RESUSCITATION OF THE NEWBORN

Though the need for resuscitation can be anticipated in some situations, in many instances a
baby is born in poor condition without forewarning. It is essential that resuscitation
equipment is always available and in working order and that personnel in attendance at the
birth of a baby are familiar with the equipment, resuscitation techniques and local policies
regarding the provision of medical aid.

In some units resuscitation of babies is undertaken in a specific area, whereas in others each
birthing room is equipped to deal with this emergency. Whenever problems are anticipated,
such as preterm delivery, instrumental or breech delivery or foetal compromise, it is desirable
that a paediatrician, neonatal nurse or midwife experienced in resuscitation techniques is
present at the delivery. (In some centres an anaesthetist may be the person responsible for
neonatal resuscitation.) At home, the midwife is the responsible person.

Those newly born infants who do not require resuscitation can generally be identified by a
rapid assessment of the following 3 characteristics:

 Term gestation?
 Crying or breathing?
 Good muscle tone?

If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and
should not be separated from the mother. The baby should be dried, placed skin-to-skin with
the mother, and covered with dry linen to maintain temperature. Observation of breathing,
activity, and color should be ongoing.

If the answer to any of these assessment questions is “no,” the infant should receive one or
more of the following 4 categories of action in sequence:

A. Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)
B. Ventilation
C. Chest compressions
D. Administration of epinephrine and/or volume expansion

Approximately 60 seconds (“the Golden Minute”) are allotted for completing the initial steps,
reevaluating, and beginning ventilation if required. The decision to progress beyond the
initial steps is determined by simultaneous assessment of 2 vital characteristics: respirations
(apnea, gasping, or labored or unlabored breathing) and heart rate (whether greater than or
less than 100 beats per minute). Assessment of heart rate should be done by intermittently
auscultating the precordial pulse. When a pulse is detectable, palpation of the umbilical pulse
can also provide a rapid estimate of the pulse and is more accurate than palpation at other
sites.

AIMS OF RESUSCITATION.

These are to:

 establish and maintain a clear airway, by ventilation and oxygenation

 ensure effective circulation

 correct acidosis

 prevent hypothermia, hypoglycaemia and haemorrhage.

As soon as the baby is born, the clock timer should be started. The Apgar score is assessed in
the normal manner at 1 minute. In the absence of any respiratory effort, resuscitation
measures are commenced. The baby's upper airways should be cleared by gentle suction of
the oro- and nasopharynx and the presence of a heartbeat verified. The baby is dried quickly
and transferred to a well-lit resuscitative and placed on a flat, firm surface at a comfortable
working height and under a radiant heat source to prevent hypothermia. The baby's shoulders
may be elevated on a small towel, which causes a slight extension of the head and straightens
the trachea. Hyperextension may cause airway obstruction owing to the short neck of the
neonate and large, ill-supported tongue.

Rationale for Resuscitation

The goals of resuscitation are to establish and maintain a clear airway, ensure effective
circulation to correct the acidosis, and prevent hypothermia, hypoglycemia, and haemorrhage.
Careful intrapartum assessment of the foetal heart rate can alert the midwife to the probable
need for resuscitation. The foetus undergoing a prolonged period of asphyxia may make
gasping attempts followed by apnoea in utero (primary apnoea). At birth, weaker gasps may
be followed by the last gasp and secondary period of apnoea. The heart rate falls dramatically
and without intervention, the infant dies. The infant born with secondary apnoea cannot be
revived with suctioning and tactile stimulation; ventilation and perhaps cardiac massage are
required.

The asphyxiated infant has low oxygen levels, elevated carbon dioxide, and lower blood pH
(acidosis). This condition contributes to vasospasm of pulmonary arterioles and increased
resistance to blood flow in the lungs after birth. The weak gasp of the asphyxiated newborn
cannot overcome this resistance and establish adequate respiration. As the hypoxia continues,
the heart rate slows, and the myocardium contracts ineffectively. The BP drops and systemic
circulation slows, leading to organ damage.

Degrees of Resuscitation

Resuscitative requirements vary with the infant's condition at 1 minute of age:

1. The baby with an Apgar score of 7-10 has a blood pH of 7.20-7.40. This baby has
minimal depression and a normal transition period can be expected:

a. Suction the oropharynx and then the nose to clear the airway and provide tactile
stimulation.

b. Dry the infant and provide warmth: Apply warm blankets to the baby on the mother's
abdomen or use a radiant warmer (warmer may not be required in the tropics).

c. Continue to observe transition closely.

2. The baby with an Apgar score of 4-6 has a blood pH of 7.09-7.19(moderate acidosis). This
baby has moderate depression probably reflecting a period of primary apnoea:

a. Dry the infant.

b. Place infant under the radiant heat source.

c. Suction the oropharynx and then the nose to clear the airway and provide tactile
stimulation; give free-flow oxygen by face mask.

d. If the infant is still apnoeic or has a heart rate below 100, begin positive pressure
ventilation by face mask attached to an anaesthesia bag or self-inflating bag with an oxygen
reservoir; both give nearly 100% oxygen.

e. Continue free-flow oxygen after the infant has established good respiratory effort.

b. Dry the infant.

3. The infant with an Apgar score of 0-3 has a blood pH of 7.00 or below (severe acidosis).
This baby has severe depression reflecting secondary apnoea:

a. Suction the infant to clear the airway.

c. Place the infant in the work area under the radiant heat source.

d. Begin positive pressure ventilation.

e. If positive pressure ventilation does not ensue with bag and mask, perform endotracheal
intubation.

f. If the heart rate is less than 60 after 30 seconds of adequate ventilation, begin the cardiac
massage. Continue massage until infant can sustain heart rate over 80 with ventilation alone.

Supplies and Equipment

Though the need for resuscitation can be anticipated in some situations, there are occasions
when a baby is born in poor condition without forewarning. Resuscitation equipment must be
always available and in working order in the delivery room and nursery area near oxygen and
suction outlets. The equipment and medications should include those that will provide
adequate ventilation or resuscitation, thermoregulation, correction of hypoglycaemia, fluids
and electrolytes, plasma expanders, and cardiac stimulants. The personnel in attendance at the
delivery of a baby must be familiar with the equipment and resuscitation techniques. A list of
essential equipment includes the following.

RESUSCITATION EQUIPMENT

Suctioning Equipment

 Bulb syringe

 DeLee mucus trap with No. 10 French (Fr) catheter or mechanical suction

 Suction catheters No. 6, 8and 10 Feeding tube No. 8 Fr and 20 mL syringe.

Bag and Mask Equipment

Infant resuscitation bag with pressure release valve or pressure gauge with a reservoir capable
of delivering

90-100% oxygen Face masks with cushioned rims: Newborn and premature sizes

Oral airways: Newborn and premature sizes • Oxygen with flow meter and tubing.

