Infant Resuscitation

VIRGINIA APGAR"

Columhia University College of Physicians and
Surgeons, New York

APPROXIMATELY 6 per cent of the infants
born at Sloane Hospital for Women in New
York have severe respiratory depression at
birth. To treat these babies successfully, every-
one in the delivery room should be familiar
with sound principles of resuscitation. "Every-
one" includes the obstetrician, the anesthesiolo-
gist, the pediatrician, the medical students and
the obstetric nurses, both graduate and under-
graduate. The task of resuscitation should not
be assigned to one of these persons or groups.
The infant does not "belong" to the obstetri-
cian, the pediatrician or the anesthesiologist.
The most experienced available person should
manage the severe depression promptly; no-
where is the success of teamwork more evi-
dent than in the delivery room.

1. Free Airway
At the moment of birth, consideration is
given to maintaining a free airway. The in-

`Profnsor of Anesthesiology, Columbia University College of Physi.
Cim. and Surgeons. New York, New York.
Pr-nted before the fortieth annual Assembly of the Interstate Post-
Iradurte Medical Association at Milwaukee.

fant's head always should be lower than the
trunk during delivery and until the pharynx
has been examined and aspirated.' Gravity is
a more important aid than any mechanical
device. After prompt division of the cord be-
tween clamps, the infant, still in the head-
down position, is placed in a bassinet with the
head lowered. If the first inspiration consists
of pharyngeal material rather than air, a strong
basis is laid for development of secondary ate-
lectasis, pneumonia and death in the first 48
hours. Mouth suction or electric suction (with
a rubber catheter and trap) is used to empty
the pharynx as long as any material remains
in it. Prolonged suctioning is harmful both
because of the marked bradycardia produced
and because of removal of oxygen from the
pharynx. After the pharynx is empty, almost
all infants can be made to cough or sneeze
(inspire deeply as well) by placing the end
of the catheter just inside the nostril. After
such a cough or sneeze the pharynx should be
suctioned briefly again.
Amniotic fluid and its contents normally fill
the tracheobronchial tree before birth, and al-

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though the fluid is easily absorbed by the pul-
monary circulation, and the foreign debris
moved upward by ciliary action, the volume
which the infant must handle is less if he can
expel some by coughing.
Usually, infants do not require further at-
tention. One group' believes that leaving the
stomach empty has a favorable effect in pre-
venting the later development of pulmonary
complications, but we have not found such a
relation as yet.
If artificial ventilation is necessary because
of persistent apnea, it is essential to keep the
tongue from acting as an obstruction in the
pharynx. The tongue of a limp child lying on
his back falls backward against the bodies of
the cervical spine and obstructs the passage
of air from either the nose or mouth. A small
plastic pharyngeal airway placed between the
tongue and palate corrects this obstruction im-
mediately and always should be inserted if
some type of positive pressure breathing is
planned. If the infant has enough tone to keep
his tongue forward in his mouth, he does not
need the artificial ventilation.
When inflation of the lungs does not pro-
duce a slight rise of the upper chest, some ob-
struction still is present. One should rule out
choana1 atresia by slipping the catheter into
the nasopharynx; this rare anomaly necessi-
tates tracheostomy. More often the obstruc-
tion is at the larynx, and direct laryngoscopy
is immediately indicated if efforts at ventila-
tion do not improve the child's condition after
two to three breaths. We have encountered
both blood clots and vernix caseosa as the
cause of obstruction, and these were removed
easily by direct suctioning. If a complete la-
ryngeal web is seen, immediate tracheostomy
is indicated.

2. Ventilation

The best ventilation is accomplished by the
infant himself, and very few babies need any
mechanical assistance. After making sure the
pharynx is empty, a brisk slap on the soles of
the feet will bring about sharp inspiration and
precipitate crying. Obviously, a child deeply
depressed and in shock is not so stimulated.
If respirations are very inadequate or absent,

some type of IPPB (intermittent positive pres-
sure breathing) should be applied. Numerous
mechanical devices are available for this pur-
pose, or mouth-to-mouth inflation is always
available and does not get out of order. The
principle of application is a short, sharp
"puff." Better results and less lung damage
are produced by one or two such puffs than
by a low pressure application of several sec-
onds' duration.
The best gas to use is oxygen-enriched air.
We know that excessive exposure to 100 per
cent oxygen produces secondary atelectasis,
pulmonary hemorrhage and retrolental fibro-
plasia in premature infants. It is doubtful
whether a few seconds' use of 100 per cent
oxygen in the delivery room will be followed
by such complications, but this procedure will
be discontinued when a practical method of
applying positive pressure with a mixture of
air and oxygen has been developed.
If application of positive pressure using a
face mask does not bring improvement in two
to three breaths, direct laryngoscopy and in-
sertion of a flanged endotracheal tube are in-
dicated. The flange prevents the tube from be-
ing inserted below the carina and allows a
snug fit at the cords. The endotracheal route
is the most efficient and direct in ventilating
lungs, and the entire delivery room personnel
should take all opportunities to practice in-
tubation in warm, dead infants.

