor.M em branes should not be ruptured before 4 cm s dilatation for fear o f doing so in a patient who is not in fact in labour.They should o f course also not be ruptured in a patient with a high floating head because of hydram nios, or w ith a m alpresentation, as such patients should in any case be transferred im m ediately to hospital.
Finally it means that the midwife must carefully feel for occipito-parietal and parieto-parietal moulding o f the fetal skull every tim e she perform s a vaginal exam ination on the patient in labour.Such m oulding should be graded according to the method described by P hilpott,1 and correlated with the am ount o f head palpable above the brim and the rate of cervical dilatation, in order to detect evidence o f cephalopelvic disproportion as early as possible.The use o f a graphic display o f progress in labour is very im portant in such a task.2 All patients with abnorm al fetal heart patterns, meconium staining o f the liquor, especially in early labour, and evi dence o f cephalo-pelvic disproportion, including a second stage o f longer than 30 m inutes, should be urgently transfer red for delivery in hospital where the best facilities for the resuscitation and care o f the newborn are available.

CLIN IC RESUSCITATION OF THE HEA LTH Y N EW BORN
M eticulous antenatal and intrapartum care will help ensure that only vigorous babies with good (7-10) A pgar scores are delivered in the clinic.Resuscitation o f such newborns con stitutes no serious problem , but there are important details which require emphasis:

Tem perature M aintenance
Newborns arrive in the world with a wet skin from their uterine incubator in which their bodv tem perature has been com fortably m aintained by the mother.They are suddenly precipitated into a room temperature which dry, clothed adults find com fortable but w hich for them is extrem ely cold.It is important to their survival that labour wards should be as warm as is com fortably perm issible, and that the baby be dried and his body covered as soon as possible.If he is handed to his m other, her body will help to keep him warm.

Clear the airway gently
The mucosal lining o f a new born's naso-pharynx is deli cate and easily dam aged.Rough, prolonged suctioning can therefore produce ulceration and predispose to infection and oedem a o f the nasal m ucosa which can lead to respiratory difficulty in a new born baby who does not know how to breathe through his mouth.In addition, such suctioning is a m ajor vagal stim ulus and can provoke reflex apnoea.Suc tioning should therefore be gentle and aim only at rem oval of m ucus from nose''and pharynx, not at the stim ulation of respiration.This latter aim is better achieved by flicking the heels.

The Um bilical Stum p
This is an open wound with a poor blood supply, and must be treated as such.Thus the midwife should never blow on the abdom en o f the newborn in order to stim ulate him .She should always wash her hands and use sterile instrum ents and sterile ties in attending to the umbilicus.

RESU SCITA TIO N OF THE BABY WITH A LOW APGAR SCO RE IN THE CLINIC
It is unfortunately true that even when the clinic m idw ife's selection o f patients is excellent, she will still be faced by the birth o f the occasional baby with a low A pgar score.The m ajority o f these will be born to unbooked patients or pa tients who have not co-operated in their antenatal care.
The basic principles o f resuscitation of such babies are as follows:

Be Prepared
Set out below is a list of the basic equipm ent essential to the task o f resuscitation o f the new-born: An oxygen cylinder with reduction valve, flow m eter, tubing and connections.A spare, full oxygen cylinder should alw ays be on the prem ises.
An infant's laryngoscope that works.A suction source.Catheters for oxygen adm inistration and suctioning.
T ranslucent plastic bags 27 x 50 cm in size.
A sterile 10 ml syringe with needle.
A sterile 2 ml syringe with needle.
A bag and mask suitable for interm ittent positive pressure ventilation o f a newborn is desirable.(Good patterns are m arketed by Penlon and Am bu).If the m idw ife has been trained in intubation o f the new born, the necessary 12 and 14 F .G .(no 3 and no.2,5) neonatal endotracheal tubes with adaptors should be available for her use.

R ecogn ise the baby n eed in g active resu scita tio n rapidly
It is essential to realise that the baby bom with a very low A pgar score may leave the m idw ife only a m inute or two in w hich to save his life.He can be recognised by feeling the pulse rate at the umbilicus and noting his response to suction ing.A pulse rate o f under 100 beats per m inute means significant asphyxia is present, and dem ands urgent action.A pulse rate of under 60 beats per minute means that the baby requires immediate interm ittent positive pressure ventilation with pure oxygen.