Intubation Equipment

Laryngoscope with straight blades No. '0' (premature), No. '1' (newborn)

Extra bulbs and batteries for laryngoscope

Endotracheal tubes-

 sizes 2.5, 3.0, 3.5, and 4.0 mm internal diameter

 Stylet
 Scissors.

Medications

 Epinephrine 1/10, 000 ampules (1 mL ampule of 1:1,000 available in India)

 Naloxone hydrochloride (neonatal Narcan 10.02 mg/mL)

 Volume expander (one or more)

 . Albumin solution of 5%

 . Normal saline

 Ringer's lactate Sodium bicarbonate 1.2\ %( (1 mEq/2 mL)(7 % strength available in

India approximately 0.9mEq / mL

 Dextrose 10% concentration 250 mL

 Sterile water 30 mL

 . Normal saline 30 mL.

MISCELLANEOUS

 Radiant warmer

 Stethoscope

 Adhesive tapes

 Syringes 1 mL, 2 mL, 5 mL and 20 mL sizes

 Needles No. 21, 22 and 26

 Umbilical cord clamp

 Umbilical catheters 3.5 and 5 Fr sizes.

  Umbilical artery catheterization tray

 Gloves.

INITIAL STEPS

PREVENTING HEAT LOSS

 Place infant under a warmer Quickly dry off amniotic fluid

 Replace wet sheets with a dry ones.

POSITIONING

 Place the baby on his/her back with head slightly down (15° tilt).
 Neck slightly extended.

SUCTIONING

 Suction the mouth first and then the nose

 Tactile stimulation

 If the infant does not breathe immediately give tactile stimulation, but only twice
(flick or tap the sole twice or rub the back).

WARMTH

Hypothermia exacerbates hypoxia as essential oxygen and glucose are diverted from the vital
centers in order to create heat for survival. Wet towels should be removed and the baby's
body and head should be covered with a prewarmed blanket leaving only the chest exposed.
NB, It is hazardous to use a silver Swaddler under a radiant heater because this could cause
burning.

STIMULATION
Rough handling of the baby merely serves to increase shock and is unnecessary. Gentle
stimulation by drying the baby and clearing the airway may initiate breathing, but there are a
number of different methods that can be used, for example, a single finger flick to the sole of
the foot, or gentle back rubbing; this will give an indication as to whether tactile stimulation
is likely to be effective. Under no circumstances should the method used cause significant
pain or bruising. A number of unsafe methods of stimulation have been used including back-
slapping and sternal pressure, which could physically damage the baby. Directing a low flow
(2 - 4L / m * in) of oxygen over the baby's face may be all that is needed to stimulate a gasp
reflex.

CLEARING THE AIRWAY

Most babies require no airway clearance at birth; however, if there is obvious respiratory
difficulty a suction catheter may be used size 10 FG (8 FG in preterm babies). It is
recommended that the catheter tip should be inserted no further than 5 cm and that each
suction attempt should last no longer than 5 seconds). Even with a soft catheter, it is still
possible to traumatise the delicate mucosa, especially in a premature baby. If meconium is
present in the airway, suction under direct vision should be performed by passing a
laryngoscope and visualising the larynx. Care should be taken to avoid touching the vocal
cords as this may induce laryngospasm, apnoea and bradycardia. Thick meconium may need
to be aspirated out of the trachea through an endotracheal tube.

EVALUATION

1. After the above steps evaluate the baby's vital signs:

 Respirations

 Heart rate

 Colour.

2. If respiration is normal, go on evaluating heart rate.

3. If the baby is apnoeic, begin positive pressure ventilation.

4. If the heart rate is over 100 bpm, go on evaluating colour.

5. If less than 100 bpm, initiate positive pressure ventilation.

6. If the infant is pink, no further action is necessary.

7. If there is central cyanosis, administer free-flow oxygen (tip of the tube held 1.25 cm from
nares delivers approximately 90% oxygen).

VENTILATION AND OXYGENATION

If the baby fails to respond to these simple measures, assisted ventilation is necessary. This
can be achieved in a variety of ways. Face-mask ventilation is the most commonly used
method of inflating the baby's lungs. It is effective and relatively safe in experienced hands.
Choose an appropriately sized mask (usually 00 or 0/1) and position it on the face so that it
covers the nose and mouth and ensures a good seal. Using a 500 ml bag as a smaller 250 ml
bag does not permit sustained inflation. Care should be taken not to apply pressure on the soft
tissue under the jaw as this may obstruct the airway. To aerate the lungs deliver five sustained
inflations using oxygen or air or a combination of both, with a pressure of 30cm*H_{2}*O
applied for 2 - 3 seconds and repeated five times, then continue to ventilate at a rate of 40
respirations per minute. Insertion of a neonatal airway helps to prevent obstruction by the
baby's tongue. Note that overextension of the baby's head causes airway obstruction. A longer
inspiration phase improves oxygenation. Higher inflation pressures may be required to
produce chest movement. The bag and mask technique, therefore, requires a skilled operator
to achieve success. Used correctly this method can avoid the need for endotracheal intubation.

BAG AND MASK VENTILATION/ POSITIVE PRESSURE VENTILATION

INDICATIONS
GBV
 Infant apneic

 Heart rate less than 100 bpm.

PROCEDURE

 The newborn should be on his/her back with the neck slightly extended.
 A tight seal to be formed over the infant's mouth and nose:
o Ventilate at the rate of 40-50 per minute with 20-25 cm H 2 O| pressure
o Ventilate for 15-30 seconds and evaluate
 Have an assistant evaluate, listen to the heart rate for 6 seconds, and multiply by 10.

EVALUATION

1. Heart rate above 100 bpm and spontaneous respiration -discontinue bagging.
2. Heart rate 60- bpm and increasing-continue ventilation.

3. Heart rate 60 - 100 bpm and not increasing continue ventilation.

4. Check whether the chest is moving adequately.

5. Heart rate below 80 bpm-start chest compressions.

6. Heart rate below 60 bpm-in addition to bagging and chest compressions, consider
intubation and initiate medications.

Signs of Improvement

 Increasing heart rate

 Spontaneous respiration Improving color.

 Continue to provide free flow oxygen by face mask after respiration has established.

If the baby deteriorates, check the following:

• Placement of face mask for tight seal

• Head position and presence of secretions

Pressure being used

Oxygen being delivered (100% or not). For bagging lasting for more than 2 minutes insert an
orogastric tube to vent the stomach.

CHEST COMPRESSIONS

 Presence of air in the stomach prevents chest expansion

 Chest compressions consist of rhythmic compressions of the sternum that compresses

the heart against the spine, increases the intrathoracic pressure, and circulates blood to
the vital organs.

