Despite the fact that there have been very clear guidelines published by the Canadian Pediatric Society under its neonatal resuscitation program, there are still instances where newborns requiring resuscitation suffer a brain injury simply because these guidelines were not followed. The simple fact is that every person who chooses to deliver babies and every hospital offering obstetrical services must ensure that the appropriate resuscitation equipment is available at the time of delivery and that qualified individuals competent in newborn resuscitation are readily available. Instances of negligent resuscitation have occurred with home birth deliveries managed by midwives where there was a failure to have the appropriate equipment available, and a failure to follow the guidelines for resuscitation. This issue has also come up in the context of deliveries at rural hospitals were appropriately trained staff are not available for the resuscitation and even in large urban hospitals where the paging system malfunctioned.
The neonatal resuscitation guideline can be found in the Neonatal Resuscitation textbook published by the Canadian Pediatric Society, American Academy of Pediatrics and the American Heart Association. The original guidelines were published approximately thirty years ago and, while there have been revisions to those guidelines, the basic principles have remained constant.
The Golden Minute
The first 60 seconds of life, often referred to as the “Golden Minute” is the time when the newborn baby should be stabilized through the provision of warmth, clearing of the airway if required, drying, stimulating and ventilating if necessary. Ventilation is usually by a mask placed over the newborn’s face. The mask is attached to a machine or bag. The clearing of the airway by suction is usually reserved for babies with obvious obstruction to spontaneous breathing or who require ventilation.
If the baby passed meconium prior to being delivered the person performing the resuscitation may suction the baby’s throat to remove the meconium if the baby is not vigorous. For babies born in the presence of meconium who are vigorous at birth suctioning is not an absolute requirement. The ventilation, sometimes referred to as positive pressure, is usually with room air however there can be an adjustment to the oxygen concentration if the baby’s heart rate is low. One of the signs of successful resuscitation is a prompt improvement in the newborn’s heart rate. If there is not an immediate improvement in the heart rate with the mask ventilation, the person performing the resuscitation should consider intubation and possibly further suctioning or chest compressions. The person performing the resuscitation must be trained and proficient in intubation and must be able to establish the proper position of the intubation tube. It is not uncommon for the intubation tube to go into the esophagus and not the baby’s trachea.
In any situation where a baby is born in a compromised condition, there should be a review of the medical records to determine whether the healthcare professional in charge of the newborn baby had access to all necessary resuscitative equipment and performed the resuscitation in compliance with the existing guidelines.