The document provides guidance on assessing and caring for a newborn infant immediately after birth. It outlines the key steps to take which include: 1) Ensuring the newborn is dry, warm and their airway is clear through positioning, suctioning if needed, and stimulating breathing. 2) Assessing breathing, heart rate and color to evaluate circulation and provide oxygen or ventilation support if necessary. 3) Checking the umbilical cord is securely clamped and applying pressure if bleeding. 4) Repeatedly reassessing the newborn every 5 minutes to evaluate the effects of any interventions.

1. EMS SKILLEMS SKILL
OBSTETRICAL EMERGENCY / EMERGENCY CHILDBIRTH
NEWBORN ASSESSMENT & MANAGEMENT
PERFORMANCE OBJECTIVES
The examinee will demonstrate proficiency in assessing the newborn and performing initial care and interventions as necessary.
CONDITION
The examinee will be requested to assess and perform the initial care of the newborn and intervene as necessary using a simulated patient.
The newborn is full term with no major complications during pregnancy. The newborn was suctioned during the birth process, the cord
clamped and cut and the baby is wrapped in a blanket. Required equipment will be in the room readily accessible.
EQUIPMENT
Baby manikin with umbilical cord clamped, bulb syringe, baby blankets, oxygen tank with flow meter, oxygen tubing, neonatal oxygen mask,
neonatal bag-valve-mask device, stethoscope, goggles, masks, gown, gloves.
PERFORMANCE CRITERIA
100% accuracy required on all items designated by a diamond ( ) for skills testing and must manage successfully all items indicated by
double asterisks (**).
Documentation, identified by the symbol (§), must be practiced, but is not a required test item.
Appropriate body substance isolation precautions must be instituted.
• Ventilations and compressions must be at least at the minimum rate required.
PREPARATION
Skill Component Key Concepts
Take body substance isolation precautions • Mandatory personal protective equipment – gloves
Evaluate additional BSI needs • Situational - goggles, masks, gown
Determine:
Additional resources
Specialized equipment
PROCEDURE
Assessment of the newborn is performed after the baby is dried, wrapped, airway cleared, and stimulated
Skill Component Key Concepts
Assess and support body temperature:
Dry newborn completely - if not done previously
Keep wrapped with head covered
Newborns become hypothermic very easy which can precipitate
hypoglycemia, respiratory problems, increased oxygen demand and
bradycardia.
Wrap the baby so only the face is exposed, they lose most of their
heat from the head area.
Assess and support the airway:
Position on back or side with neck in a neutral position
Suction with bulb syringe - if needed
Hyperextension or flexion of neck may cause an airway obstruction.
To maintain in position, place a rolled blanket or towel under the
neck and shoulders.
If copious secretions, place baby on the side with the neck slightly
extended. This allows the secretions to collect in the mouth and not
in the posterior pharynx.
When suctioning with a bulb syringe:
- make sure that the bulb syringe is compressed first before placing
in the mouth and nose
- place the syringe approx. 1"-1 1/2” into the mouth and no more
than 1/2” into nostrils, slowly release the bulb drawing fluid into the
syringe and discharge contents onto a towel.
Prolonged or deep suctioning of the newborn’s oropharynx may
cause bradycardia and/or apnea. Never suction longer than 3-5
seconds per attempt.
Obstetrical Emergency – Newborn Assessment & Management
© 2001, 2004
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2. Obstetrical Emergency – Newborn Assessment & Management
© 2001, 2004
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Skill Component Key Concepts
Assess breathing:
If adequate - continue with assessment
If respirations shallow or slow - administer oxygen and
stimulate by:
- vigorously rubbing back with a towel slapping or
flicking the soles of the feet
If gasping or respirations are inadequate - ventilate
with bag-valve-mask at 40-60 breaths per minute
Ventilate baby with bag-valve-mask if no response to administration
of 100% oxygen and stimulation of 5-10 seconds.
Oxygen should be administered by:
- using a face mask with at least 5 Liters/minute, held loosely over
the baby’s face
- blow-by with oxygen tubing at least 5 Liters/minute, held near the
baby’s nostrils
For effective bag-valve-mask ventilations, the mask must be the
appropriate size and have a tight seal.
