Birth practices in the US, in 1936 and in 1962
In his 1936 textbook on obstetrics, Frederick Irving, MD, recommended not suctioning the oropharynx or nares of newborns.1 If a newborn did not immediately start to cry, he advised that the baby be “drained”—by holding it upside down by its ankles and holding the head back to straighten the trachea. If necessary, Dr. Irving wrote, administer a few gentle pats over the lower ribs.
Dr. Irving approved of delayed cord clamping. In the protocol he described, the newborn typically was placed on a small baby table, just below the level of the vaginal introitus. The cord was clamped and cut when it stopped pulsating.1
Fast forward, 26 years
In his 1962 textbook on obstetrics, Duncan Reid, MD, recommended that, at birth, a baby should be immediately held upside down by the ankles and the oropharynx and nares suctioned with a bulb.2 Dr. Reid recommended that obstetricians make their own decision about delayed or immediate clamping of the cord. If the preference was for delayed cord clamping, he observed that the cord typically ceased to pulsate approximately 1 minute after birth—at which time it could be clamped.2
References
1. Irving FC. A Textbook of Obstetrics for Students and Practitioners. New York, NY: Macmillan Company; 1936:163
2. Reid DE. A Textbook of Obstetrics. Philadelphia, PA: WB Saunders; 1962:446, 468
Vigorous newborns who have been birthed through meconium-stained amniotic fluid do not need airway suctioning
Most obstetric providers have been trained to aspirate the upper airway—first the oropharynx, then the nares—of infants who have been born through meconium-stained amniotic fluid. Why? It was long believed that suctioning would reduce the risk of meconium aspiration syndrome.
Recent expert guidelines, however, no longer recommend that you suction the upper airway of vigorous infants born through meconium-stained fluid.1,10
Findings from a clinical trial. Fetuses from 2,514 term pregnancies that were characterized by meconium-stained amniotic fluid were randomized to 1) suctioning of the oropharynx, nasopharynx, and hypopharynx before delivery of the shoulders or 2) no suctioning. No differences in outcome were observed between the two groups—including no difference in the incidence of meconium aspiration syndrome; need for mechanical ventilation or duration of mechanical ventilation; oxygen dependency; and length of stay.11
The same guidelines recommend endotracheal suctioning in nonvigorous newborns,1,10—even though strong evidence to support the practice is lacking. Of course, suctioning is always warranted when the airway is clearly obstructed.
For preterm birth
Keep the preterm newborn warm with a polythene wrap
Obstetrical providers and pediatricians know: It’s important to keep preterm newborns warm because they are at high risk of hypothermia. The preterm infant has poorly developed thermoregulatory mechanisms and a very high surface area, which increase the rate of heat transfer from the newborn to the environment.
A new recommendation is that every preterm newborn who was born earlier than 28 weeks’ gestation should be kept 1) wet and 2) wrapped up to its neck in a polythene garment (known as a “life-support pouch”) to decrease the risk of hypothermia. Only the head should be dried. In a timely manner, the infant should then be placed under a radiant heater and resuscitated or stabilized, if this is indicated.
That approach has been demonstrated to be superior to drying and placing the newborn under a radiant heater as a means to prevent hypothermia.12
If wrapping is not possible, use of an exothermic mattress helps to reduce the risk of hypothermia. However, use of both polythene wrapping and an exothermic mattress may increase the risk of hyperthermia. Timely placement of a newborn under a radiant heater competes with the recommendation (discussed above) to delay clamping of the cord.
Reduce the use of 100% O2 during resuscitation
Surprisingly, use of 100% oxygen may be associated with more harm than benefit when a newborn requires resuscitation. Why? 100% oxygen may increase the level of free oxygen radicals, thereby damaging tissue. In fact, some studies report that use of 100% oxygen is associated with an increased risk of neonatal mortality.13,14
When a newborn requires resuscitation, AAP recommends:
- Initiate resuscitation with blended O2; if this is not available, use ambient air
- Adjust the O2 concentration to achieve SpO2 targets that are based on minutes-since-birth
- Use 100% oxygen if the infant’s heart rate is below 60/min at 90 seconds of resuscitation—but only until the heartbeat reaches a normal rate.1
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