Airway Management If the baby is not breathing, opening the airway is always the first step. A flat surface is needed so the umbilical cord can be cut and secured. In the home sefing, the floor is a tempting location to place the baby, especially if the room is clufered. However, the floor is not ideal, as even in the summer it is ohen cold and draughty and therefore likely to cool the baby. Furthermore, in any resuscitation situation, the first consideration is practitioner safety.

The midwife must always make sure the environment is safe for her to function, and bad posture in particular can contribute to poor performance and awkward communications. It is therefore befer to clear a table or use the seat of a firm chair to place the baby on.

The prominence of the neonatal occipital protuberance can affect the natural position of the baby's head, when lying on its back, with the result of either the chin falling down to the chest in flexion or extending into the chin-up position. Both postures consequently close the airway. The head should be placed in the neutral position (Fig. 29.1) with the nose uppermost, the ideal situation being when another person can hold the baby's head for the midwife (Tracy et al 2011).

FIG. 29.1 Neutral position Alternatively, a small sheet/towel or equivalent can be placed under the neck of the baby to secure the neutral position (sniffing position) (Fig. 29.2).

FIG. 29.2 Small towel under the neck (sniffing position). Intermitent positive pressure ventilation (IPPV) will then be commenced using a bag and mask if available or a T-piece, mask and resuscitative in the hospital. The mask must be the correct size for the baby to prevent any leaks of air to occur on inflation of the bag. The mask should be rolled onto the face from the chin, using the stem of the mask (like a champagne glass) to hold it in position. The soh part of the mask should not be touched as this may distort its shape and lead to leakage of air (

FIG. 29.3 Bagging demonstration. The bag when manually compressed will deliver positive pressure of air at 30 cmH2O. Given that the alveoli are filled with lung fluid, this pressure should be applied for 3 seconds, which is the time it takes to steadily count ‘1–2–3’, to begin the process offorcing the lung fluid into the lymphatic channels of the lungs.

The bag should be allowed to refill before giving the second breath, ‘2–2–3’, the third breath, ‘3–2–3’, ‘4–2–3, and finally ‘5–2–3’. Five inflation breaths should be sufficient to clear the lung fluid to make room for the air. While these inflation breaths are being given, the baby should be covered but with the chest exposed so that any chest movement (which is the sign of an open airway) can be seen and noted It must be appreciated that while there is an exchange of one substance with another, i.e. lung fluid with air, there is no accumulation of air to lih the chest until the 4th or 5th inflation breath .

As soon as normal respiratory effort is established and their heart rate is over 100 bpm, they can be given to their mother for skin-to-skin contact. However, some babies in this category may not be breathing spontaneously because there remains too much CO2 in their blood and tissues (hypercapnoea) that is depressing their respiratory effort

Ventilatory breaths are then commenced to provide oxygen (21% in air) and blow off the excess CO2. Given at a rate of 30 breaths per minute, these breaths are therefore 2 seconds in duration. It is important to assess the baby every 30 seconds to see if they are making spontaneous efforts to breathe. It is vital that the midwife does not over-ventilate the baby and reduce their CO2 too much and cause apnoea. Babies should be allowed to resuscitate themselves, noting the time when the baby is breathing spontaneously. (See Box 29.1.)

Box 29. 1 Reflect iv e question Box 29.1 Reflect iv e question ‘If a baby is not breathing, is it acceptable to blow oxygen onto the baby’s face instead of using IPPV with a bag and mask?’ This is totally inappropriate for two reasons: 1.You must first establish that the airway is open. The only way to do this is by giving five inflation breaths and seeing the chest rise by the fifth inflation breath. The time you spend not giving IPPV is wasted and the baby is not receiving any benefit from you. 2.Resuscitation gas now consists of air as standard not oxygen. Air is a cold gas and if you blow this onto the face of the baby, you will quickly cool the baby.