Resuscitation of the newborn

RESUSCITATION OF THE NEWBORN* ANDREWA. MARCHETTI, M.D. Instructor

in Obstetrics

and

Gynecology, and

CornelI University Genecologist, New

hiedica1 ColIege; York HospitaI

Assistant

Attending

Obstetrician

NEW YORK

T

HE study of the deveIopment of a method in the prevention and treatment of disease will show that it e\,oI\.es from an attempt to understand the normaI conditions and the cause of abnorma1 alterations which surround and are produced by the pathoIogica1 state of the organism. As newer scientific appreciation and knowIedge deveIop and as experience over a Iong period of time is recorded, the method is discarded, changed, improved or substituted. The disease does not change even though there may be gradual transitions from one form to another. However, ideas reIated to the diseases do change and with that, naturaIIy, the rstionaIe of prevention and of treatment. Very seIdom are there circumstances when one is unabIe to show how old the new is, and this may we11 appIy to the methods that have been devised for the treatment of asphyxia neonatorum. Thus, it is not thought amiss to review briefly the historical development of procedures employed in the resuscitation of the newborn. It was not unti1 the middIe of the eighteenth century that resuscitation of the newborn was considered with any real scientific approach. Perhaps one of the older methods, if not the oIdest, which was empioyed before this time was insufIlation. In connection with insufIIation, it was soon Iearned that the air passages-the nostriIs, mouth and pharynx-must be cIeared of obstruction caused by the accumuIation of inhaIed foreign substances. One then, in the very earIy days, became aware of the most essentia1 factor in effecting measures to resuscitate the newborn. Mauriceau in 1-2 I recommended holding the infant’s * From the Department

ofObstetrics and

Gynecology,

mouth haIf open in order to cleanse it with a cloth pledget. Among the first to practice insufllation with a cannula are SmeIIie and Monro Secundus. The former in 1768 used a silver cannuIa; Monro empIoyed a cannuIa which he passed through the mouth down to the Iarynx preventing air from entering the stomach, an advance certainIy in the art of resuscitation. W. CuIIen in 1766 advocated tracheotomy before insufllation, a procedure which was soon recognized to be much too radical. Various methods of insufIlation were being widely used unti1 I 783 when Blumenbath, an opponent of the method, stated that it Ied to the death of many infants. He devised experiments on dogs to prove his contention. As a resuIt Aitken, Hi11 and others recommended procedures by which pure atmospheric air couId be lead into the air passages. Hufeland in 1783 initiated for the first time the use of electricity in resuscitation of the newborn. He advised its application so that the heart and diaphragm might be stimurated to establish respiration. Among the many who have recommended eIectricity enthusiasticaIIy in some form or another as a measure of resuscitation since Hufeland may be mentioned Bo&, Froriep, Herder, Ziemssen, Baer, Pernice, and only recently, Israel. In 1785 Chaussier devised a “tube laryngien pour insoufIIer (‘air dans les poumons. ” This tube was a curved silver cannula with a smooth, blunt, rounded end and two oval IateraI openings a short distance from the end. When the wide usage