3. Position

The head-down position from the moment
of birth already has been stressed. There is
much current discussion of the proper posi-
tion of the infant in relation to the placenta
before the cord is clamped. Since no com-
petent valves function in the umbilical cord,
blood volume easily can be shifted to the in-
fant or to the placenta. In the case of a sensi-
tized Rh infant it is recommended that the
baby be held above the level of the placenta
for .5 to 10 seconds before clamping the cord.
thus lessening the likelihood of hypervolemia
after exchange transfusion. We feel strongly
that premature infants should not be held be-
low the level of the placenta, for a large in-
crease in blood volume will result. We believe

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SIGN 0

-

Heart rate
Respiratory effort

Absent

. Absent

\Iuscle tone Limp
Response to catheter in nostril        No response
Color Blue
                          Pale

(tested after oropharynx is clear)

1

~~~~ ~

Slow

Slow
Irregular
Some flexion of extremities

Grimace
Body pink
Extremities blue

2

Over 100

Good
Crying

Active motion

Cough or sneeze
Completely pink

at present that this hypervolemia is related
to the high incidence of hyaline membrane in
premature infants. The best "routine" posi-
tion is level with the placenta. The cord should
be clamped promptly to allow immediate at-
tention to the airway. After respiration is es-
tablished, a head-up position will provide a
larger thoracic cage for the expanding lungs,
since the weight of the viscera lowers the dia-
phragm. At present, we feel this position is
desirable.

4. Temperature

The time-honored habit of keeping babies
warm at all times is undergoing investigation.
Cooler temperatures reduce tissue metabolism
considerably, and warm ones raise it. Theo-
retically, cooling would be of aid to small, sick
infants with respiratory insufficiency. There
are few data regarding the normal behavior of
the temperature after birth. The full-term in-
fant's temperature drops 2 to 3" F., whereas
the premature infant's may drop 4 to 8" F.
and remain at that level for one or two weeks,
apparently without detriment. A controlled ex-
periment is under way at the Babies Hospital
to study the survival of premature infants
at different environmental temperatures. Our
present practice is to omit hot water bottles,
warmed blankets and other undue covering.

5. Humidity

Controlled experiments do not provide evi-
dence that excessive humidity or vaporization
of various wetting agents improves survival in
the newborn period.

6. Use of Drugs

Rarely are agents other than oxygen indi-
cated in the delivery room. If maternal depres-
sion exists, and if it is likely that it was caused
by an opiate, intravenous injection of 0.25 mg.
of N-allylnormorphine into the umbilical vein
is worth a trial. If this is done and the diag-
nosis is in error, moderate sedation is pro-
duced in the infant.
Antibiotics always should be used after dif-
ficult resuscitation, and digitalis frequently is
of help in severe cardiac problems.

7. Scoring

Every infant is evaluated 60 seconds after
birth according to a simple, objective scale,
reproduced in table 1.

8. Gastric Aspiration

After respiration is well established, every
infant's stomach is aspirated by introducing a
soft rubber catheter and aspirating the con-
tents. The main purpose is to rule out esopha-
geal atresia, the second purpose being to
measure the gastric contents. If the tip of the
catheter is not seen in the left half of the ab-
domen, a stethoscope is placed over the abdo-
men and a short puff of air is blown into the
catheter. No noise indicates atresia.

9. lmmediate Neonatal Diagnosis
of Operable Anomalies

I already have mentioned esophageal atresia.
If more than 50 cc. is aspirated from the in-
fant's stomach, the abdomen should be x-rayed

May 1956

449

within the hour to rule out duodenal or jejunal
atresia. Absence of gas below the pylorus in-
dicates atresia and immediate operation.
The chest should be auscultated in the first
few minutes. A shift in loudest cardiac sounds
and absent breath sounds in one side of the
chest suggest diaphragmatic hernia, another
operable emergency.
Imperforate anus should be treated by oper-
ation immediately. The newborn infant is most
resistant to surgical assault and anesthesia in
the first 24 hours after birth. Every delay in
diagnosis of an operable anomaly jeopardizes
his chances for survival.

10. Maternal Polyhydramnion
A history of maternal polyhydramnion

should lead to an especially thorough search
for anomalies, most of which are operable.
We have found the following anomalies to be
directly associated with polyhydramnion: an-
encephalia, hydrocephalus, tracheo-esophageal
fistula with esophageal atresia, diaphragmatic
hernia, congenital cardiac disease, duodenal
and upper jejunal atresia, volvulus, and per-
forated stomach. Rapid diagnosis in the de-
livery room is one of the most hopeful means
of

1.

2.

reducing neonatal mortality.

REFERENCES

Anoxia of the Newborn: A Symposium. Oxford. England. Black-
well Scientific Publieations, 1953. p. 35.
FRXKMAN, L. C. and Scorr. R. B.: Gastric suetion in infants
delivered by Cesarean section. Am. J. Dis. Child. 87:570 (May)
1954.

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