 Chest compressions must always be accompanied by ventilation with 100% oxygen to

assure that the circulating blood is well oxygenated.
INDICATIONS

1. Heart rate less than 60 bpm after bagging with 100% oxygen for 15-30 seconds.

2. Heart rate 60-80 bpm and not increasing after bagging with 100% oxygen for 15-30
seconds.

PROCEDURE

 Site: Lower third of the sternum below an imaginary line between the two nipples.

 Depth: Depress the sternum to a depth of 1/2 - 3/4 inch at a rate of 100-120 bpm.

Compressions should be delivered on the lower third of the sternum to a depth of

approximately one-third of the anterior-posterior diameter of the chest. Two techniques have
been described: compression with 2 thumbs with fingers encircling the chest and supporting
the back (the 2 thumb–encircling hands technique) or compression with 2 fingers with a
second hand supporting the back. Because the 2 thumb–encircling hands technique may
generate higher peak systolic and coronary perfusion pressure than the 2-finger technique, the
2 thumb–encircling hands technique is recommended for performing chest compressions in
newly born infants. The 2-finger technique may be preferable when access to the umbilicus is
required during insertion of an umbilical catheter, although it is possible to administer the 2
thumb–encircling hands technique in intubated infants with the rescuer standing at the baby's
head, thus permitting adequate access to the umbilicus.

Compressions and ventilations should be coordinated to avoid simultaneous delivery. The

chest should be permitted to reexpand fully during relaxation, but the rescuer's thumbs should
not leave the chest. There should be a 3:1 ratio of compressions to ventilations with 90
compressions and 30 breaths to achieve approximately 120 events per minute to maximize
ventilation at an achievable rate. Thus each event will be allotted approximately 1/2 second,
with exhalation occurring during the first compression after each ventilation.

There is evidence from animals and non-neonatal studies that sustained compressions or a
compression ratio of 15:2 or even 30:2 may be more effective when the arrest is of primary
cardiac etiology. One study in children suggests that CPR with rescue breathing is preferable
to chest compressions alone when the arrest is of noncardiac etiology. It is recommended that
a 3:1 compression to ventilation ratio be used for neonatal resuscitation where compromise of
ventilation is nearly always the primary cause, but rescuers should consider using higher
ratios (eg, 15:2) if the arrest is believed to be of cardiac origin.

Respiration, heart rate, and oxygenation should be reassessed periodically, and coordinated
chest compressions and ventilations should continue until the spontaneous heart rate is ≥60
per minute. However, frequent interruptions of compressions should be avoided, as they will
compromise artificial maintenance of systemic perfusion and maintenance of coronary blood
flow.

ENDOTRACHEAL INTUBATION

INDICATIONS

 Discontinue when infant can maintain heart rate above 80 by ventilation alone.

 Rate: 100-120 bpm. Coordinate heart compression with ventilation.

1. Heart rate below 60 bpm despite bagging and chest compressions.

2. Presence of meconium in the amniotic fluid.

PROCEDURE

1. Place infant with head lightly extended with a rolled towel under the shoulder.

2. Introduce a laryangoscope over the baby's tongue at the right corner of the mouth.

3. Advance 2-3 cm, while rotating it to the midline, until the epiglottis is seen. Elevation of
the epiglottis by the tip of the laryngoscope reveals the vocal cord.

4. Suction secretions, if needed.

5. Pass the endotracheal tube to a distance of 1.5-2 cm into the trachea, hold it firmly, but
gently place and withdraw the laryngoscope slowly.

6. Attach the endotracheal tube to the adapter on the bag.

7. Ventilate with oxygen by the bag. An assistant should check for adequate ventilation of
both lungs with a stethoscope.

MEDICATIONS

Medications should be administered if, despite adequate ventilation with 100% oxygen and
chest compressions, the heart rate remains at 80 bpm. Medications used are adrenalin (for
hypotonic), sodium bicarbonate (to correct acidosis), volume expanders (for hypovolemia),
and dopamine (for hypotension). Naloxone is given if needed to reverse the effects of
maternal narcotics given in the preceding 3 hours.

USE OF DRUGS

If the baby's response is slow or he remains hypotonic after ventilation is achieved,

consideration will be given to the use of drugs. In specialist obstetric units, pulse oximetry
(see Ch. 39) may be employed to monitor hypoxia and blood obtained through the umbilical
artery or vein to ascertain biochemical status. Results will enable the appropriate
administration of resuscitation drugs, as discussed below.

Naloxone hydrochloride. This is not an emergency drug per se and should be used with
caution and only in specific circumstances. It is a powerful anti-opioid drug used to reverse
the effects of maternal narcotic rugs given in the preceding 3 hours. Ventilation should be
established prior to its use. It must not be given to apnoeic babies. A dose of up to 100
micrograms per kilogram body weight may be administered intramuscularly for prolonged
action. As opioid action may persist for some hours the midwife must be alert for signs of
relapse when a repeat dose may be required. NB, it should not be administered to babies of
narcotic-addicted mothers as this may precipitate acute withdrawal. Policies relating to
dosage and route of administration may vary in different hospitals.

Sodium bicarbonate. This is not recommended for brief periods of cardiopulmonary

resuscitation once tissues are oxygenated by lung inflation with 100% oxygen and cardiac
compression, the acidosis will self-correct unless asphyxia is very severe. If the heart rate is
less than 60 despite effective ventilation, chest compression and two intravenous doses of
adrenaline (epinephrine), then sodium bicarbonate 4.2% solution (0.5 mmol/ml), can be
administered using 2 - 4ml / k * g (1 - 2mmol / k * g) by slow intravenous injection at a rate
of 1ml / m * in order to avoid rapid elevation of serum osmolality with the attendant risk of
intracranial haemorrhage (Drew et al 2000, Howell 1987). It should not be given prior to
ventilation being established. THAM 7% (tris-hydroxymethyl-amino methane), 0.5 mmol/kg
may be used in preference to sodium bicarbonate.

Adrenaline (epinephrine). This is indicated if the heart rate is less than 60 despite 1 minute
of effective ventilation and chest compression. An initial dose of 0.1 - 0.3ml / k * g of 1:10
000 solution (10 - 30mcg / k * g) can be given intravenously; this can be repeated after 3
minutes for a further two doses. The Royal College of Paediatrics and Child Health (1997)
recommends a higher dose of 00mcg / k * gi i.v. if there is no response to the boluses. It is
reasonable to try giving one dose via the endotracheal tube of adrenaline (epinephrine) 0.1
ml/kg of 1:1000 as this sometimes has an immediate effect.