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of a catheter, tube or cannuIa in the numerous methods of resuscitation is considered, Chaussier’s tube is a reaI advance, inasmuch as the dehcate airways of an infant become Iess IiabIe to trauma. The chief advocates of Chaussier’s method and tube with their own persona1 modifications were BIundeII, DepauI and Cazeaux. The outstanding contribution of this earIier period was made by PauI ScheeI in 1798. ScheeI studied in Giittingen and Copenhagen, Iater becoming director of the Copenhagen Lying-In. He again pIaced, as many others had before him, the greatest amount of importance on cIearing the air passages and was the first to recommend aspiration of amniotic ffuid from the trachea. He stated that before anything eIse the mouth and pharynx of the newborn must be cIeansed of mucus by means of a feather and the smaI1 finger. Then the head shouId be heId downward so that the ffuid substances in the pharynx might drain into the posterior nares. This shouId be foIIowed by mouth-to-mouth insuflIation with moderate compression towards the trachea and away from the esophagus in order to prevent the entrance of air into the stomach. If according to this procedure, the ffuid did not ffow out of the trachea, one shouId gentIy stroke the trachea again with the baby’s head hanging downward and again air shouId be bIown into the Iungs by the mouth-to-mouth technique. ShouId one not accompIish one’s purpose by carrying out these measures, then ScheeI recommended cIearing the trachea by passing a Iong fIexibIe catheter into it and by means of a syringe attached to the other end, draw out the fIuid by suction. After that, he continued, one can even make atmospheric air accessibIe to the Iungs without having to take care of distending the intestina1 cana through the esophagus. His procedure has been described in some detai1 purposeIy because, however crude and simpIe it was, there is much in the rationaIe that is fundamentaIIy not unIike that which is practiced by the more commonIy used and more refined methods of today. ScheeI’s work

on the resuscitation of the newborn is impressive. He emphasized the importance of cIearing the airways, used intratrachea1 intubation, and was the first to recommend intratrachea1 aspiration of amniotic fIuid. About I 80 I PIenck pIaced much emphasis on the time at which the umbiIica1 cord shouId be cut and tied. In asphyxia paIIida, Ieaving the cord intact as Iong as the pIacenta is attached to the uterus, is advised; whereas, in asphyxia Iivida, the cord shouId be cut at once and a few ounces of bIood aIIowed to escape before tying it. In the meantime, not Iess interesting and more important, are the various measures that he advocated for the stimuIation of the infant, name1 y, wrapping the baby in cIoths soaked in warm wine, giving spirits of hart’s horn to smeII and a smaI1 amount of saIt by mouth, in addition to an enema of saIt soIution, bIowing air in the mouth, stroking the soIes of the feet with a brush, rubbing the Iimbs towards the heart with toweIs, and sometimes gentIy compressing the chest with the hands, omitting anything sudden or hasty. In 1820 StempeImann, influenced by the work of BIumenbach and FIeisch and Pittschoft, connected a doubIe chambered beIIows to a cannuIa instead of insufllating air. According to Arthur Keith, John Hunter used the beIIows in 1776. BIundeII in I 824 recommended artificia1 respiration and the warm bath. He used a Chaussier tube for intratrachea1 intubation and gentIy pressed the thorax twenty-five to thirty times a minute to expe1 the air foIIowing each insuffiation through the tube. He disapproved of the use of the beIIows. In 1828 Toogood advised mouth-tomouth insulation with a napkin between the infant’s and operator’s mouths and a hand on the chest to deflate the Iungs. Dewees had empIoyed the mouth-to-mouth technique with a cIoth as recommended by Toogood for forty years. Twenty years Iater, in 1844, Couper procedure in empIoyed an interesting breech presentation, that is, inflation of the

lungs before the extraction of the head. Accordingly, he introduced the left hand in the vagrna and inserted the forefinger in the baby’s mouth, then using it as a guide, passed an elastic tube we11 into the infant’s mouth. He bIew two or three times through the other end of the tube in an attempt to estabIish respiration. The tube was not removed unti1 deIivery was accompIished. BaudeIocque thought and made use of a simiIar procedure. In 1829 Dr. Jacob BigeIow presented in the American JournaI of MedicaI Sciences an articIe “On the Means of Affording Respiration to ChiIdren in Reversed Presentation.” In Pugh’s Treatise of Midwifery (I 744) he recommended such a method. Even though today the procedure is forgotten or veriIy unheard of in breech presentation, it does bear historica interest. About the middIe of the nineteenth century newer methods of resuscitation based upon posture and artificia1 respiration were introduced. The procedures outIined and proposed by Marsha11 Ha11 and SiIvester gained much attention. About the same time SchuItze’s method became popuIar and shortIy afterwards, his procedure was modified notabIy first by Byrd in 1874 and then by Dew in 1893. Howard in 1877 criticized the methods of Ha11 and SiIvester because of the eIement of physica injury to the baby. SchuItze’s method was Iikewise one that exposed the infant to many hazards. These and aIIied procedures today are obsoIete and because of the possibIe physica dangers to the newborn can be dismissed without any description. Many recommended the use of the warm bath with Forest cIaiming to be the first to apply external heat and artificial respiration SimuItaneousIy. The so-caIIed method of tubbing whereby the baby is pIaced in a bath of warm water then suddenIy immersed in one of cofd water is now heId more injurious than heIpfu1. It is obvious that the shock of the cold water cannot be of great benefit to an already feebIe baby. Laborde’s technique of grasping the tongue and exercising rhythmic traction