Use only enough force to allow for good chest rise. Over-inflation
causes gastric distention, which will affect tidal volume by elevating
the diaphragm.
Assess circulation:
Heart rate
If > than 120 beats/minute - continue assessment
If 100-120 beats/minute -administer oxygen
If < than 100 beats/minute - ventilate with bag-valve-
mask device attached to 100% oxygen
If < 60 beats/minute - start CPR @ rate of
120 compressions/minute
Color
If pink or peripheral cyanosis of hands and feet - no
treatment indicated
If central cyanosis and good respirations and heart
rate > 100 beats/minute - administer oxygen
If generalized pallor or cyanosis and no response to
oxygen administration - ventilate with bag-valve-mask
device attached to 100% oxygen
The heart rate is a reliable indicator of the newborn’s distress level.
Check pulse by one of the following:
- palpate pulse at base of umbilical cord
- palpate brachial or femoral pulse
- auscultate apical pulse
Normal newborn heart rate is 120-160 beats/minute.
If ventilating with a bag-valve-mask device, or performing chest
compressions the heart rate must be re-assessed every
30 seconds.
Compression to ventilation ratio is 3 compressions to 1 ventilation.
Color is the least important indicator of adequate circulation. The
newborn must also be assessed for activity, grimace cry, heart rate
and respirations.
DO NOT attempt to obtain an APGAR score if the newborn requires
resuscitation measures.
APGAR score is determined at 1 minute and 5 minutes after birth. If
the score is less than 7, it is repeated every 5 minutes for 20
minutes.
Los Angeles County does not required an APGAR score, nor is the
APGAR score part of the National DOT Curriculum. However, EMT
and Paramedic textbooks provide this information and many EMS
systems use this score as part of the newborn assessment.
Assess umbilical cord for:
Bleeding - apply sterile dressing and direct pressure if
indicated
Security of clamps or ties - use additional clamps or
ties as indicated
Make sure clamps are secure and will not slip or the baby may
hemorrhage.
Use ties in case of an enlarged umbilical cord.
The mother and newborn should be transported to the same facility.
BLS units shall call for an ALS unit or transport to the most
appropriate hospital as per Reference:
- 511 - Perinatal Patient Destination
- 808 - Base Hospital Contact and Transport Criteria.
ONGOING ASSESSMENT
Skill Component Key Concepts
§ Repeat an ongoing assessment every 5 minutes:
Initial assessment
Relevant portion of the focused assessment
Evaluate response to treatment
Compare results to baseline condition and vital signs
The initial and focused examination is repeated every 15 minutes for
stable patients and every 5 minutes for priority patients.
Every patient must be re-evaluated at least every 5 minutes, if any
treatment was initiated or medication administered, unless changes
in the patient’s condition are anticipated sooner.
Priority patients are patients who have abnormal vital signs, signs/
symptoms of poor perfusion or if there is a suspicion that the
patient’s condition may deteriorate.

3. Obstetrical Emergency – Newborn Assessment & Management
© 2001, 2004
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DOCUMENTATION
Skill Component Key Concepts
§ Verbalize/Document:
Time of delivery of baby
Problems with this pregnancy
Presence of meconium
Integrity of the cord
Condition of the baby
Documentation must be on either the Los Angeles County EMS
Report or departmental Patient Care Record form.
Time of delivery for the baby is the time when the baby’s body is
delivered.