Human albumin 4.5%. This is infrequently needed in practice. If pulmonary haemorrhage

shock persists despite adequate resuscitation then or 4.5% human albumin 10 - 20ml / k * g
as a volume expander should be administered as quickly as possible. Despite the ongoing
controversy over the use of sign of human albumin solution, there is currently insufficient
evidence on which to base the choice between crystalloid and colloid for resuscitation. The
use of human albumin solution in neonates is widespread and based on clinical experience.
Hypoglycaemia is not usually a problem unless resuscitation has been prolonged. A solution
of dextrose 10% 3ml / k * g may be given intravenously to correct a blood sugar of less than
2.5mmol / L

Volume Expansion

Volume expansion should be considered when blood loss is known or suspected (pale skin,
poor perfusion, weak pulse) and the baby's heart rate has not responded adequately to other
resuscitative measures. An isotonic crystalloid solution or blood is recommended for volume
expansion in the delivery room. The recommended dose is 10 mL/kg, which may need to be
repeated. When resuscitating premature infants, care should be taken to avoid giving volume
expanders rapidly, because rapid infusions of large volumes have been associated with
intraventricular hemorrhage.

POSTRESUSCITATION CARE

Babies who require resuscitation are at risk for deterioration after their vital signs have
returned to normal. Once adequate ventilation and circulation have been established, the
infant should be maintained in, or transferred to an environment where close monitoring and
anticipatory care can be provided.

Naloxone

Administration of naloxone is not recommended as part of initial resuscitative efforts in the

delivery room for newborns with respiratory depression. Heart rate and oxygenation should
be restored by supporting ventilation.

Glucose

Newborns with lower blood glucose levels are at increased risk for brain injury and adverse
outcomes after a hypoxic-ischemic insult, although no specific glucose level associated with
worse outcomes has been identified. Increased glucose levels after hypoxia or ischemia were
not associated with adverse effects in a recent pediatric series or in animal studies, and they
may be protective. However, there are no randomized controlled trials that examine this
question. Due to the paucity of data, no specific target glucose concentration range can be
identified at present. Intravenous glucose infusion should be considered as soon as practical
after resuscitation, with the goal of avoiding hypoglycemia.
Induced Therapeutic Hypothermia

Several randomized controlled multicenter trials of induced hypothermia (33.5°C to 34.5°C)

of newborns ≥36 weeks gestational age, with moderate to severe hypoxic-ischemic
encephalopathy as defined by strict criteria, showed that those babies who were cooled had
significantly lower mortality and less neurodevelopmental disability at 18-month follow-up
than babies who were not cooled.96–98 The randomized trials produced similar results using
different methods of cooling (selective head versus systemic).96–100 It is recommended that
infants born at ≥36 weeks gestation with evolving moderate to severe hypoxic-ischemic
encephalopathy should be offered therapeutic hypothermia. The treatment should be
implemented according to the studied protocols, which currently include commencement
within 6 hours following birth, continuation for 72 hours, and slow rewarming over at least 4
hours. Therapeutic hypothermia should be administered under clearly defined protocols
similar to those used in published clinical trials and in facilities with the capabilities for
multidisciplinary care and longitudinal follow-up (Class IIa, LOE A). Studies suggest that
there may be some associated adverse effects, such as thrombocytopenia and increased need
for inotropic support.

Guidelines for Withholding and Discontinuing Resuscitation

For neonates at the margins of viability or those with conditions that predict a high risk of
mortality or morbidity, attitudes and practice vary according to region and availability of
resources. Studies indicate that parents desire a larger role in decisions to initiate resuscitation
and continue life support of severely compromised newborns. Opinions among neonatal
providers vary widely regarding the benefits and disadvantages of aggressive therapies in
such newborns.

Withholding Resuscitation

It is possible to identify conditions associated with high mortality and poor outcome in which
withholding resuscitative efforts may be considered reasonable, particularly when there has
been the opportunity for a parental agreement.

A consistent and coordinated approach to individual cases by the obstetric and neonatal teams
and the parents is an important goal. Non initiation of resuscitation and discontinuation of
life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians
should not hesitate to withdraw support when functional survival is highly unlikely. The
following guidelines must be interpreted according to current regional outcomes:

 When gestation, birth weight, or congenital anomalies are associated with almost
certain early death and when unacceptably high morbidity is likely among the rare
survivors, resuscitation is not indicated. Examples include extreme prematurity
(gestational age <23 weeks or birth weight <400 g), anencephaly, and some major
chromosomal abnormalities, such as trisomy 13.
  In conditions associated with a high rate of survival and acceptable morbidity,
resuscitation is nearly always indicated. This will generally include babies with
gestational age ≥25 weeks and those with most congenital malformations.
 In conditions associated with uncertain prognosis in which survival is borderline, the
morbidity rate is relatively high, and the anticipated burden to the child is high,
parental desires concerning the initiation of resuscitation should be supported.

Assessment of morbidity and mortality risks should take into consideration available data,
and maybe be augmented by the use of published tools based on data from specific
populations. Decisions should also take into account changes in medical practice that may
occur over time.

Discontinuing Resuscitative Efforts

In a newly born baby with no detectable heart rate, it is appropriate to consider stopping
resuscitation if the heart rate remains undetectable for 10 minutes. The decision to continue
resuscitation efforts beyond 10 minutes with no heart rate should take into consideration
factors such as the presumed etiology of the arrest, the gestation of the baby, the presence or
absence of complications, the potential role of therapeutic hypothermia, and the parents'
previously expressed feelings about the acceptable risk of morbidity.
INTIATION OF FEEDING
BREASTS AND LACTATION

The breasts are secreting glands, composed of 15-24 lobes, separated from one another by
fatty tissue. These lobes are divided into lobules, each lobule containing a certain number of
alveoli and ducts. The alveoli contain acini cell, which produce milk and are surrounded by
myoepithelial cells, which propel the milk out into small ducts. These ducts connect with
larger ones called lactiferous ducts. One large duct leaves each lobe and widens to form a
lactiferous sinus or ampulla which acts as a temporary reservoir for milk. A lactiferous tubule
from each sinus opens on the surface of the nipple.

The nipple which is composed of erectile tissue is covered with epithelium contains plain
muscle fibers and have sphincter-like action in controlling the flow of milk. Surrounding the
nipple is an area of pigmented skin called areola, which contains the Montgomery's glands.
These produce a sebum-like substance, which acts as a lubricant during pregnancy and
throughout breastfeeding. Breasts, nipples and areolae are varying considerably in size from
one woman to another.

The mechanism of milk production and ejection, called let-down, is determined hormonally.
During pregnancy, estrogens and progesterone induce alveolar and ductal growth as well as
stimulate the secretion of colostrum. Other hormones are also involved and they govern a
complex sequence of events, which prepare the breasts for lactation. The production of milk
is held in abeyance until after delivery, when the levels of placental hormones fall.
Immediately after the delivery of the placenta, these hormones diminish, thereby activating
the anterior lobe of the pituitary to release prolactin which acts on the acini cells stimulating
them to produce milk. This process which takes from 2 to 4 days, is enhanced by the sucking
stimulus of the baby.

