Neonatal Respiratory Care
Adequate respiratory function is of utmost importance in newborn care and must be assessed frequently.
Health care providers should practice universal precautions when caring for newborns.
Respiratory care is guided by the Apgar score which is obtained at one minute and five minutes after birth through observation of the newborn. The caregiver assesses the newborn for heart rate, respiratory effort, muscle tone, reflex irritability, and color. The newborn receives scores of 0, 1, or 2 for each category and all five scores are added together. An infant scoring less than 4 is in grave danger and requires immediate resuscitation. A score of 4 to 6 indicates that the newborn's condition is serious and that the baby may require clearing of the airway and oxygen therapy. A score of 7 to 10 indicates that the infant is doing well. The highest score a newborn can receive is 10.
Respiratory care of the newborn can be separated into two general categories: care of the healthy, term newborn and care of the high-risk newborn.
Respiratory care of the healthy, term newborn
RESPIRATORY EFFORT. A healthy, term newborn generally releases a lusty, spontaneous cry within 30 seconds after delivery. By one minute, the newborn normally maintains regular, but often rapid respirations. If the mother received large amounts of narcotic analgesia or a general anesthetic in labor or birth the baby's respirations might be depressed. The administration of a medication to counter this effect, such as naloxone (Narcan) may be indicated.
The newborn should be able to maintain a clear airway with little assistance and should have a respiratory rate of 30 to 60 breaths per minute. Physical signs of respiratory distress are retractions (the skin is pulling against the ribs), nasal flaring, and grunting. The lungs should sound clear when listened to with a stethoscope (auscultated).
Care of the normal newborn's respiratory status includes the following actions:
- Assess the baby's respiratory rate every 15 minutes for 1 hour. Observe for an increase in respiratory rate, the development of retractions, nasal flaring, or grunting.
- Position the newborn with the head down and on one side to aid in the drainage of secretions from the respiratory tract.
- Suction the baby's mouth first with a bulb syringe and then the nose. Suctioning the nose before the mouth can induce the aspiration of secretions through the mouth.
- Frequently change the baby's position to encourage the drainage of secretions thereby helping the lungs to aerate and expand.
- Keep the baby warm either by wrapping loosely with a blanket and placing a hat on the baby's head or by placing the baby under a radiant warmer. Check the baby's temperature frequently at first. A cold baby experiences an increase in metabolic rate that raises oxygen requirements resulting in a more rapid respiratory rate.
Respiratory care of a high-risk newborn
The high-risk newborn may be premature, may have a congenital condition, or may have experienced some degree of asphyxia in utero from compression of the umbilical cord, maternal anesthesia or analgesia, placenta previa, or a partial separation of the placenta. The manner in which the first few moments of life are managed will determine the eventual outcome for the high-risk newborn. It is imperative that respirations are established within two minutes of birth or severe respiratory acidosis may develop that is difficult to reverse. Any baby that does not take a first breath or has difficulty breathing adequately requires resuscitative intervention.
Resuscitation of the newborn consists of three sequential steps:
ESTABLISHING AN AIRWAY. If the baby does not initiate spontaneous respirations, suction the mouth and nose with a bulb syringe. Stimulating the skin by rubbing the baby's back may initiate breathing. If the baby's skin color is not pink, hold an oxygen tube with warmed oxygen by the baby's nose or provide oxygen by face mask. If these interventions are ineffective, administer oxygen by a positive pressure bag and mask.
EXPANDING THE LUNGS. A baby who cannot sustain effective breathing may need oxygen via bag and mask. The mask should cover the mouth and the nose but
should not cover the eyes. The bag and mask deliver 100% oxygen and are compressed at a rate of 40 to 60 compressions per minute until the baby breathes spontaneously.
If the baby's Apgar score remains low, deeper suctioning with a suction catheter may be required. Position the infant on his or her back and place a folded towel beneath the baby's shoulders. Pass a catheter above the infant's tongue to the rear of the throat and suction for no longer than 10 seconds. A baby who initiates no respiratory effort is likely to require immediate placement of an endotracheal tube into the airway through a technique called intubation. The instrument used to open the airway so that the endotracheal tube can be placed in the airway is called a laryngoscope. After placement of the endotracheal tube, deeper suctioning of the trachea through the endotracheal tube is possible. A pressure bag can then be attached to the endotracheal tube and deliver 100% oxygen. The bag is compressed 40 to 60 times a minute.
If the amniotic fluid was meconium-stained, stimulation of the baby's breathing by rubbing the back or the administration of oxygen under pressure could cause the infant to aspirate meconium into the lungs. Instead, only provide oxygen therapy by mask without pressure. Passing a laryngoscope and suctioning the trachea should remove the meconium. Then tactile stimulation and oxygen therapy under pressure can be initiated.
MAINTAINING EFFECTIVE VENTILATION. All newborns, particularly those who encountered respiratory problems at birth, should be carefully assessed for several hours after birth. It is also of utmost importance to keep the baby warm. If the baby continues to produce copious secretions from the respiratory tract he or she should be suctioned out with a catheter or bulb syringe. If the baby is intubated, preventilating with a bag means suctioning can be performed through the endotracheal tube. If the baby's respiratory status remains critical, administration of pressure and oxygen via a ventilator or by continuous positive airway pressure (CPAP) may be necessary.
It is essential that a well stocked area for infant resuscitation be maintained and frequently checked. Necessary equipment includes oxygen; various sized laryngoscopes and endotracheal tubes for preterm to large infants; suction catheters of different sizes; bulb syringes; and blankets. Supplies are usually placed alongside a radiant warmer.
Health care team roles
Nurses, respiratory therapists, and physicians should become certified in neonatal resuscitation. Health care practitioners who are trained to intubate with a laryngoscope include: obstetricians, midwives, pediatricians, neonatologists, anesthesiologists, and neonatal nurse practitioners. At least one person who can intubate an infant should be present at every delivery of a high-risk infant.
Acidosis—An abnormal pH of the blood characterized by reduced alkalinity.
Asphyxia—A deficiency of oxygen or state of carbon dioxide over-saturation within the body.
Meconium—The substance that forms in the baby's intestines starting at 16 weeks gestation. It is black or dark green. A physiological response can trigger the release of meconium in utero when the baby experiences a decrease in oxygenation. At birth, if the baby has meconium-stained amniotic fluid, he or she is at risk of aspirating the meconium into the lungs.
Placenta previa—A low implantation of the placenta on the uterus that may occlude the cervix resulting in complications during labor and delivery.
Maternal & Child Health Nursing. 3rd ed. Philadelphia: Lippincott, 1999.
American Heart Association (AHA). 7272 Greenville Avenue, Dallas, TX 75231. 1-877-AHA-4-CPR. <http://www.americanheart.org/>.
Nadine M. Jacobson, R.N.