Developed 12/01 Revised 7/04

4. OBSTETRICAL EMERGENCY / EMERGENCY CHILDBIRTH
NEWBORN ASSESSMENT & MANAGEMENT
Supplemental Information
DEFINITIONS:
• Baby - name used to indicate newborn
• Newborn - neonate in the first minutes to hours after birth
• Neonate - infants in first month after birth (28 days)
• Infant - includes the neonate period to 1 year (12 months)
• Central cyanosis - bluish color on trunk and face
• Peripheral cyanosis - bluish color limited to hands and feet
• Meconium - fetal feces that is normally passed as the baby’s first bowel movement. However, during fetal or maternal stress,
defecation may occur before birth
• Oxygen administration - administration of free-flow oxygen directly to baby’s face by either mask or blow-by method:
- mask - at least 5 Liters/minute, held loosely over baby’s face
- blow-by with oxygen tubing - at least 5 Liters/minute, held near the nostrils
INDICATIONS FOR BAG-VALVE-MASK VENTILATIONS:
• Apnea, gasping, or inadequate respirations
• Heart rate less than 100 beats/minute
• Persistent central cyanosis unresponsive to administration of oxygen
INDICATIONS FOR CARDIOPULMONARY RESUSCITATION:
• Pulseless
• Heart rate less than 60 beats/minute
NOTES:
• Newborns must make three rapid transitions to the out side world from their protected environment in utero:
- Changing their circulatory pattern
- Emptying fluid from their lungs and beginning ventilation
- Maintaining body temperature
• Four main objectives in caring for the newborn:
- Provide and maintain warmth. Important to dry and wrap baby with only face exposed, they lose most of their heat from the head
area.
- Continually assess respirations, heart rate and color.
- Maintain adequate respirations by positioning, suctioning, administration of oxygen, and ventilate with a BVM if indicated
- Provide cardiac compressions for heart rate < 60
• The mother and newborn should be transported to the same facility.
• BLS units shall call for an ALS unit or transport to the most appropriate hospital as per Reference No. 511 and 808
• Signs of poor perfusion are: weak cry, bradycardia (heart rate < 100 beats/minute), inadequate respirations (< 40 breaths/minute), and
cyanosis.
• Hyperextension or flexion of neck may cause an airway obstruction. To maintain in position, place a folded blanket or towel under
the neck and shoulders.
• If copious secretions are present, position the baby on the side and slightly extend the neck. This allows the secretions to collect in
the mouth and not in the posterior pharynx.
• When ventilating with a BVM, use only enough force to allow for good chest rise. Over-inflation causes gastric distention which will
affect tidal volume by elevating the diaphragm
• If ventilating with a bag-valve-mask device, heart rate must be re-assessed every 30 seconds.
• Check pulse by one of the following:
- auscultate apical pulse
- palpate pulse at base of umbilical cord
- palpate brachial or femoral pulse
• Normal newborn heart rate is 120-160 beats/minute.
• Compression to ventilation ratio is 3 compressions to 1 ventilation.
• APGAR score is not required in Los Angeles County and is not in the EMT-I DOT Curriculum, but is found in all ECB literature.
Obstetrical Emergency – Newborn Assessment & Management
© 2001, 2004
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5. • APGAR score is assessed at 1 minute and 5 minutes and if the score is less than 7, it is repeated every 5 minutes for 20 minutes.
OBSTETRICAL EMERGENCY / EMERGENCY CHILDBIRTH
NEWBORN ASSESSMENT & MANAGEMENT
APGAR SCORE
Evaluation Factor Findings Score
Appearance (color) - cyanotic or pale
- blue hands and feed with pink body
0 points
1 point
- extremities and trunk pink 2points
Pulse - no pulse
- < 100/ minute
0 points
1 point
- > 100/minute 2 points
Grimace (reflex irritability) - no reflex to stimulation
- slight reflex to stimulation
0 points
1 point
- grimace, cough, sneeze, or cry in response to stimulation 2 points
Activity (extremity movement, degree of flexion and resistance to
straightening them)
- limp, no extremity movement
- some flexion with no movement
0 points
1 point
- actively moving 2 points
Respirations - no respiratory effort
- slow, irregular effort with weak cry
0 points
1 point
- good effort with strong cry 2 points
7-10 points = normal - provide routine care 4-6 points = moderately depress - provide stimulation and oxygen 0-3 points = severely depressed - provide CPR and BVM ventilations
• The inverted pyramid - reflects the frequencies for neonatal resuscitation without meconium stained amniotic fluid
INVERTED PYRAMID
STEPS
Step 1 - always needed 1
Step 2 - frequently needed 2
Step 3 - infrequently needed 3
Step 4 - infrequently needed 4
Step 5 - rarely needed 5
• Always assess and manage:
 Temperature (warm & dry) American Heart Association Pyramid
 Airway (position & suction)  Breathing (stimulate to cry)
 Circulation (heart rate & color)
Obstetrical Emergency – Newborn Assessment & Management
© 2001, 2004
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