Prolactin is more important to the initiation of lactation than to its continuation. As lactation
progresses, the prolactin response to suckling diminishes and milk removal (by the baby
feeding or breast expression) becomes the driving force behind milk production. Oxytocin
causes contraction of the myoepithelial cells as well as the uterine myometrial cells. In the
early days of lactation, the let-down or milk ejection reflex is unconditioned and therefore
likely to be inhibited by emotions. Later, it becomes a conditioned reflex responding to the
baby's cry or other circumstances associated with the baby or feeding. Negative emotions
such as fear, anger, anxiety and embarrassment as well as the presence of pain may inhibit the
let-down reflex.

PROPERTIES AND COMPONENTS OF BREAST MILK

Breast milk is bluish-white in colour and appears to be very watery. It is high in both lactose
and fat, but low in protein and phosphate. The composition is reversed in its precursor,
colostrum, which is normally found in the alveoli during the later phase of pregnancy.
Colostrum, a yellowish fluid, which is high in antibodies, is an excellent food for the baby
during 2-3 days before the milk comes in.

Fat

Fat in breast milk provides the baby with more than 50% of caloric requirements. The fat
content is lowest in the morning and highest in the afternoon, and the proportion increases
during the course of the feed. It is utilized very rapidly due to the action of the enzyme lipase
which is present in the milk.

Lactose

Lactose in breast milk is converted into galactose and glucose by the action of the enzyme
lactase, and these sugars provide energy to the rapidly growing brain. Lactose enhances the
absorption of calcium and promotes the growth of lactobacilli which increases intestinal
acidity.

Protein

Protein in breast milk is much less compared to any other mammalian milk, which makes it
thinner. Breast milk is whey dominant and forms soft, flocculent curds when acidified in the
stomach. This provides a continuous flow of nutrients to the baby. Colostrum contains nearly
three times the amount of protein that is present in mature milk and contains all amino acids.
It also contains secretory immunoglobulin A(IgA) and lactoferrin.

Fat-soluble Vitamins

Mature breast milk contains vitamin A, D, E, and K. For blood clotting factors vitamin K is
essential and the baby's gut flora synthesizes adequate amounts only after 2 weeks of birth.
All babies are given vitamin K soon after birth to meet the need until the colonization of the
gut occurs.

Water-soluble Vitamins

All of the B vitamins are present at levels necessary for daily requirements. Vitamin C which
is required for collagen synthesis is also present in adequate quantity if the mother eats a
good diet.

Minerals and Trace Elements

Although the amounts of iron are less than those found in formula, the bioavailability of iron
found in breast milk is very much higher; 70% of the iron found in breast milk is absorbed,
whereas only 10% is absorbed from formula. Babies who are fed on fresh cow^ prime s milk
or formula need iron supplements to prevent anemia. Preterm babies do not have good iron
stores and may need supplementation with oral iron. Breast milk contains zinc, calcium,
phosphorus, sodium, and potassium in quantities lesser than in formula. However, the higher
bioavailability of these minerals and trace elements ensures that the infant's needs are met.

Anti-infective Factors

Breast milk has the following anti-infective agents which are protective for the newborn:

1. Leukocytes (macrophages and neutrophils) that surround and destroy harmful bacteria by
their phagocytic activity.

2. Secretory IgA and interferon produced by lymphocytes in breast milk,

3. Immunoglobulin IgA, IgG, IgM, and IgD are all found in breast milk. It 'paints' the
intestinal epithelium and protects the mucosal surface against entry of pathogenic bacteria
and enteroviruses. of

4. Lysozyme, a general anti-infective agent.

5. Lactoferrin prevents pathogenic Escherichia coli from obtaining the iron which they need
for survival.

6. The Bifidus factor promotes the growth of gram-positive bacilli in the gut flora particularly,
Lactobacillus Bifidus, which discourages the multiplication of pathogens.

INITIATION OF BREASTFEEDING

Early initiation of breastfeeding for the normal newborn

 Increases duration of breastfeeding

 Allows skin-to-skin contact for warmth and colonization of baby with maternal
organisms
 Provides colostrum as the baby’s first immunization
 Takes advantage of the first hour of alertness
 Babies learn to suckle more effectively
 Improved developmental outcomes
 Keep mother and baby together
 Place baby on mother’s chest
 Let baby start suckling when ready
 Do not hurry or interrupt the process
 Delay non-urgent medical routines for at least one hour
Antenatal Preparation

The majority of women decide when they conceive that they want to breastfeed their babies.
Some may not make a decision early. However, it is important to teach all pregnant women
about the benefits of breastfeeding. Preparation for breastfeeding must begin when pregnancy
starts altering the breasts and nipples. A comfortable brassiere that does not compress the
breast may be worn to support the increasing weight. Daily cleansing with water and a soft
clean cloth followed by careful drying must be done. If nipples are inverted or flat, the
procedure of nipple rolling must be explained to the mother. With a lightly lubricated thumb
and index finger, the mother will need to roll the nipple of each breast for approximately 30
seconds every day in the 9th month. If the mother understands how the milk is produced and
how much her baby will be benefited from breastfeeding, she may well succeed in feeding
her baby.

Commencement of Breastfeeding

The first feed is a profoundly important experience for the mother and her baby. Unless
individual circumstances indicate otherwise, the mother should have her baby with her
immediately after delivery and breastfeeding should begin as soon as possible. The time of
the first feed depends largely on the needs of the baby. Some babies demonstrate a need to
feed almost as soon as they are born. Other babies show no interest until they are an hour or
so old.

Whenever the first feed takes place, the quality of that experience is of utmost importance for
the mother and baby. The early feedings might best consist of approximately 5-10 minutes of
suckling on each breast, while the nipples are accustomed to it. This frequent suckling
stimulates the production and let-down of lactation and reduces the potential severity of
engorgement. Therefore, it is essential that there be no missed feedings, including those at
night.

Preparation and Position of the Mother

The mother should be prepared for each feeding. She should be:

1. In a comfortable position, this means any position that is comfortable for her and allows
for proper positioning of her baby. This can be accomplished in a side-lying, reclining, or
sitting position. Generous use of pillows for support and comfort is most useful.

2. Without discomfort or pain. Her bladder should be empty. Any pain such as afterbirth
pains, episiotomy, or laceration repair pain should have received comfort measures prior to
breastfeeding time.
3. Rested and relaxed.

4. Assured of available help as necessary.

5. Her hands should be washed and her nipples cleaned with plain water.

Preparation and Position of the Baby

The baby's immediate preparation for breastfeeding is to have a clean, dry diaper and if
necessary, to be swaddle wrapped. Swaddle wrapping when properly done, may be
comforting rather than confining to babies because they feel held close and secure rather than
bound. The wrapping is to be loose enough for freedom of movement of the legs. What has to
be achieved in the control of waving arms. For new mothers who will need this initially, it
will be just a few feedings before they can cope without swaddle wrapping their baby.

