Warmth & Breathing

Part of Midwifery and Childbirth

The two most immediate life-threatening risks to the newborn — hypothermia and asphyxia — and how to address them in the first minutes of life.

Why This Matters

A newborn enters the world wet, in an environment cooler than the womb, with blood vessels in the skin that dilate in response to the temperature drop. At the same moment, the baby must transition from receiving oxygen through the placenta to extracting it from air through lungs that have never expanded. Both transitions can fail within minutes, and both failures are fatal if not recognized and corrected.

Neonatal hypothermia and birth asphyxia together account for a large fraction of the estimated 2.5 million newborn deaths that occur globally each year. The tragedy is the preventability — neither condition requires sophisticated intervention at its earliest stage. Warmth requires only physical contact and dry cloth; breathing requires only correct positioning, stimulation, and in most cases a few minutes of manual ventilation with basic equipment.

The birth attendant who masters these two skills — keeping the newborn warm and ensuring it breathes — will prevent more neonatal deaths than any other single area of expertise. They require no technology. They require knowledge, practice, and calm action in the first critical minutes.

Understanding Newborn Heat Loss

A wet newborn loses heat through four mechanisms simultaneously. Understanding these mechanisms explains why the standard interventions work.

Evaporation: Water evaporating from the wet skin surface carries enormous amounts of heat. This is the most rapid cause of heat loss in the immediate post-delivery period. Intervention: dry immediately and thoroughly.

Convection: Moving air carries heat away from the skin surface. Even a warm room with air movement accelerates heat loss from a wet baby. Intervention: draft-free environment, immediate covering.

Radiation: The newborn’s warm body radiates heat to cooler surrounding surfaces (walls, windows, floor). Intervention: warm the surrounding environment, use skin-to-skin contact to provide a warm radiating surface close to the baby.

Conduction: Direct contact between the baby and a cooler surface transfers heat to the surface. Intervention: avoid placing the baby on cold surfaces; prewarmed cloths and direct skin contact.

Physiology of cold stress: When a newborn is cold, it cannot shiver (the primary adult mechanism for generating heat). Instead, it metabolizes brown adipose tissue — a special fat present in the baby’s back, neck, and around the kidneys that generates heat through a non-shivering process. This consumes glucose. A cold baby rapidly develops hypoglycemia (low blood sugar), which impairs brain function and further reduces the ability to generate warmth. A cycle can develop: cold → hypoglycemia → poor feeding → more hypoglycemia → worsening cold stress.

Normal newborn temperature: 36.5–37.5°C (97.7–99.5°F) Mild hypothermia: 36.0–36.4°C — requires warming Moderate hypothermia: 32.0–35.9°C — requires active warming, monitor closely Severe hypothermia: below 32°C — emergency; risk of cardiac arrest

Preventing Hypothermia: The Warm Chain

The “warm chain” concept defines the sequence of actions from delivery to discharge that together prevent hypothermia. Each link matters.

Link 1: Warm delivery room Before labor begins, the delivery environment should be prepared:

• Close windows and doors; eliminate drafts
• Heat the room — the ideal ambient temperature for receiving a newborn is 25-28°C
• Warm all linens: cloths can be warmed by the fire, in a heated oven for a few minutes, or by body heat stored under clothing
• Have warm water available (not hot — test on inner wrist)

Link 2: Immediate drying Within seconds of delivery:

• Place the baby on the mother’s abdomen or chest
• Dry vigorously with a prewarmed cloth — rub the back, limbs, and head
• Remove the wet cloth immediately and replace with a dry warm one
• Drying also provides tactile stimulation that often initiates breathing

Link 3: Skin-to-skin contact After drying:

• Remove wet cloths
• Place the naked baby face-down on the mother’s bare chest (or abdomen)
• Cover both with a warm blanket, including the baby’s back and head
• The mother’s skin is the ideal thermal environment — her body automatically adjusts its temperature to warm a cold baby or cool an overheated one

Link 4: Delayed cord clamping Wait 1-3 minutes before clamping and cutting the cord. In addition to the iron-store benefits, the umbilical blood transfer maintains the baby’s core temperature during this vulnerable period.

Link 5: Head covering The head represents 25% of neonatal body surface area and is responsible for significant heat loss. Any cloth fashioned into a hat — even a square of fabric wrapped around the head — makes a meaningful difference.

Link 6: Warmth during procedures If the newborn requires any procedure (resuscitation, examination, weighing), maintain warmth throughout. This may mean performing the procedure on the mother’s chest, or under a heat source if available.

Link 7: Warmth during transport If the baby must be moved: skin-to-skin with a caregiver, covered with blankets, protecting from outdoor air. Kangaroo positioning (baby against chest, covered with caregiver’s clothing) is the most effective transport method for premature and low-birth-weight infants.

Recognizing and Treating Hypothermia

Signs of hypothermia in a newborn:

• Cool skin on the trunk (hands and feet being cool is normal in the first hour)
• Pale or mottled (blotchy) skin color
• Reluctance or inability to feed — a cold baby conserves energy and suppresses hunger signals
• Lethargy, reduced movement
• Weak or absent cry
• Rapid or irregular breathing (the body attempts to increase oxygen delivery)
• In severe cases: bradycardia (slow heart rate), apnea (breathing pauses)

Warming a hypothermic newborn:

1. Remove all cold, wet clothing
2. Provide skin-to-skin contact immediately with a warm caregiver
3. Cover with prewarmed dry blankets
4. Warm the environment
5. If baby can feed: breastfeed immediately — calories and fluid help generate heat
6. Do not use direct heat sources (hot water bottles, radiant heaters close to skin) — neonatal skin burns at temperatures that feel merely warm to adults
7. Reassess temperature every 30 minutes until normalized

Rewarming rate: Warming should be gradual — approximately 0.5-1°C per hour. Rapid rewarming causes vasodilation that can drop blood pressure dangerously.

