A baby should breathe within 1min of birth, and usually does so. If he does not, he needs resuscitating, which may make all the difference between normality and brain damage. ‘Flat’ babies, who don’t breathe, are often a surprise, but you should be able to predict and prepare for most of them as described below. Most follow difficult deliveries, which are more likely to damage his brain by anoxia during and after delivery, than by trauma during it.
The aim of resuscitation is to make sure that the lungs expand, the baby is well oxygenated, his circulation and temperature are normal, and he is breathing normally. Mask ventilation and intubation will not help him if he does not need them; so follow the indications below.
Ideally, all your midwives should be able to intubate a baby. They can learn how to do it on a fresh stillbirth. But if normal deliveries are done by a continuously changing succession of midwives in training, you will not be able to train all of them to intubate the occasional baby who needs it. For these babies immediate bag and mask, or mouth to mouth ventilation, will be much better than intubation delayed by the time it takes to call you.
Traditionally, the Apgar score has been used to decide which babies to resuscitate. The instructions given below simplify this, and use only the heart rate and the respirations, on the grounds that if these are unfavourable, the other parts of the score will be unfavourable, too.
• LARYNGOSCOPE, neonatal, straight-bladed, Seward, with two blades sizes 0 (80 mm) and 1 (110 mm), also ten spare batteries and five spare bulbs, two laryngoscopes only. You will need a spare laryngoscope—at least one of them must be working always!
• TUBES, tracheal, neonatal, transparent, plastic or rubber, non–disposable (or disposable but reusable), either Cole pattern with neck and T–piece, or straight pattern with uniform diameter and stylet (optional), sizes 2.5 mm (10 Ch), 3 mm (12 Ch), and 3.5 mm (14 Ch). Pack these locally in sets.
• ADAPTOR, tracheal, neonatal, various sizes, five only. This fits the tracheal tubes to the Ambu bag.
• SUCTION CATHETERS, 4, 6, 8, and 10 Ch. These fit down the tracheal tubes.
• AIRWAYS, neonatal, sizes 00 and 000, five only of each size.
• MASK, neonatal, soft and clear, sizes 00, 0, and 1, Ambu (AMB) Laerdal, Bennett, or Samson.
• BAG, self-inflating, neonatal or infant size 250 or 500 ml, Cardiff, Laerdal, or Ambu (AMB), with reservoir or extension tube, and expiratory pressure release valve, one only. The pressure release valve will prevent you inflating him at >40 cm of water. The valves must be present and working.
• SUCTION DEVICE, electric, with overflow bottle and gauge, maximum vacuum 100-120 mm Hg (0.16-0.26 Bar), as ‘de Vilbiss 721 Vacu Aide’ (deV), one only. Don’t use a standard anaesthetic sucker—it sucks much too powerfully. Alternatively, use a mucus extractor.
• FOOTPUMP, ‘minipump’ Ambu (AMB), one only. You will need this if you don’t have electricity, or it fails.
• MUCUS EXTRACTOR tube and fluid trap, 10 Ch (CHI). If necessary, you can make these from old IV sets. The danger with a mucus extractor is that you may get secretions in your mouth, which is not acceptable where HIV is a risk. Unfortunately, there is presently no mouth-operated sucker which avoids this.
• STETHOSCOPE, with small head.