Position the baby so that he/she will not be doubled up or have a twisted neck when sucking
and that the head and body are supported. In bringing the baby and breast together, the
following are helpful:

1. Let the baby find the breast and grasp the nipple. Do not thrust the breast in the baby's face,
as this is frightening to the baby.

2. Help the mother learn to hold her breast in such a way as to guide and control the breast
and facilitate the baby's grasping of it.

3. Touch the baby's cheek with the nipple so the baby will turn towards the breast (use of the
rooting reflex).

4. Express a few drops of colostrum/milk so they are on the surface of the nipple. This
provides the baby with instant gratification and reinforcement.

5. As the baby grasps the nipple, the mother must make sure that the infant has enough of it
for proper positioning in the mouth. The baby must grasp more than just the end of the
mother's nipple. The baby must compress the lactiferous sinuses located beneath the areola
with the gums when sucking in order to obtain colostrum or milk. The sequence of
movements of compression, sucking, and swallowing is rhythmic and the mother can feel a
steady pull.

6. Once the baby's mouth is properly positioned well onto the areola, the mother releases her
breast. She now provides breathing space for the baby, grasp if needed by pressing with a
finger on her breast whereof the baby's nose is. This may be needed during the learning
period only.

Helping the Mother to Begin

During the early days of nursing, the mother should be instructed not to feed too long at any
one feeding, as her nipples will become sore. It is recommended that the nurse from 3 to 5
minutes at every feeding during the 1st day, from 5 to 7 minutes during the 2nd day, and from
7 to 10 minutes during the 3rd day. In a week, she should be able to nurse for 10-20 minutes
on each side (the time it will probably take to empty it).

If the infant is crying hard when she wants to start breastfeeding, she should first calm the
baby by holding them firmly and closely, and by talking gently to him/her An upset baby
who is put to the breast does not realize the nipple is in the mouth and will continue to cry
loudly which may upset the mother and frustrate the baby. Once the baby is calm, he will be
able to grasp the nipple and begin sucking.

The mother should nurse from both breasts at each feeding, alternating the side on which she
begins. A suggestion to help the mother remember which side to start on at the next feeding is
to have her put a safety pin in the bra strap on the side on which she will begin to nurse the
next time. The baby should nurse on both sides because he sucks hardest on the first side and
gets about 90% of the milk in that breast during the first 5-10 minutes of nursing. Using both
breasts provides the necessary stimulus to keep up a sufficient amount of milk production in
the breasts. This is especially important during the early weeks of nursing.

Feeding Behaviours

Babies usually will suck a bit; rest a bit (maintaining their hold on the nipple, while they rest)
and then suck some more. Some babies go to sleep once they get little food in their stomachs
and feel warm and comfortable next to their mother. The mother should be prepared for this,
so she does not get upset. She can loosen the blankets around the baby so that he is not quite
so warm and drowsy during feeding. If this does not work, she may try any of the following-
rub the soles of the baby's feet, stroke the abdomen or change the position. The mother
should also be prepared for the strong uterine contraction; she will feel when the baby first
latches on to her breast.

Suction must be broken before trying to remove the baby from the breast. Pulling the baby
off causes injury to the nipple. Suction is broken by slipping a finger into the corner of the
baby's gums. Once the suction is broken, the baby is easily removed from the breast without
injury to the nipple. The baby is then burped and put on the other breast.

Lactation is established and maintained by a combination of the following:

 Start breastfeeding as soon as possible after delivery. Frequent feedings during the
first few days using both breasts. No missed feedings or supplementary feedings

 Rotation of breasts as the starting and ending breasts to provide for complete
emptying of both breasts. Rested, relaxed and pain-free mother during feeding times.
  Baby properly positioned on the breast.

 The baby's neck should be slightly extended and the chin should be in contact with the
breast. A generous portion of the areola should be taken in by the lower jaw.

Timing and Frequency of Feeding

It is usually on the 1st or 2nd day for the baby to have 6–8 hours gaps between good feeds.
This is normal and provides an excellent opportunity for the mother to rest. As the milk
volume increases, the feeds become more frequent and a little shorter. After the first few days,
the baby will settle into his / her individual pattern of feeding frequency. This is described as
'self-demand feeding' or 'baby-led feeding' (i.e. feeding the baby when he /she is hungry). It is
unusual for a healthy baby to feed less often than six times in 24 hours from the 3rd day. If he
demands fewer feeds, the reasons should be investigated. Individual mother-baby pairs
develop their own unique pattern of feeding and providing the baby is thriving, there is no
need to change it.

CARE OF THE BREASTS

1. Daily washing is necessary for breast hygiene. Normal skin flora is beneficial to the baby.
Using soap, alcohol or other drying agents can lead quickly to cracking of the nipples.
Providing good support to breasts is important to avoid discomfort.

2. If the breasts become engorged, apply warmth to the breasts, prior to each breastfeeding, to
promote milk flow. This can be accomplished with warm washcloths or warm showers.

3. If there is areolar enlargement; manual expression of the milk to soften the area prior to
nursing the baby will help the baby latch on to the nipple properly and easily.

4. Use manual expression of milk to empty the breasts after the baby has been nursed if they
are still uncomfortably full and engorged after the feeding.

5. Ice bags may be applied to breasts between feedings to reduce swelling and pain.

6. If the nipples become tender:

a. Nurse on the less sore nipple first until there is let down, then switch the baby to the
sore nipple to empty that breast and meet the baby's sucking needs.

b. Use a pacifier rather than the end of feedings on the nipples to meet the baby's
sucking needs until the nipples are not sore.

c. Breastfeed more frequently for shorter periods.

 d. Be sure the baby is properly positioned on the breast and change the baby's position
which will change the precise pressure points on the nipple. For example, shifting
from an arm hold to a football hold.

7. Be sure to use a combination of exposure (of the breasts) to both air and heat after each
breastfeeding, followed by the application of nipple cream. Be sure to break the suction
before removing the baby from the breast.

BENEFITS OF BREASTFEEDING TO THE MOTHER

There are well-known and documented physiological benefits to the breastfeeding mother: 1.
Studies conducted on women of various cultures have shown that women who breastfeed
have a markedly decreased chance of developing breast cancer.

2. The incidence of thrombophlebitis is lower in breastfeeding mothers.

3. Postpartum uterine involution is more rapid in mothers who breastfeed. Therefore, delayed
postpartum hemorrhage is also less common.

4. Lactation has been shown to suppress ovulation for about 75 days postpartum in almost
100% of women who do not supplement their infants with a bottle. Thus, breastfeeding for a
short time is a preferred contraceptive.

To the Baby

1. Breast milk is of ideal composition for easy digestion with a low osmotic load.

2. Colostrum and breast milk provide antibody protection (passive immunity) against several
types of viruses.

3. Breastfed babies show a marked decrease in respiratory infections and gastroenteritis.

Lysozyme, an enzyme present in breast milk destroys invasive organisms, especially E. coli.
Additional resistance to the gut from invading organisms is given by lactoferrin and Bifidus
factor and secretory IgA contained in breast milk.

