NCM

Suctioning the Newborn

Topic Outline
1. Definition and Introduction
2. Principles and Concepts
3. Discussion Related L
4. Proper procedure of Suctioning the Newborn

Learning Outcomes
After studying this unit, you will be able to:
 Perform proper assessment of infant at birth.
 Define the importance and purpose of Suctioning the Newborn
 Know the Principles and Concepts of Suctioning the Newborn
 Perform the proper procedure of Suctioning the Newborn

Introduction

Routine suctioning at birth has been the standard of care for newborns for decades. But recent evidence calls this practice
into question, and many hospitals are moving away from it. But this doesn’t mean that suctioning is obsolete. Newborns in
respiratory distress, those with low Apgar scores, and those struggling with the transition from fetus to newborn may still need bulb
suctioning, or occasionally, suctioning with a machine.
The World Health Organization (WHO) now advises against routine bulb suctioning of neonates in the minutes following
birth. If the baby is born through clear amniotic fluid and begins breathing on their own shortly after birth, do not suction. However,
if the baby struggles with signs of respiratory distress, do not delay suctioning. Aspirated meconium can be especially lethal to
newborns, and the faster you are able to suction them, the greater their likelihood of survival.

Read
 Maternal and Child Health Nursing (Care of the Child Bearing and Child Bearing Family) 7 th Edition by Adele
Pillitteri focusing on Essential Newborn Care/ Intrapartum Newborn Care
 Fundamentals of Nursing 8th Edition by Potter and Perry focusing on suctioning techniques.

Demonstration Link (Essential Newborn Care/ Intrapartum Newborn Care)

View this video demonstration by clicking the following link to learn more about Suctioning the Newborn:
 https://www.youtube.com/watch?v=TUxQCPhaYbc

Discussion: Assessing the infant at birth

Most newborn infants start to breathe well without assistance and often cry immediately after birth. By 1
minute after delivery most infants are breathing well or crying. If an infant fails to establish adequate, sustained
respiration after delivery (gasps only or does not breathe at all) the infant is said to have failed to breathe well at birth.
About 10% of all newborn infants fail to breathe well and require some assistance to start breathing well after birth.

APGAR Scoring System

At 1 minute and 5 minutes after birth, newborns are observed and rated according to an Apgar score, an
assessment scale used as a standard for newborn evaluation since 1958. The 1-minute score determines how well the
baby tolerated the birthing process. The 5-minute score tells the health care provider how well the baby is doing outside
the mother's womb. Virginia Apgar, MD (1909-1974) introduced the Apgar score in 1952. Heart rate, respiratory effort,
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.
 muscle tone, reflex irritability, and color of the infant are each rated 0, 1, or 2. There is a high correlation
between low 5-minute Apgar scores and neurologic illness. The following points should be considered in obtaining the
rating.

Heart Rate. Auscultating a newborn heart with a stethoscope is the best way to determine heart rate; however, heart
rate also may be obtained by observing and counting the pulsations of the umbilical cord at the abdomen if the cord is
still uncut.
Respiratory Effort. Respirations are counted by observing chest movements. A mature newborn usually cries and
aerates the lungs spontaneously at about 30 seconds after birth. By 1 minute, he or she is maintaining regular, although
rapid, respirations. Difficulty with breathing might be anticipated in a newborn whose mother received large amounts
of analgesia or a general anesthetic during labor or birth.
Muscle Tone. Term newborns hold their extremities tightly flexed, simulating their intrauterine position. Muscle tone
is tested by observing their resistance to any effort to extend their extremities.
Reflex Irritability. One of two possible cues is used to evaluate reflex irritability: response to a suction catheter in the
nostrils or response to having the soles of the feet slapped. A baby whose mother was heavily sedated for birth will
probably demonstrate a low score in this category.
Color. All infants appear cyanotic at the moment of birth. They grow pink with or shortly after the first breath, which
makes the color of newborns correspond to how well they are breathing. Acrocyanosis (cyanosis of the hands and feet)
is so common in newborns that a score of 1 in this category can be thought of as normal.