in order to estabIish respiration on the basis that the phrenic nerve is uItimateIy stimuIated to cause contractions of the diaphragm and intercostal muscles is now held untenabIe as a satisfactory procedure. Mention shouId be made of the use of drugs. In genera1 the administration of the greater part of drugs has proved more injurious than beneficia1. LobeIine, for exampIe, unquestionably a respiratory stimulant, has been shown by many to be aIso a cardiac depressant. More recentIy and especiaIIy in Germany, good results have been cIaimed for coramine as a respiratory and cardiac stimuIant. It is obvious that even if drugs may be administered with beneficia1 stimuIating effect upon the cardiac or respiratory centers, or both, McGrath and Kuder have pointed out that “no drug therapy provides the fundamenta1 cIearance and patency of the air passages.” Many more and various methods have been devised in the past, a11 modifications of some one procedure or another that has aIready been described or mentioned. At this point, the more current procedures wiI1 be considered. For the resuscitation of the newborn the fundamenta1 requirement must be gentIeness and as PIenck once said, anything sudden or hasty must be omitted. The principa1 objective is to get the air passages from the lips to the Iungs clear. The greatest caution shouId be exercised to avoid any posture or procedure that wiI1 add insult to a suspected intracrania1 injury. As long as the heart beat is strong and the rate regular, and as long as the pharyngeal and IaryngeaI refIexes are not feeble, the usua1 milder measures will suflice to resuscitate the newborn should it not cry shortIy after deIivery. Suspending the newborn ’ infant by its feet with the head hanging downward and gentIy stroking the trachea towards the head, cleansing the mouth and pharynx with the Iittle finger co\.ered by a soft piece of gauze, preventing undue exposure by wrapping the infant in warm bIankets and placing it in a warm basinette

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are a11 generaIIy we11 accepted measures. ShouId one suspect the incompIete remova or drainage of mucus and fluid from the

to foIIow it after it has been estabIished, in addition to preventing injury to the tissues of the puImonary unit by administering

I. InhaIation of CO, and 02 with artificia1 respiration in partial asphyxia (good feta1 (Stander, H. J. WiIIiams Obstetri&, Ed. 7. heart, cyanosis with attempts to breathe) New York, D. AppLeton-Century, 1936.)

FIG.

air passages, the carefu1 introduction of a soft rubber catheter into the posterior pharyngea1 spaces or into the trachea, with suction appIied, wiI1 suffice to accompIish the purpose. Babies with partia1 asphyxia, that is, babies with a good feta1 heart and cyanosis, with attempts to breathe, are made to inhaIe a mixture of 3 to IO per cent carbon dioxide and go to g$ per cent oxygen (Fig. I). After the air passages have been cIeared as described, such a measure has been found very effective in stimuIating respiration. In the presence of a poor response or no that is, change in the infant’s response, compIexion for the worse, a feebIe and irreguIar heart beat, faiIure to show any sign of a respiratory movement, more urgent measures are indicated. Today the better devised procedures aim to suppIy the infant with artificia1 respiration and oxygen or a mixture of oxygen and carbon dioxide. The desirabiIity to obtain an adequate rhythm to estabhsh respiration and