Understanding Birth Asphyxia

Asphyxia means oxygen deprivation. In newborns, it results from failure to establish effective breathing after delivery. The oxygen supply through the umbilical cord stops when the cord is clamped or ceases pulsation; if the lungs do not take over within minutes, brain damage begins.

Timeline of asphyxia:

• 0-1 minute: breathing not yet established — normal; cord still supplying some oxygen
• 1-3 minutes: if not breathing, hypoxia begins developing
• 3-5 minutes: significant brain cell death begins without intervention
• 5-10 minutes: risk of permanent neurological damage increases sharply
• Beyond 10 minutes: risk of severe disability or death without resuscitation

Causes of failure to breathe:

• Prematurity (lungs underdeveloped, surfactant deficient)
• Difficult delivery causing cerebral compression or hemorrhage
• Meconium aspiration (thick meconium in airways)
• Infection (sepsis)
• Congenital abnormalities of the airway or lungs
• Maternal sedation (opioid pain relief given close to delivery may suppress the baby’s first breath)

Newborn Resuscitation Protocol

The ABC sequence — Airway, Breathing, Circulation — guides resuscitation in the correct order.

Initial assessment (first 30 seconds): Ask three questions:

1. Is the baby breathing or crying?
2. Does the baby have good muscle tone (limbs flexed, active movement)?
3. Is the baby full-term?

If yes to all three: routine care (dry, warm, skin-to-skin).

If no to any one: begin stimulation.

Step 1: Stimulation (30-60 seconds) Vigorous drying is often sufficient to stimulate breathing. Additional stimulation:

• Rub the back firmly
• Flick the soles of the feet with a finger
• Reposition the head in slight extension (the “sniffing position” — chin slightly up, not hyperextended)

Do not: shake the baby, submerge in cold water, hold upside down, or do anything that risks injury.

Step 2: Airway clearing If breathing is attempted but appears obstructed:

• Wipe the mouth and nose with a clean cloth
• If a bulb syringe is available: gently suction the mouth first (to prevent aspiration), then the nostrils
• In the presence of thick meconium and a depressed baby: more aggressive airway suctioning before initiating positive pressure is appropriate if equipment allows

Step 3: Positive pressure ventilation (if not breathing by 60 seconds)

With a bag and mask:

1. Select the correct mask size (covers nose and mouth, does not cover eyes, does not extend past the chin)
2. Position the baby on a flat surface in the sniffing position (head slightly extended)
3. Form a tight seal between the mask and face
4. Squeeze the bag to deliver a breath — chest should rise visibly
5. Rate: 40-60 breaths per minute
6. Pressure: just enough to see the chest rise — over-inflation can rupture underdeveloped lungs

Without a bag and mask:

• Mouth-to-mouth-and-nose resuscitation: cover both the infant’s mouth and nose with your mouth; gentle puffs only — the volume of air in your cheeks is enough for an infant’s lungs
• Rate: 40-60 breaths per minute

Assess response after 30 seconds of ventilation:

• Heart rate improving (>100 bpm) and beginning to breathe: success — continue supporting until spontaneous breathing is established
• Heart rate below 60 despite ventilation: add chest compressions

Step 4: Chest compressions If heart rate remains below 60 after 30 seconds of effective ventilation:

1. Place two thumbs on the lower third of the sternum, fingers wrapped around the chest
2. Compress the chest one-third of its depth
3. Rate: 3 compressions to 1 breath (90 compressions + 30 breaths per minute)
4. Reassess heart rate every 30 seconds
5. Continue until heart rate rises above 60

Step 5: Medications (if available) If heart rate remains below 60 despite adequate compressions and ventilation: epinephrine 0.1 mL/kg of 1:10,000 solution via umbilical vein or endotracheal tube. This is beyond field midwifery capacity in most settings but worth knowing if supplies are present.

When to stop resuscitation: If there is no detectable heartbeat after 10 minutes of continuous, adequate resuscitation, survival without profound disability is extremely unlikely. The decision to stop is one of the most difficult in obstetric care and depends on available resources, gestational age, and clinical circumstances. There is no universal rule.

Post-Resuscitation Care

A baby who required resuscitation needs close monitoring and continued warmth.

• Maintain skin-to-skin contact or equivalent warmth continuously
• Monitor breathing every 15-30 minutes for the first 4 hours
• Monitor color: persistent blue lips and tongue indicate inadequate oxygenation
• Feed as soon as the baby is strong enough to suckle effectively
• Watch for seizures (rhythmic jerking) in the hours following birth asphyxia — these indicate hypoxic brain injury and require urgent referral to any available medical facility
• Document everything: time of delivery, time first breath, resuscitation steps taken, response

The first minutes of a newborn’s life are irreversible — no amount of later intervention can undo brain damage from those critical moments. But with knowledge and preparation, most of those deaths are preventable.