4. Allergic disorders, such as infantile eczema, asthma, and hay fever are much less common
in breastfed babies.

5. Since the weight gain of a breastfed baby is less than that of a bottle-fed one, obesity is less
common.

6. Breastfeeding offers a psychological benefit by establishing a healthy mother-baby

relationship.
7. Breast milk is readily available for the baby at the right temperature.

The volume of the Feed

Well-grown infants are born with good glycogen reserve and high levels of antidiuretic
hormone. Consequently, they do not need large volumes of milk or colostrum any sooner
than they are made available physiologically. In the first 24 hours, the baby takes an average
of 5 mL per feed; in the second 24 hours, this increases to 14 mL per feed. The average
requirement of milk is about 100mL / kg / 24 h on the 3rd day and is increased to over line
150 r kg / 24 h by the 10th day.

The indications of expressing breast milk are

(i) Where the baby is separated from the mother due to prematurity or illness.
(ii) Where there are difficulties in breastfeeding as in attaching the baby to the breast,
e.g. cleft palate.
(iii) When the mother is separated from the baby because of work.
(iv) Colostrum should always be expressed and given to the babies.

Methods of milk expression :

(a) Manual expression is advantageous over mechanical pumping. It increases the level of
prolactin which helps to maintain lactation for a longer period. It can be practiced anywhere
and costs nothing.

(b) Breast pumps may be electrical or manually controlled.

METHODS OF ESTABLISHMENT OF LACTATION:

The following methods may be employed with varying success to establish lactation after it
has been temporarily withheld.

For the baby:

(1) To discontinue bottle feedings.

(2) To put the baby to the breast at frequent intervals.
(3) Baby should suck in a well-attached manner.

For the mothers :

(1) To encourage plenty of fluid and milk intake

(2) Drugs like metoclopramide or oxytocin (nasal spray) are of help.
DIFFICULTIES IN BREASTFEEDING AND MANAGEMENT

At times, breastfeeding causes some problems.

Difficulties due to Mother

Inadequate supply of milk: The mother who says she does not have enough milk for her
baby probably is not nursing often enough. The nurse should instruct the mother that the
oftener the baby nurses, the more milk she will have. The milk supply is directly related to
the frequency of nursing the more often the baby nurses, the more milk is produced.

A baby who will not suck: An infant who refuses to suck at the breast or who thrusts the
tongue toward the roof of the mouth presents a special problem. These babies will usually
suck beautifully from a bottle nipple and therefore it is important not to supplement them
with an artificial nipple. Expressed milk may be given by spoon or eyedropper. Milk can be
dribbled down over the breast into the baby's mouth which might help the baby to begin
sucking from the breast.

Breast ailments such as engorgement of the breast cracked nipple, depressed nipple,
and mastitis: For mastitis, she should consult the physician. Once treatment has begun, she
will be able to nurse the baby.

Anxiety and stress: Anxiety, upset or emotional trauma influences milk ejection; therefore a
mother who is not able to relax prior to nursing may find that her milk will not let down. If
possible, she should be encouraged to lie down, while nursing and concentrate on relaxing
her baby. If lying down is not possible, she could sit down, put her feet up, and perhaps read
something. Her goal must be gearing her thoughts toward something other than the cause of
the upset.

Blistered nipple: A blistered nipple is usually an indication of improper sucking by the baby.
It most often is caused by the infant grasping only the nipple and not the areolar area. These
blisters may bleed when they are broken. Ultraviolet light and resting the nipple for 24-48
hours are preferred methods of treatment.

Poor attachment of breast: It leads to quick, shallow sucks instead of slow and deep. Areola
remains outside the mouth. This causes nipple pain. Assistance and instructions from the
midwife can improve the technique of breastfeeding. Proper placement of the nipple is on top
of the baby's tongue with as much of the areolar space as possible in the mouth.

Short nipples: As the baby has to form a teat from both the breast and nipple, short nipples
can cause problems and the mother should be reassured of this.
Abnormally large nipples: If the baby is small, his/her mouth may not be able to get beyond
the nipple and onto the breast. Lactation could be initiated by expressing the milk. As the
baby grows and the breast and nipple become more protractile, breastfeeding may become
possible.

Inverted and flat nipples: Many babies are able to attach to the breast, even if the nipple is
considered unfavourable. In difficult cases, it may be necessary to initiate lactation by
expressing and delaying attempting to attach the baby to the breast until lactation is
established and the breasts have become soft and the breast tissue more protractile.

Difficulties due to Baby

Low birth weight baby: The baby is too small or too feeble to suck. Tube feeding of
expressed milk and artificial feeding is given until the baby becomes able to suck from the
breasts. Temporary illness: Such as cerebral irritation, respiratory tract infection and nasal
obstruction due to congestion, and lethargy due to jaundice or oral thrush may all lead to
improper suckling. Due to a lack of proper nipple stimulation and improper emptying, the
milk may dry up. This must be recognized early and prevented.

Over distention of the stomach with swallowed air: The problem can be prevented by
burping the baby several times during feeding.

Cleft palate: The baby is unable to form a vacuum and thus form a teat out of the breast and
nipple. Feeding expressed milk using a special teat device can be done until the baby has had
a surgical repair. Feeding with a spoon can be another method.

CONTRAINDICATIONS TO BREASTFEEDING

1. Drugs used for cancer, certain hormones, and radioactive isotopes. When the mother uses
any of these, breastfeeding should be suspended.

2. The human immunodeficiency virus (HIV) infection may be transmitted in breast milk. In
cases where artificial feeding is difficult, the mother may be counseled as regards the risks
and benefits and helped to make an informed choice.

3. Chronic medical illness, such as decompensated organic heart lesion and pulmonary
tuberculosis.

4. Puerperal psychosis.

5. Women receiving high doses of antiepileptic, anticoagulant, and antithyroid drugs.

6. Breastfeeding may be suspended when the mother is treated with metronidazole and
chloramphenicol.
Underfeeding and Overfeeding

Normal progress of feeding is evidenced by:

1. General condition-happy baby sleeps between feeds and at night, does not vomit and
passes urine at least six times in 24 hours.

2. Vigour which is manifested by movements of the and cry.

3. Expected level of weight gain.

Features of Underfeeding

Failure of the infant to gain weight as per schedule evidenced from the weight curve
Dissatisfied baby evidenced by cry in between feeds and at night
Constipation
Scanty, high-colored urine.

BABY FRIENDLY HOSPITAL INITIATIVE: In 1992, United Nations Children's Fund

(UNICEF) and World Health Organisation (WHO) launched the baby-friendly initiative
among doctors, nurses, health workers, and parents, in hospitals and maternity centers to
promote, protect and support breastfeeding. The object is to re-establish the superiority of
breastfeeding in order to protect the newborn's health by becoming baby-friendly. To fulfill
the initiative UNICEF and WHO laid down ten steps to creating a baby-friendly environment.

