Newborn Resuscitation: The Golden Minute

   Delivering a newborn may occur only once in your EMS career, but delivering a new life into the world can be one of the most rewarding and looked-forward-to calls. At the same time, it may cause some anxiety prior to and during the delivery.

   Roughly four million babies are born each year,1 the vast majority of whose births go smoothly. Around 10% of newborns will require some assistance following delivery, and less than 1% will require major resuscitation.₂ With advances in medicine, most high-risk mothers are followed closely by their obstetricians and may even be admitted early to a hospital or regional medical center that deals with high-risk pregnancies, thus reducing the 10% that may require assistance and resuscitation in the prehospital environment even further. That being said, the need for assistance and resuscitation of newborns in the prehospital environment may still occur. Newborn resuscitation should be considered the Golden Minute.₃ That is, if ventilations or chest compressions are required, they are initiated within one minute following delivery; however, do not wait one minute to calculate the APGAR score and then determine that there is a need for resuscitation. The most common cause of bradycardia in the newborn is hypoxia, which is easily reversed with bag-valve mask ventilation.

Time Before Delivery

   The time before delivery should be looked at in two periods, the first being the period prior to the call. What classes have you attended or how much review have you done on newborn delivery and resuscitation in the last six months? Do you know what items are in your OB kit for delivery and resuscitation? Due to the low number of newborn deliveries and even fewer major resuscitations that you perform, education, training and review are crucial.₂

   The second period is the minutes before delivery, when you should be asking the mother key questions and preparing your equipment for a possible or imminent delivery. Some of the questions that will help determine if the delivery is imminent or how much time you have to prepare for it include: Is she having contractions? If so, how far apart are they and how long are they lasting? Have the membranes (water) ruptured? If so, when, and was the fluid clear, bloody or meconium-stained?₅ (See Table I for more questions.) The answers will help you determine if you should open the OB delivery kit or just keep it nearby.

   If delivery is imminent, open and prepare the OB delivery kit and make sure you have resuscitation equipment ready if needed. This equipment can be kept in an airway, pediatric or first-in bag, or in a newborn resuscitation kit containing bulb suction (there may already be one in the OB delivery kit), a neonate bag-valve mask, suctioning equipment, laryngoscope and neonate-sized Miller blades, epinephrine and intravenous administration equipment (see Table II).

   In addition to preparing the equipment, find a flat, firm surface in a warm environment for effective resuscitation, if needed. In the prehospital environment, the patient compartment of the ambulance is ideal and can address both issues. The stretcher can provide an initial assessment area for the newborn and will be adequate for most deliveries. If the newborn is depressed and requires further resuscitation, he/she can be moved to the bench seat for further management prior to transport. It is best to keep the mother and newborn together, if possible, although safety and having adequate room and resources to manage the newborn may require transporting the mother and baby separately to the same hospital, which allows family to gather at one facility.

   Maintaining the newborn's body temperature is imperative. Following most deliveries this can be accomplished by drying the newborn, removing wet towels, placing the baby on the mother's chest,₅ and covering both with dry, warmed blankets. If resuscitation is required, temperature can best be controlled in the patient compartment of the ambulance, which will avoid exposing the baby to extreme temperatures while moving it from the scene to the vehicle.