gases under undue pressure, are obvious factors to be considered. Apparatus have been devised in which the rate of inflating the Iungs can be reguIated and the mixture as we11 as the administration of gases reaIized under controIIed pressure. The apparatus of Drinker and McKhann, of Kreiselman, Kane and Swope, and that of FIagg deserve special mention. In this cIinic the method of direct exposure intubation with a smaI1 size Iaryngoscope and controIIed intratrachea1 insuflation of IO per cent carbon dioxide and go per cent oxygen under measured pressure as devised by FIagg has proved very satisfactory. The resuscitation outfit and the technique as empIoyed in our cIinic and as described in the 1936 edition of WiIIiams’ Obstetrics are as foIIows: The outfit consists of a smaI1 size Iaryngoscope, a straight as we11 as a curved metal suction tube, connecting with an electric suction apparatus, and a FIagg resuscitation machine carrying two containers of IO per

cent carbon dioxide and 90 per cent oxygen, to which may be fitted either an infant insuffiation tube or a baby pharyngea1 air-

and deflating it by removing the thunrb, at first simulating as nearly as possible normaI respiratory rhythm. In this manner the

FIG. 2. Suction applied directIy into trachea which has been exposed by means of the FIagg Iaryngoscopc. Used in cases with slowing of the heart rate, cyanosis and obstructron with Iarge amounts of mucus. (Stander, IT. J. Williams’ Obstetrics, Ed. 7. New York, D. Appleton-century Co., 1936.)

way. In addition there is avaiIable an infant size resuscitation inhaIer for use when intubation does not seem indicated; this can also be fitted to the FIagg apparatus (Fig. I). When the more serious forms of asphyxia prompt it, the baby is pIaced flat on its back with the shoulders sIightIy elevated and the head in somewhat hyperextension. Then we resort to the use of the infant laryngoscope, exposing the trachea and, under direct vision, the straight suction tube is inserted into the trachea and all the mucus removed under controIIed electric suction. With the Iaryngoscope stiI1 in place, the infant insufllation tube now replaces the suction tube and by connecting this with the FIagg apparatus, carbon dioxide and oxygen in the mentioned concentration under a pressure of twelve inches of water (25 mm. Hg) is forced into the trachea by obdurating the respiratory Dart. of the insufIIation tube with the thumb

obstetrician is given compIete control over the respirations he is attempting to induce. However, since the carbon dioxide content of the blood effects respiration and this in turn is dependent upon proper oxygenation once respiration is established, the rate and rhythm of the newIy established respiration should be followed by the operator, as any attempt to set an artificial rate and rhvthm wil1 serve to inhibit the newIy established respiratory effort. Once this procedure is begun, the Iaryngoscope is removed while the insufflation tube remains in situ and the procedure continued until respirations are spontaneous and regular and the color of the infant is normal. It is sometimes necessary to continue this for an hour or Ionger in order to bring about norma respirations (Figs. z and 3). There is a great need for a standardized and we11 organized method of resuscitation of the newborn in every hospital or institution where obstetrics is orncticed. In gen-

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eraI, the subject of resuscitation of the newborn has not been treated seriously enough. A study of the statistics in the

Cruickshank, carefuIIy studying the autopsy findings of 800 neonata1 deaths (excIuding stiIIbirths) which occurred in

FK. 3. uwwllatlon tube repIacing suction and connected with CO, and 02 under controIIed pressure with thumb obdurating the respiratory port. This step folIows the one ilIustrated in Figure Z. (Stander, 13. J. Williams’ Obstetrics, Ed. 7. New York, D. Appleton-Century Co., 1936.)

