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Background

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References

Evaluating the need to initiate and continue resuscitation should begin immediately after birth and proceed throughout the resuscitation.

The initial assessment should address:

  • • 
    tone
  • • 
    breathing
  • • 
    heart rate

Subsequent assessment throughout the resuscitation is based on the infant's heart rate, breathing, tone and oxygenation, (which is preferably assessed using pulse oximetry). A prompt increase in heart rate remains the most sensitive indicator of resuscitation efficacy (extrapolated evidence1).

Evaluation and intervention are simultaneous processes, especially when more than one resuscitator is present. However, for clarity, this process is described as a sequence of distinct steps shown in the algorithm, adapted from The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,2 and the European Resuscitation Council Guidelines for Resuscitation 2010.3

Tone and response to stimulation

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References

The assessment of tone is subjective and dependent on gestation, but an infant with good tone (moving the limbs and with a flexed posture) is unlikely to be severely compromised whereas a very floppy infant (not moving and extended posture) is very likely to need active resuscitation.

Most newborn infants will commence movement of all extremities, start breathing and their heart rates will rise to over 100 beats/minute soon after birth. They do not require any assistance and should not be separated unnecessarily from their mothers.

If these responses are absent or weak, brisk but gentle drying with a soft towel should be used to stimulate the infant to breathe [Class A, expert consensus opinion]. Note that for premature infants who are placed in/under a polyethylene bag/sheet to prevent evaporative heat loss (see Guideline: The Resuscitation of the Newborn Infant in Special Circumstances), drying beforehand is unnecessary and potentially counterproductive, but tactile stimulation can be provided through the bag or sheet, if needed.

In non-vigorous, meconium-exposed infants who are to be intubated to suction meconium from the trachea, the intubation should be done immediately and stimulation should be withheld until suction is completed (see Guideline: Airway Management and Mask Ventilation of the Newborn Infant) [Class B, expert consensus opinion].

Slapping, shaking, spanking, or holding the newborn upside down are potentially dangerous and should not be used. During all handling, care should be taken to ensure that the infant's head and neck are supported in a neutral position, especially if muscle tone is low[Class A, expert consensus opinion].

If the infant does not breathe, assisted ventilation should be started (see Guideline: Airway Management and Mask Ventilation of the Newborn Infant) [Class A, expert consensus opinion].

Breathing

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References

After initial breathing efforts the newborn infant may pause for a few seconds and should then establish regular breaths sufficient to maintain the heart rate more than 100 per minute. Breathing may be difficult to assess well in the first minute or two after birth. However, if the infant can maintain a heart rate >100/min, immediate intervention may not be required, apart from ensuring that head, jaw and neck position allow airway patency. If the heart rate is not maintained >100/min, positive pressure ventilation is required [Class A, expert consensus opinion].

Recession, retraction or indrawing of the lower ribs and sternum, or onset of persistent expiratory grunting are important signs that the baby is having difficulty expanding the lungs. If they persist, the infant may benefit from continuous positive airway pressure (CPAP) or positive pressure ventilation [Class B, expert consensus opinion].

Persistent apnoea, particularly associated with hypotonia (floppiness), and a heart rate <100/min is a serious sign and the infant urgently requires positive pressure ventilation.

Heart rate

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References

Heart rate can be determined by listening to the heart with a stethoscope (most reliable) or in the first few minutes after birth, by feeling for pulsations at the base of the umbilical cord [Class A, expert consensus opinion]. The base of the umbilical cord is preferable to other palpation locations, but if a pulse is not felt at the base of the cord this is not a reliable sign that the heart rate is absent. Other central and peripheral pulses are difficult to feel in newborn infants making the absence of these pulses an unreliable sign.4–6 Pulse oximetry can provide an accurate and continuous display of the heart rate within about a minute of birth [LOE IV7,8].

