1. Airway management :Prepare By Enas Qwaider Sara Al- Ashar
Reem Esleem Samah Ewada
Dena Abu- Smaha

2. Assessment of the newborn baby:
Whilst keeping the baby warm make an initial assessment by assessing:

3. Respiration:
Most babies will establish spontaneous regular breathing sufficient to maintain the heart rate above 100 beats/min and to improve the skin colour within 3 minutes of birth. If apnoea or gasping persists after drying, intervention is required.

4. Apnoea, low or absent heart rate, pallor and floppiness together suggest terminal apnoea. However, initial management of such babies is unchanged but resuscitation may be prolonged
After assessment, resuscitation follows:
Airway
Breathing
Circulation

5. Indication For Airway Management:
Increased secretions
Increased respiratory effort
Increasing oxygen requirement
Increasing respiratory distress
Increasing apnoeas

6. Sign&Symptoms for Airway Obstruction
Increased work of breathing (suprasternal, intercostal, subcostal retractions).
Tachypnoea.
Cyanosis and decreased conscious state are late signs.

7. Airway:
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 setting, the floor is a tempting location to place the baby, especially if the room is cluttered. However, the floor is not ideal, as even in the summer it is often cold and draughty and therefore likely to cool the baby.

8. 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 better to clear a table or use the seat of a firm chair to place the baby on.

9. 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 with the nose uppermost, the ideal situation being when another person can hold the baby's head for the midwife.

10. neutral position

11. neonatal occipital protuberance

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

13. Intermittent positive pressure ventilation (IPPV) will then be commenced using a bag and mask if available or a T-piece, mask and resuscitaire 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 soft part of the mask should not be touched as this may distort its shape and lead to leakage of air.

14. Bagging demonstration
T-piece

16. 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 of forcing 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

17. 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 lift the chest until the 4th or 5th inflation breath

18. This can be a nervous time for the midwife because it is natural to think that the chest will rise on the first inflation and it is easy for midwives to blame their own technique. Once chest movement has been seen, the facemask should be removed to assess if the baby is spontaneously breathing. The heart rate can also be assessed at this time to establish whether the rate has increased.

19. Babies that are blue with good muscle tone and a heart rate above 60 bpm often do not need any further assistance. 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.

20. 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.

21. 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.

23. Difficulties in establishing an open airway:
If there is no chest movement after five inflation breaths, this indicates that the airway is not open, so the alveoli will remain filled with lung fluid. This is a good time to consider calling for medical assistance because failure of the following interventions may result in the need for tracheal intubation.

24. tracheal intubation

25. In the home, paramedic support will take longer to arrive so early anticipation of problems is considered good practice. If the baby has a poor colour and muscle tone, this may indicate that the position of their head has not been maintained in the neutral position and there is a definite need for a second person's help both to hold the head and apply jaw thrust.

26. The jaw of a floppy baby can fall backwards and as the tongue is attached to the jaw, the tongue falls back into the airway, blocking the airway. A second person, with their fingers on each side of the jaw, can push the jaw forwards and hold it in that position. This is an easily performed manoeuvre because the baby does not offer any muscle tone resistance.

27. Five inflation breaths should then be given
Five inflation breaths should then be given. If there is still no chest movement, suction to the oropharynx under direct vision using the light of a laryngoscope may be considered should there be an obstruction.

28. Occasionally if there is maternal bleeding at the birth, some blood may have entered the baby's mouth, initially as fluid but then over time may have clotted. (Please note: The management of meconium is not considered in this context, as the resuscitation would be approached in a different way).

29. After this intervention five inflation breaths are given
After this intervention five inflation breaths are given. If not successful, an oropharyngeal (Guedel) airway can be inserted to open the airway mechanically, especially in babies who may have congenital abnormalities such as choanal atresia and/or micrognathia

30. choanal atresia

31. Micrognathia

32. The correct sizing of the airway is vital
The correct sizing of the airway is vital. When held along the line of the lower jaw with the flange at the level of the middle of the lips, the end of the airway should reach the angle of the jaw. The airway is slipped over the tongue in the same attitude that it will finally lie.

33. The midwife should make sure that the tongue is not pushed back into the back of the mouth. Once in situ the mask can be placed over the airway (both the mouth and nose) and a further five inflation breaths should be given. If the chest fails to rise after these interventions, intubation of the trachea will be required and an experienced neonatal registrar will be needed to assist.