Birth Registration area of the United States shows that within the first twentynewfour hours after birth about I IO,OOO born babies are Iost annuaIIy. If this figure is correIated with the number of Iive births, it wiI1 show that about one baby out of cause. every 20 dies from some obstetrica

the first four weeks after birth, showed that 67.5 per cent resulted from causes associated with childbirth, that is, asphyxia neonatorum, prematurity, conor birth injury. The genitaI ateIectasis, interrelation among these four causes of neonata1 death is so cIose that any attempt

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to draw a line of demarcation in order to discuss them singIy ,is we11 nigh futile. Asphyxia neonatorum may be of intrauterine or extrauterine origin. The intrauterine origin may be maternal or fetaI. Under the materna1 factors that may cause asphyxia of intrauterine origin are enumerated disturbances of the pIacenta1 circuIation of any form during Iabor, protracted Iabor, proIonged second stage, administration of drugs during labor, hemorrhage, convuIsions, and death of the mother. Under the feta1 factors are considered pressure on the cord, winding of the cord about the baby’s neck and pressure upon the head. Extrauterine asphyxia may be primary to disease or maIformation of the vital organs, or secondary to injury to the brain or any other vita1 organ. Premature infants because of imperfect deveIopment should aIso be considered under this heading. The best way to treat asphyxia is to make every possibIe effort to prevent it. It is especraIIy under the heading of its intrauterine orrgin that the best efforts of good obstetrics can be directed. In connection with the use of drugs, analgesics and anesthetics during Iabor, Irving presented the foIIowing figures: Of the patients who received no anaIgesia, 98. I per cent of their babies breathed at once as soon as deIivered; of those who received nitrous oxide, oxygen and ether, 80 per cent breathed at once; and of those who received drugs (barbiturates, recta1 ether, paraIdehyde, scopoIamine), 50 to 65 per cent of their babies breathed immediateIy. These figures should make one guard against the indiscriminate use of such necessary agents during Iabor. Jbrg in 1832 was the first to describe and differentiate ateIectasis from pneumonia in the newborn. Lord states that weakness or UnderdeveIopment of the respiratory muscIes such as in premature or weakIy infants, or diminished irritabiIity of the respiratory center from intracrania1 hemorrhage, compression of the skuI1, or injury of the spina cord during birth, may be the cause of congenita1 ateIectasis in the newborn.

Prolonged or difIicuIt Iabor favors its occurrence. However, the most important and most frequent cause is mechanica obstruction by inhaled amniotic fluid, meconium, or mucus before, during or immediately after birth. Lord further states that after the baby is born alive, cries and lives several hours, acquired atelectasis may be caused by obstruction of the air passages or retraction or compression of the lungs. SUMMARY

The writer wishes briefly to summarize the theories advanced for the cause of the onset of respiration before concIuding. There are three hypothetica factors that may initiate the expansion of the Iungs and thereby estabIish respiration in the newborn : the physica1, chemica1 and biologica1. Under the first, Preyer’s theory is that the infant begins to breathe at birth as a consequence of reflex stimuIation set up by the trauma resuIting from labor. When one considers how adverse and difficult labor may be and the injury that the newborn may sustain as a resuIt, such a theory is obviousIy untenabIe. Others propose that inasmuch as carbon dioxide stimuIates the respiratory center, it is the increase in carbon dioxide tension in the bIood of the newborn at the time of birth that initiates respiration. Eastman has shown from his studies on the fetal blood that the baby wiI1 begin to breathe whether the carbon dioxide tension is either high or Iow. This Ieads one to question definiteIy this hypothesis. Barcroft, from his recent studies on the goat, proposes that the initiating factor is a Iack of oxygen, a minor degree of anoxemia. Thrs again has been shown by RosenfeId and Snyder not to be the case. From the evidence that is avaiIabIe, it appears that chemica1 factors do not entireIy satisfactoriIy expIain the onset of respiration. Rosenfeld and Snyder, by ingeniously pIanned experiments, have demonstrated in rabbits the existence of rhythmic respiratory movements that simurate those of extrauterine life. This phenomenon may

