MAINTAIN BODY TEMPERATURE Maintain the infant below the level of the placenta prior to clamping the cord. When the cord is clamped, blot the infant dry with a sterile towel and place the infant under a preheated radiant warmer on a sterile table. Neonates should be placed either on the back or the left side somewhat in the Trendelenburg position, with the neck in a neutral position.
CLEAR THE AIRWAY Gently suction the nose and mouth with a bulb syringe, DeLee trap, or mechanical suction apparatus with an 8F suction catheter. A 5- to 10-s examination should be performed to determine the need for resuscitation. This examination should include an assessment of heart rate, respiratory effort, color, and muscular activity. If the infant has a lusty cry, is pink, has spontaneous respirations, and has a heart rate above 120 beats per minute (Apgar > 8), no further therapy is needed.
INITIATE BREATHING If the infant is apneic or the heart rate is slow and irregular (<100 beats per minute) and the color is cyanotic (Apgar 4 to 7), administer positive-pressure ventilation with the mask over the infant's face and 100% oxygen. The respiratory rate should be maintained at 40 breaths per minute, with pressure applied to gently move the chest wall. In an infant who has not yet taken a breath, over 40 cmH 2O pressure may be necessary to expand the lungs. In mildly depressed infants, this will produce a prompt increase in heart rate and the onset of regular spontaneous respirations. If no improvement is noted in 15 to 30 s and the condition deteriorates (Apgar £ 4), the trachea should be intubated and assisted ventilation continued.
MECONIUM STAINING Meconium staining of the amniotic fluid occurs in from 0.5 to 20 percent of all births. Aspiration of thick meconium carries a 20 to 50 percent mortality rate; however, with proper management it is almost entirely preventable. When gross meconium is noted at the time of delivery, the following procedure should be followed. After delivery of the infant's head (but before delivery of the shoulders), the nose, mouth, and pharynx should be thoroughly suctioned with a DeLee suction catheter. Repeat suctioning of the upper airway should be performed as the infant is placed under the radiant warmer. The trachea should then be visualized with a laryngoscope and meconium aspirated by direct suctioning through an endotracheal tube. Suctioning should be repeated until no more meconium is present in the trachea. The infant may then be ventilated with positive pressure as indicated. Failure to clear the trachea before assisted or spontaneous ventilation may result in dissemination of the meconium through the airways.
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