European Resuscitation Council Guidelines for Resuscitation ... - CPR

An organised educational programme in the standards and skillsrequired for resuscitation of the newborn is therefore essential forany institution in which deliveries occur.Planned home deliveriesRecommendations as to who should attend a planned homedelivery vary from country to country, but the decision to undergoa planned home delivery, once agreed with medical and midwiferystaff, should not compromise the standard of initial resuscitationat birth. There will inevitably be some limitations to resuscitationof a newborn baby in the home, because of the distance from furtherassistance, and this must be made clear to the mother at thetime plans for home delivery are made. Ideally, two trained professionalsshould be present at all home deliveries; one of these mustbe fully trained and experienced in providing mask ventilation andchest compressions in the newborn.Equipment and environmentUnlike adult CPR, resuscitation at birth is often a predictableevent. It is therefore possible to prepare the environment and theequipment before delivery of the baby. Resuscitation should ideallytake place in a warm, well-lit, draught free area with a flat resuscitationsurface placed below a radiant heater, with other resuscitationequipment immediately available. All equipment must be checkedfrequently.When a birth takes place in a non-designated delivery area, therecommended minimum set of equipment includes a device forsafe assisted lung aeration of an appropriate size for the newborn,warm dry towels and blankets, a sterile instrument for cutting theumbilical cord and clean gloves for the attendant and assistants. Itmay also be helpful to have a suction device with a suitably sizedsuction catheter and a tongue depressor (or laryngoscope) to enablethe oropharynx to be examined. Unexpected deliveries outside hospitalare most likely to involve emergency services who should planfor such events.Temperature controlNaked, wet, newborn babies cannot maintain their body temperaturein a room that feels comfortably warm for adults.Compromised babies are particularly vulnerable. 5 Exposure of thenewborn to cold stress will lower arterial oxygen tension 6 andincrease metabolic acidosis. 7 Prevent heat loss:18 de 0ctubre de 2010 www.elsuapdetodos.comS. Richmond, J. Wyllie / Resuscitation 81 (2010) 1389–1399 1391Initial assessmentThe Apgar score was proposed as a “simple, common, clear classificationor grading of newborn infants” to be used “as a basisfor discussion and comparison of the results of obstetric practices,types of maternal pain relief and the effects of resuscitation” (ouremphasis). 10 It was not designed to be assembled and ascribed inorder to then identify babies in need of resuscitation. 11 However,individual components of the score, namely respiratory rate, heartrate and tone, if assessed rapidly, can identify babies needing resuscitation(and Virginia Apgar herself found that heart rate was themost important predictor of immediate outcome). 10 Furthermore,repeated assessment particularly of heart rate and, to a lesser extentbreathing, can indicate whether the baby is responding or whetherfurther efforts are needed.BreathingCheck whether the baby is breathing. If so, evaluate the rate,depth and symmetry of breathing together with any evidence of anabnormal breathing pattern such as gasping or grunting.Heart rateThis is best assessed by listening to the apex beat with a stethoscope.Feeling the pulse in the base of the umbilical cord is ofteneffective but can be misleading, cord pulsation is only reliable iffound to be more than 100 beats per minute (bpm). 12 For babiesrequiring resuscitation and/or continued respiratory support, amodern pulse oximeter can give an accurate heart rate. 13ColourColour is a poor means of judging oxygenation, 14 which is betterassessed using pulse oximetry if possible. A healthy baby is bornblue but starts to become pink within 30 s of the onset of effectivebreathing. Peripheral cyanosis is common and does not, by itself,indicate hypoxemia. Persistent pallor despite ventilation may indicatesignificant acidosis or rarely hypovolaemia. Although colour isa poor method of judging oxygenation, it should not be ignored: ifa baby appears blue check oxygenation with a pulse oximeter.Tonewww.elsuapdetodos.comA very floppy baby is likely to be unconscious and will needventilatory support.Tactile stimulation• Protect the baby from draughts.• Keep the delivery room warm. For babies less than 28 weeksgestation the delivery room temperature should be 26 ◦ C. 8,9• Dry the term baby immediately after delivery. Cover the headand body of the baby, apart from the face, with a warm towelto prevent further heat loss. Alternatively, place the baby skin toskin with mother and cover both with a towel.• If the baby needs resuscitation then place the baby on a warmsurface under a preheated radiant warmer.• In very preterm babies (especially below 28 weeks) drying andwrapping may not be sufficient. A more effective method of keepingthese babies warm is to cover the head and body of the baby(apart from the face) with plastic wrapping, without drying thebaby beforehand, and then to place the baby so covered underradiant heat.Drying the baby usually produces enough stimulation to induceeffective breathing. Avoid more vigorous methods of stimulation. Ifthe baby fails to establish spontaneous and effective breaths followinga brief period of stimulation, further support will be required.Classification according to initial assessmentOn the basis of the initial assessment, the baby can be placedinto one of three groups:1. Vigorous breathing or cryingGood toneHeart rate higher than 100 min −1This baby requires no intervention other than drying, wrappingin a warm towel and, where appropriate, handing to the