These are

(i) There must be a written breastfeeding policy.

(ii) All health care staff must be trained to implement this policy. way of holding the
baby
(iii) All pregnant women must be informed about the benefits of breastfeeding.
(iv) Mothers should be helped to initiate breastfeeding within half an hour of birth.
(v) Mothers are shown the best way to breastfeed.
(vi) Unless medically indicated, the newborn should be given no food or drink other
than breast milk.
(vii) To practice 'rooming in by allowing mothers and babies to remain together 24
hours a day.
(viii) To encourage demand for breastfeeding. (ix) No artificial teats to babies should be
given.
(ix) Breastfeeding support groups are established and mothers are referred to them on
discharge.
A baby-friendly hospital should also provide other preventive health care e.g. infant
immunization, rehydration salts against diarrhoeal dehydration, and child's growth and
development surveillance.
CONCLUSION

Effective management of the breastfeeding mother and infant requires that caregivers are
knowledgeable about the benefits, as well as the basic anatomic and physiologic aspects, of
breast feeding. Caregivers also need to know how to assist the mother with feedings and
interventions for common problems. Ongoing support of the mother enhances her self-
confidence and promotes a satisfying and successful breastfeeding experience. During the
time in the hospital the mother is encouraged to view each breastfeeding session as a "feeding
lesson" or "prac tice session" that will foster her self-confidence and promote a satisfying
experience for herself and her infant.

Theory of Caring

“Caring is a nurturing way of relating to a valued other toward whom one feels a
personal sense of commitment and responsibility.” (Swanson, 1991, p. 162)
MAJOR CONCEPTS & DEFINITIONS
CARING
Caring is a nurturing way of relating to a valued other toward whom one feels a personal
sense of commitment and responsibility (Swanson, 1991).
KNOWING
Knowing is striving to understand the meaning of an event in the life of the other, avoiding
assumptions, focusing on the person cared for, seeking cues, assessing meticulously, and
engaging both the one caring and the one cared for in the process of knowing (Swanson,
1991).
BEING WITH
Being with means being emotionally present to the other. It includes being there in person,
conveying availability, and sharing feelings without burdening the one cared for (Swanson,
1991).
DOING FOR
Doing for means to do for others what one would do for self if at all possible, including
anticipating needs, comforting, performing skillfully and competently, and protecting the one
cared for while preserving his or her dignity (Swanson, 1991).
ENABLING
Enabling is facilitating the other’s passage through life transitions and unfamiliar events by
focusing on the event, informing, explaining, supporting, validating feelings, generating
alternatives, thinking things through, and giving feedback (Swanson, 1991).
MAINTAINING BELIEF
Maintaining belief is sustaining faith in the other’s capacity to get through an event or
transition and face a future with meaning, believing in other’s capacity and holding him or
her in high esteem, maintaining a hope-filled attitude, offering realistic optimism, helping to
find meaning, and standing by the one cared for no matter what the situation (Swanson, 1991).

MAJOR ASSUMPTIONS
In 1993, Swanson further developed her theory of informed caring by making explicit her
major assumptions about the four main phenomena of concern to the nursing discipline:
nursing, person/client, health, and environment.

Nursing
Swanson defines nursing as informed caring for the well-being of others. She asserts that the
nursing discipline is informed by empirical knowledge from nursing and other related
disciplines, as well as “ethical, personal and aesthetic knowledge derived from the humanities,
clinical experience, and personal and societal values and expectations”.

Person
Swanson (1993) defines persons as “unique beings who are in the midst of becoming and
whose wholeness is made manifest in thoughts, feelings, and behaviors”. She posits that the
life experiences of each individual are influenced by a complex interplay of “a genetic
heritage, spiritual endowment and the capacity to exercise free will”. Hence, persons both
shape and are shaped by the environment in which they live.

r
Neonatal Resuscitation in the Delivery Room from a Tertiary Level
Hospital: Risk Factors and Outcome

Abstract

Objective

Timely identification and prompt resuscitation of newborns in the delivery room may cause a
decline in neonatal morbidity and mortality. We try to identify risk factors in mother and
fetus that result in birth of newborns needing resuscitation at birth.

Methods

Case notes of all deliveries and neonates born from April 2010 to March 2011 in Mahdieh
Medical Center (Tehran, Iran), a Level III Neonatal Intensive Care Unit, were reviewed;
relevant maternal, fetal and perinatal data was extracted and analyzed.

Findings

During the study period, 4692 neonates were delivered; 4522 (97.7%) did not require
respiratory assistance. One-hundred seven (2.3%) newborns needed resuscitation with bag
and mask ventilation in the delivery unit, of whom 77 (1.6%) babies responded to bag and
mask ventilation while 30 (0.65%) neonates needed endotracheal intubation and 15 (0.3%)
were given chest compressions. Epinephrine/volume expander was administered to 10 (0.2%)
newborns. In 17 patients resuscitation was continued for >10 mins. There was a positive
correlation between the need for resuscitation and following risk factors: low birth weight,
preterm labor, chorioamnionitis, pre-eclampsia, prolonged rupture of membranes, abruptio
placentae, prolonged labor, meconium staining of amniotic fluid, multiple pregnancy and
fetal distress. On multiple regression; low birth weight, meconium stained liquor and
chorioamnionitis revealed as independent risk factors that made endotracheal intubation
necessary.

Conclusion

Accurate identification of risk factors and anticipation at the birth of a high-risk neonate
would result in adequate preparation and prompt resuscitation of neonates who need some
level of intervention and thus, reducing neonatal morbidity and mortality.

Bibliography :
 Myles. Textbook for Midwives. 16th edition. 2016. Elsevier Publishers. Pg.:515,709.
 Annamma J.A. Comprehensive textbook of Midwifery.2nd edition. Jaypee Brothers
Medical Publishers. Pg.:120-121
 Pillitteri, A. Maternal and child health nursing. Philadelphia Lippincott Williams and
Wilkins.6TH edition. 2016. Pg. no: 390-404
 Lowdermilk, D.L., &Perry, S.E. Maternity & women’s health care. Missouri: Mosby
Elsevier. 9th Edition. 2007. Pg. no: 245-260.
 Dutta, D.C. Textbook of Obstetrics. Kolkata, India: New Central Book Agency. 6th
edition.2007.Pg no:345-450
 Fraser, D.M., & Cooper, M.A., (Eds.). Myles Textbook for midwives. New York:
Churchill Livingstone.15th edition. 2005. Pg. no: 520-546

Journal reference:

 Afjeh SA, Sabzehei MK, Esmaili F. Neonatal resuscitation in the delivery room from
a tertiary level hospital: risk factors and outcome. Iran J Pediatr. 2013;23(6):675-680