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be considered the bioIogica1 factor and as Eastman points out, the work of these investigators has far reaching implications. It is diffIcuIt to understand how such a vita1 function as respiration should suddenIy become initiated as soon as extrauterine Iife begins. Cardiac, hepatic and renaI mechanisms begin in intrauterine Iife. Respiration as a function is vital; as a process it is mechanical. This reviewer is led to beIieve from a11 the evidence at hand that the mechanism of respiration bioIogicaIIy is established in intrauterine Iife and assumes its vita1 function at birth. This function may we11 be awakened by a combination of the chemica1 factors considered in the foregoing. It appears pertinent to cIose this paragraph by quoting Eastman : “ Instead of being an attempt to start something new, the treatment of apnea at birth now becomes an effort to preserve and safeguard a sensitive mechanism aIready in active existence.” In reIation to the brief historica survey that has been presented of the methods used in the resuscitation of the newborn, a comment made by Thomas Denman in an earIy American edition of his Introduction to the Practice of Midwifery (I 807) is worthy of repetition: In a11 these different methods, and many others founded on caprice, or on directly contrary principIes, children have been treated in different times and countries, and yet they have generaIIy done well; the operations of Nature being very stubborn, and happiIy admitting of considerabIe deviation and interruption, without the prevention of her ends. There is yet in a11 things a perfectIy right as we11 as a wrong method; and, though the advantage or disadvantage of either may be overIooked, the propriety and advantage of the right method must be evidentIy proved by individua1 cases, and of course by the genera1 resuIt of practice. In this, as we11 as in many other points, we have been too fond of interfering with art, and have consigned too IittIe to nature, as if the human race had been destined to wretchedness and disaster from the moment of birth, beyond the aIIotment of other creatures.

CONCLUSION

A brief historica survey of the methods that have been used for the resuscitation of the newborn is presented. 2. GentIeness is the fundamenta1 requirement, and getting the air passages from the Iips to the Iungs cIear, the principa1 objective for the resuscitation of the newborn. 3. GeneraIIy we11 accepted measures are enumerated for the stimuIation of respiration in babies who do not breathe spontaneousIy shortly after birth as a resuIt of a miIder form of apnea or partia1 asphyxia. 4. In the more serious forms of asphyxia neonatorum, the better devised procedures aim to suppIy the infant with artificia1 respiration and oxygen or a mixture of oxygen and carbon dioxide. 5. The method of direct exposure intubation with a smaI1 size Iaryngoscope and controIIed intratrachea1 insufflation of IO per cent carbon dioxide and go per cent oxygen under measured pressure as devised by FIagg is used in this cIinic with very satisfactory resuIts. The method is described in detai1. 6. A brief summary of the theories advanced for the cause of the onset of respiration is given. I.

REFERENCES AHLMEYER, E. Historisch-BibIiographische ZusammensteIIung der Methoden der WiederbeIebung _ Neugeborenen. Inaug-Diss. Marburg, 1897. DRINKER and MCKHANN. The use of a new aooaratus for the prolonged administration of artificia1 respiration. J. A. M. A., 92: I 658, 1929. EASTMAN. Asphyxia Neonatorum. Internat. Clin., 2: 274, 1936. FASBENDER. Geschichte der Geburtshilfe. Jena, G. Fischer, 1906. FLAGG. Treatment of asphyxia in the new born. J .A. M. A., 91: 788, 1928. KREISELMAN, KANE and SWOPE. A new apparatus for resuscitation of asphyxiated new born babies. Am. Jour. Obst. and Gynec., 15: 552, 1928. LORD. CycIopedia of Medicine. PhiIadeIphia, Saunders, 1935. VIII: 364. MCGRATH and KUDER. Resuscitation of the new born. J. A. M. A., 106: 885, 1936. STANDER. WiIIiams Obstetrics, Ed. 7. New York, D. AppIeton-Century, 1936.