Although a baby is occasionally born sick without prior warning, most of the time, physicians know when a baby will be born prematurely or at risk for problems. A neonatal team (made up of physicians, nurses, and respiratory therapists who are specially trained in the care of newborn babies) will be present at the delivery and prepared to do whatever is necessary to care for your baby.
As soon as your baby is delivered, she is placed in a radiant warmer (a cart with a mattress on top and a heat source overhead) and quickly dried off. The team then performs some or all of the procedures described below. These are done in the delivery room or in an adjacent area with special equipment and supplies for those babies at risk.
All babies are born with some mucus and fluid in their nose, mouth, and throat. Suctioning helps clear this mucus and fluid so that a baby can begin breathing. There are two types of equipment that may be used for suctioning: a rubber bulb suction, which gently suctions most secretions from a baby’s mouth or nose, or a catheter connected to a suction machine. The thin, plastic catheter can be used for the baby’s nose, mouth, and throat.
Most premature or low birth weight babies need oxygen. The method of giving oxygen depends on how the baby is breathing and her color.
- If the baby is breathing, but does not turn pink immediately within several minutes after birth, a team member holds a stream of oxygen over the baby’s nose and mouth. This is called blow-by oxygen. Later on, oxygen can be given through a mask that fits over the baby’s nose and mouth or through a clear, plastic hood that fits over the head.
- If the baby is not breathing well, a team member places a mask (connected to an inflatable bag and an oxygen source) over the baby’s nose and mouth. As the team member pumps the bag, the baby receives oxygen-enriched air, as well as some pressure from the bagging, which helps inflate the baby’s lungs. This is called bagging.
After bagging, a baby usually almost immediately begins breathing on her own, cries, turns pink, and moves about. The team member then stops bagging, holds oxygen over the baby’s face, and watches the baby for continued improvement.
Sometimes a baby needs even more help than bagging. When this is the case, a member of the team will place a tube (called an endotracheal tube) in the baby’s windpipe (trachea). This procedure is called endotracheal intubation.
To intubate a baby, the team member uses a special flashlight, called a laryngoscope, to see down the baby’s throat. A plastic endotracheal tube is placed between the baby’s vocal cords, down through the larynx, and finally into the trachea. The tube is then attached to a bag that is squeezed to inflate the baby’s lungs.
Once the baby starts breathing, the heart rate usually begins to increase. If this does not happen, a team member begins to rhythmically press down on the baby’s heart (called cardiac massage or chest compressions). These compressions pump blood through the baby’s heart and body.
If bagging the baby to help her breathe and giving oxygen and compressing the heart do not improve the baby’s condition after a minute or two, the baby is given a liquid medication called epinephrine (also called adrenaline). The medication is administered into the endotracheal tube for delivery to the lungs, where it is rapidly absorbed into the blood. Another method for administering epinephrine is to cut across the umbilical cord, insert a small plastic catheter (tube) into the umbilical vein, and inject the medication through the catheter.
Babies who are very premature are at risk for developing a lung condition called respiratory distress syndrome or RDS. This syndrome occurs due to lack of a substance called surfactant. Surfactant keeps the lungs properly inflated. When a baby is born very premature, the lungs have not yet begun to produce surfactant. Fortunately, surfactant is now made artificially and can be given to babies whom doctors suspect are not yet making surfactant on their own.
To administer surfactant, your baby is placed on his or her left side, given half of a dose of surfactant through the endotracheal tube, and then ?bagged? for about 30 seconds. The procedure is then repeated on the right side. Administering surfactant in two steps like this helps distribute the surfactant evenly throughout the lungs. Surfactant may be administered in the delivery room or in the NICU. (A baby may require up to four doses of surfactant, given several hours apart in the NICU.)
Doctors routinely assess a baby’s general condition by measuring performance in five categories: heart rate, respiratory effort, color, muscle tone, and reflex irritability (the baby’s response to suctioning). This is called the Apgar score. Each category is rated from 0 to 2 (0 is the worst score and 2 is the best) and then the numbers are added together, for a maximum score of 10. The score is usually calculated for all babies when the baby is one minute and five minutes of age. If the baby requires continued resuscitation, the team may assign Apgar scores beyond five minutes.
The chart below shows what the team looks for when assigning Apgar scores.
|Category||Criteria for score of 0||Criteria for score of 1||Criteria for score of 2|
|Heart rate||Absent||< 100 beats per minute||> 100 beats per minute|
|Respiratory effort||Absent||Weak||Strong (with strong cry)|
|Color||Blue||Body pink, arms and legs blue||Pink|
|Tone||Limp||Some flexion||Well flexed|
|Reflex irritability||None||Grimace||Cough or sneeze|
An Apgar score of 7 to 10 is considered good. A baby who receives a score of 4 to 6 requires assistance, and a baby with a score of 0 to 3 needs full resuscitation. Premature babies may receive lower Apgar scores simply because they are somewhat immature and unable to respond with loud crying and because their muscle tone is often poor.
After the neonatal team finishes these procedures, you will see your baby briefly, then she goes to the neonatal intensive care unit (NICU).