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Referral and warning signs
When to refer
Refer if prolonged resuscitation (> few mins) or ongoing respiratory support needed. Refer if chest compressions/medications needed.
Red flags
- Not breathing/gasping at 1 minute
- HR < 60 bpm despite effective ventilation
- Persistent poor tone or cyanosis
- Failure to establish respiration after 20 min effective resuscitation
Signs and symptoms
- Assessment ('Golden Minute'): Crying/breathing? Good muscle tone?
- Need Resuscitation if: Not breathing/gasping, Poor muscle tone (floppy), Heart rate <100 bpm.
Risk factors
- Antenatal: Maternal illness, PET, APH, Multiple gestation, IUGR, Post-term, No ANC.
- Intrapartum: Prolonged/Obstructed labour, PROM, Chorioamnionitis, Malpresentation, Cord prolapse, Meconium liquor, Operative delivery, Maternal sedation.
Diagnosis
Clinical assessment
Rapid assessment at birth (breathing, tone, HR).
Investigations
- Clinical assessment.
- Heart rate check (umbilical pulse/auscultation).
- Observe chest rise during ventilation.
Diagnostic criteria
Not breathing/gasping OR HR <100 bpm within 'Golden Minute'.
Management
Non-pharmacological management
- Preparation: Warm/clean surface, equipment ready (suction, BVM, masks, clock, towels).
- Initial Steps (Golden Minute): Provide Warmth (dry, cover), Position Head/Clear Airway (sniffing position, suction mouth THEN nose ONLY if needed/meconium+not vigorous), Stimulate (rub back/flick feet).
- If Still Not Breathing / HR <100: Ventilate with Bag-Valve-Mask (BVM): Correct mask size/seal, Room air initially, Rate 40/min ('Breathe-two-three'), Ensure gentle chest rise. Ventilate 1 minute.
- Re-assess after 1 min: If HR >100 + Breathing -> Stop ventilation, observe. If HR 60-100 -> Continue effective BVM. If HR <60 -> Continue effective BVM + Start Chest Compressions (3:1 ratio) + Consider O2 + Call for help/transfer.
- Meconium: If NOT vigorous, suction mouth/nose before stimulation.
- Stop if no improvement after 20 min effective ventilation.
Pharmacological treatment
- Oxygen (if available & indicated).
- Adrenaline/Epinephrine (rare, advanced resuscitation).
- Volume expansion (rare).
- Naloxone NOT recommended routinely.
Monitoring
Continuous monitoring: Breathing, HR, Chest rise, Colour, Tone. Temperature.
Complications
- Hypoxic-Ischaemic Encephalopathy (HIE).
- Cerebral palsy.
- Developmental delay.
- Organ damage.
- Death.
Prevention
- Good ANC/Intrapartum care.
- Skilled birth attendance.
- Preparation for resuscitation.
Patient education
- (Post-event): Explanation why needed, steps taken, baby's condition/plan. Importance of warmth, feeding, observation. Potential need for further care.
Uganda-specific notes
Birth asphyxia major cause of neonatal death. HBB training crucial. Functioning BVM/masks key. Room air effective. Golden Minute emphasis.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.5.1
- Helping Babies Breathe (HBB) Guidelines/Materials
(Widely used training program)