Normal newborn infants have a heart rate soon after birth of about 130/min, varying between 110 and 160/min. Heart rate should be consistently more than 100/min within a minute of birth in an uncompromised newborn infant. An increasing or decreasing heart rate is the best sign that the infant's condition is improving or deteriorating [extrapolated evidence9]. If the heart rate is persistently less than 100/min, assisted ventilation should be commenced.

Colour

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References

Colour is difficult to assess accurately and is a poor means of judging oxygenation.10 Normal babies are blue at birth but start to look pink soon after the onset of breathing. Cyanosis can be difficult to recognise and is determined by examining the gums and mucous membranes in good ambient light. Bluish hands and feet are a normal finding after birth. If a baby appears persistently blue, it is important to check oxygenation with a pulse oximeter [Class A, expert consensus opinion].

Extreme pallor, especially if it persists after ventilation, can indicate severe acidosis, hypotension due to poor cardiac output with or without hypovolaemia, or sometimes, severe anaemia.

Pulse oximetry

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References

For babies requiring resuscitation and/or respiratory support, pulse oximetry is recommended9 both to monitor heart rate and to assess oxygenation. The sensor should be placed on the infant's right hand or wrist before connecting the probe to the instrument [Class A, LOE IV8,11]. Heart rate monitored using an oximeter should be checked intermittently during resuscitation by auscultation. [Class B, expert consensus opinion9].

Modern pulse oximeters, with probes designed specifically for newborns can provide readings in less than a minute of application, as long as there is sufficient cardiac output and peripheral blood flow for the oximeter to detect a pulse.7,8 Oximetry is recommended when the need for resuscitation is anticipated, when positive pressure is administered for more than a few breaths, when persistent cyanosis is suspected, or when supplemental oxygen is used [Class A, expert consensus opinion]. In babies resuscitated using supplemental oxygen, oximetry can play an important role in avoiding hyperoxaemia.

References

  1. Top of page
  2. Background
  3. Tone and response to stimulation
  4. Breathing
  5. Heart rate
  6. Colour
  7. Pulse oximetry
  8. References
  • 1
    Dawes GS. Foetal and Neonatal Physiology. A Comparative Study of the Changes at Birth. Chicago: Year Book Medical Publishers, Inc; 1968.
  • 2
    Kattwinkel J, Perlman JM, Aziz K, et al. Special Report–Neonatal Resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010.
  • 3
    Richmond S, Wyllie J. European Resuscitation Council Guidelines for Resuscitation 2010 Section 7. Resuscitation of babies at birth. Resuscitation 2010.
  • 4
    Whitelaw CC, Goldsmith LJ. Comparison of two techniques for determining the presence of a pulse in an infant. Acad Emerg Med 1997; 4: 1534.
  • 5
    Kamlin CO, Dawson JA, O'Donnell CP, et al. Accuracy of pulse oximetry measurement of heart rate of newborn infants in the delivery room. J Pediatr 2008; 152: 75660.
  • 6
    Owen CJ, Wyllie JP. Determination of heart rate in the baby at birth. Resuscitation 2004; 60: 2137.
  • 7
    Altuncu E, Ozek E, Bilgen H, Topuzoglu A, Kavuncuoglu S. Percentiles of oxygen saturations in healthy term newborns in the first minutes of life. Eur J Pediatr 2008; 167: 6878.
  • 8
    O'Donnell CP, Kamlin CO, Davis PG, Morley CJ. Obtaining pulse oximetry data in neonates: a randomised crossover study of sensor application techniques. Arch Dis Child Fetal Neonatal Ed 2005; 90: F845.
  • 9
    Perlman JM, Wyllie J, Kattwinkel J, et al. Part 11: neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122: S51638.
  • 10
    O'Donnell CP, Kamlin CO, Davis PG, Carlin JB, Morley CJ. Clinical assessment of infant colour at delivery. Arch Dis Child Fetal Neonatal Ed 2007; 92: F4657.
  • 11
    O'Donnell CP, Kamlin CO, Davis PG, Morley CJ. Feasibility of and delay in obtaining pulse oximetry during neonatal resuscitation. J Pediatr 2005; 147: 6989.