Oxygen A dm inistration
O xygen is life-saving, but only if it is in the right place, and this is in the baby's lungs.His airways should be thoroughly but gently suctioned.If a lot o f m econium is in the pharynx, this should be rem oved by suctioning under vision using the laryngoscope, ideally before the baby takes his first breath, in order to prevent the m econium aspiration syndrom e.
As soon as his airway is clear, if the baby is breathing and he is given 2 litres o f oxygen through a nasal catheter, his condition will rapidly im prove.If he is not breathing, it is essential to blow oxygen into his lungs.This can best be done in a clinic which is not equipped with a bag and m ask, by: (a) M outli-to-m outli ventilation with added oxygen.To do this, the m idw ife places the oxygen catheter in the com er o f her mouth and turns up the (low rate to 4 litres per m inute.She then holds the baby's m outh open, at the same time lifting the lower jaw forward in order to m aintain a clear airw ay, with her right hand.H er left hand is em ployed pinching the baby's nose closed and supporting his head.A m ixture o f air and oxygen can now be blown into the baby's open mouth if the midw ife applies her m outh to his.W hen the baby's lungs are expanded she rem oves her mouth to take a breath herself w hile he exhales. fh) The nasal oxygen catheter technique.To do this, the midwife raises the oxygen flow through a nasal catheter to 4-6 litres per m inute.If both nostrils are then squeezed closed, and the baby's mouth interm ittently closed with the jaw held forw ard, the pressure o f the oxygen will expand his lungs.As soon as the lungs have expanded, the jaw should be released to allow him to exhale.O nce he has done so, the mouth is again closed.Bew are o f over-inflating the lungs.Interm ittent adm inistration o f oxygen in this way can be continued alm ost indefinitely w ith the sole disadvantage that the stom ach blow s up the oxygen as well if it has to be continued for som e time.This carries with it the danger o f vom iting, and the suction m achine must always be available to prevent inhalation o f vom itus.
If a bag, endotracheal tube and laryngoscope are available, intubation and ventilation w ith this equipm ent is obviously best, care being taken to avoid intubating the right main bronchus.It is im portant with either technique to start early, and to continue until the baby has a normal pulse rate and is pink.The m idwife can then stop and stimulate the baby by flicking his feet.If he rem ains apnoeic, she should continue as long as 20 minutes.

M aintain the B aby's Body Tem perature
The baby with a low A pgar score will cool rapidly during resuscitation if he is left lying naked and wet in a room tem perature which is com fortable for an adult.As his body cools, his oxygen requirem ent rapidly rises, and thus if optimal oxygenation cannot be rapidly established, his death is hastened.He should therefore be adequately covered as early as possible during resuscitation.Most coverings how ever, have the disadvantage that the m idwife can no longer inspect the baby's chest m ovem ents and colour.A transpar ent plastic bag slipped over the baby's feet up to his shoulders has the advantage o f insulating the baby from the surround ing air while he can still be adequately inspected.It prevents loss o f heat by evaporation and irradiation and is very cheap.Provided care is taken never to cover the baby's face with the bag, it provides a safe method o f maintaining his body tem perature during transportation especially if the baby is held against the m other's body.If used routinely in babies of low birth w eight, or with low A pgar scores born in the clinic, plastic bags provide a very cheap method o f m aintains the at risk new born's body tem perature during the critical few hours after birth.

Correct A cidosis and Hypoglycaem ia
H ypoxia often leads to a vicious circle as illustrated in Figure III.
B ecause o f the developm ent o f acidosis and h y p o glycaem ia, some babies still w on't breathe even after pro longed interm ittent positive pressure ventilation with ade quate maintenance o f their body tem perature.It is essential in such babies to correct these two biochem ical abnorm alities.Acidosis can be corrected by giving half to 1 cc o f 8,5 percent Sodium Bicarbonate solution per estim ated kilogram body mass intravenously.H ypoglycaem ia is best corrected by diluting 50 percent dextrose water with sterile saline to a 20 percent solution and injecting 1-2 ml per kilogram o f esti mated body mass.The intravenous injection is most easily given by inserting a needle into the umbilical vein in the cord about 4 cm from the umbilicus.The umbilical vein is usually identified because it is the thickest and darkest o f the vessels in the cord.Injection should be slow, and an artery forcep must be applied proxim al to the site of injection to prevent subsequent haem orrhage.

Reverse the effects o f Pethidine if necessary
If the patient received Pethidine within 2-3 hours of deliv ery, depression o f the respiratory centre by this drug should be considered.It can always be rapidly corrected by giving Narcan Neonatal 2 mg intramuscularly.There is no place for o th e r re s p ira to ry stim u la n ts 3 su ch as V an d id and Nikethamide as these agents are now regarded as potentially dangerous.

Tim ing the transfer o f the baby with a low Apgar score
W hen resuscitation has been successful, it is important that the baby should be observed in an intensive care area in the base hospital for a few days.If he is progressively improving on oxygen in a warm place in the clinic, no attempt should be made to move him until optimal arrange ments have been made to maintain his body temperature and oxygenation in the ambulance.This often means that it is better to move him the following m orning when the sun is up than in a cold, poorly insulated ambulance at night when there is no portable incubator available.If he remains cynaosed and in a poor condition, urgent transfer on oxygen may however be the correct decision.

Knowing when to stop
If the baby fails to respond to all the resuscitative manoevres detailed above, intermittent positive pressure ventila tion should be continued for 20 minutes.Should he not initiate sustained, spontaneous respiration by that time, it is almost certain that he has suffered irreversible cerebral dam age and attem pts to resuscitate him should probably be dis continued.

LEARN FROM M ISTAKES
it is important to improving the standard o f care in a clinic that every delivery com plicated by the birth of a baby with a low Apgar score be discussed in detail with the supervising m edical officer.The aim o f such a discussion must be that of identifying avoidable factors and thus providing continuing education o f the midwife in order that the objective of a nil clinic perinatal m ortality can be obtained and m aintained.

FIG
FIGURE I THE EFFECT OF IN TR A -U TER IN E INFECTION ON THE FETUS