Every birth in the labor ward requires readiness for potential resuscitation. Midwives must evaluate risk factors before delivery, such as meconium-stained liquor, preterm gestation, or prolonged rupture of membranes. A dedicated resuscitation area must be pre-heated, equipped with a functioning radiant warmer, suction apparatus, self-inflating bags, masks, and a working pulse oximeter. At birth, the midwife immediately asks three rapid screening questions: Is the gestation term? Does the baby have good tone? Is the baby crying or breathing? If the answer to any of these is no, the newborn is brought to the radiant warmer for immediate care.
Once the newborn is under the radiant warmer, the focus shifts to establishing an open airway and preventing heat loss.
If the newborn remains apneic, gasping, or has a heart rate below 100 beats per minute after initial steps, positive pressure ventilation (PPV) must be initiated within the golden minute of life.
Select the correct mask size to cover the nose and mouth without pressing over the eyes or extending past the chin. Form a secure seal against the face using the thumb and forefinger. Deliver breaths at a rate of 40 to 60 breaths per minute using the rhythm: 'Breath, two, three, breath, two, three.' Monitor the effectiveness of PPV primarily by observing a rising heart rate and noticing chest movement with each breath. If the chest does not rise, check the mask seal, reposition the head, clear secretions, and ensure adequate pressure.
Accurate assessment of heart rate guides every advanced resuscitation decision. While auscultation with a stethoscope or palpation of the umbilical cord provides a quick estimate, continuous monitoring is superior in critical scenarios.
Place the pulse oximeter sensor on the right hand or wrist, which provides pre-ductal oxygen saturation readings reflecting blood flow directly to the brain and heart. Be aware that pulse oximeters take a minute or two to lock onto a weak pulse in a compromised infant. When resuscitation is prolonged or heart rates are difficult to detect accurately through pulse oximetry alone, attaching a 3-lead electrocardiogram (ECG) provides an immediate, reliable beat-by-beat heart rate without waiting for peripheral perfusion to improve.
Advanced airway management becomes necessary if PPV through a face mask fails to improve the infant, if chest compressions are required, or for extremely low birth weight infants.
Endotracheal intubation requires a laryngoscope with a straight blade (size 0 for preterm, size 1 for term). Insert the blade into the vallecula or directly lift the epiglottis to visualize the vocal cords, pass the tube, and confirm placement by observing chest rise, symmetrical breath sounds, and exhaled carbon dioxide detection. Alternatively, a laryngeal mask airway (LMA) serves as an effective rescue airway when intubation is unsuccessful or when the midwife is untrained in direct laryngoscopy, providing a reliable seal over the laryngeal inlet.
Chest compressions are indicated when the heart rate remains less than 60 beats per minute despite 30 seconds of effective positive pressure ventilation with 100% oxygen.
Use the two-thumb, encircling-hands technique, placing the thumbs on the lower third of the sternum just below the inter-nipple line, while supporting the back with the fingers. Depress the sternum approximately one-third of the anteroposterior diameter of the chest. Coordinate compressions and ventilations in a 3:1 ratio—three compressions followed by one breath—delivering a total of 90 compressions and 30 breaths per minute. Coordinate the rhythm with the verbal cue: 'One-and-two-and-three-and-breath-and.'
If the heart rate remains persistently below 60 beats per minute despite effective ventilation and chest compressions, emergency medications and vascular access are required.
Successful resuscitation in the labor ward is followed by intensive monitoring because complications such as hypoglycemia, persistent pulmonary hypertension, hypoxic-ischemic encephalopathy, and sepsis can emerge hours later.
Maintain strict thermal stability, monitor blood glucose, and avoid hyperoxia by titrating oxygen saturation targets based on age-specific minutes of life. Document all resuscitation events, timing of interventions, and APGAR scores meticulously in the case notes. Ensure smooth, stable transfer to the Neonatal Intensive Care Unit (NICU) with ongoing respiratory support and continuous monitoring intact.