Interpretation
Total score:
• Score of 4 indicates serious danger of respiratory or cardiovascular failure; newborn needs resuscitation.
• Score of 4–6 indicates a guarded condition; newborn may need clearing of the airway and supplementary oxygen.
• Score of 7–10 indicates the infant scored as high as 70%–90% of all infants at 1 and 5 min after birth or is adjusting
well to extrauterine life.

The Apgar score should be performed on all infants at 1 minute after complete delivery to record the infant’s
clinical condition after birth. If the 1-minute Apgar score is below 7, then the Apgar score should be repeated at 5
minutes to document the success or failure of the resuscitation efforts. If the 5-minute Apgar score is still low, it should
be repeated every 5 minutes until a normal Apgar score of 7 or more is achieved. In many hospitals, the Apgar score is
often routinely repeated at 5 minutes even if the 1-minute score was normal. Apgar scoring is an important way to
document the infant’s clinical condition and the response to resuscitation in the hospital or clinical records.

Stimulation of respiration after birth

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.
 Dry to stimulate breathing in all infants immediately after delivery. All infants must be thoroughly dried with a
warm towel and then placed in a second warm, dry towel before they are clinically assessed. This prevents rapid heat
loss due to evaporation, even in a warm room. Dry the infant’s head, body, arms and legs and wipe any blood or
maternal feces off the face. Handling and rubbing the newborn infant with a dry towel are usually all that is needed to
stimulate the onset of breathing. Most infants can be dried on the mother’s abdomen. There is no need to smack
newborn infants to get them to breathe. Never shake an infant. If the infant does not cry or breathe well in response to
drying and stimulation, the umbilical cord must be cut and clamped immediately and the infant must be moved to the
resuscitation area.
Infants who are active and breathe well can stay with their mother. It is best to delay clamping their umbilical
cord for 1 to 3 minutes if the infant does not need resuscitation. Then the infant should be placed in the kangaroo
mother care position to keep warm. Infants who breathe well should not be routinely suctioned as this is not
necessary and suctioning sometimes causes apnea. Infants born by Caesarean section also need not be routinely
suctioned. However, the infant’s mouth can be wiped with a clean towel if there are excessive secretions.

Suctioning the Newborn

If the infant fails to respond to the stimulation of drying, then the infant must be actively resuscitated.
Suctioning the airway is one way of improving gas exchange and ventilation. Suctioning is removing mucus and fluids
from the nose, mouth or back of the throat with a bulb syringe or a catheter (thin flexible tube).

Different Types of Suctioning

 Nasal suction (suctioning in the nose)
 With nasal suctioning, a catheter or small tip catheter is passed into the nostril. This is helpful when
secretions are visible in the nose or you suspect that secretions are blocking the nasal passage.
 Oral suction (suctioning the mouth)
 Oral suctioning is useful when your child is unable to remove secretions by coughing (for example,
they have a weak cough) or they are drooling because they cannot swallow.
 Nasopharyngeal and oropharyngeal suction (suctioning the throat)
 A suction catheter (a thin, clear, soft plastic tube preferably with depth markings on it) is inserted to a
predetermined depth through the nose (nasopharyngeal) or mouth (oropharyngeal) to the back of the
throat. This type of suctioning is useful when secretions are pooled at the back of the throat and your
child does not have the ability to cough them up or swallow them.
 Deep suctioning
 Deep suctioning lets you remove mucus from your child’s airway. This method is usually done with
an artificial airway such as a tracheostomy tube and endotracheal tube. It removes mucus between the
end of the tube and the carina (the part where the trachea splits into the bronchi, the tubes that go into
the lungs). Deep suctioning is often done in urgent situations when secretions are unable to be
removed by the other methods and the child is in distress.

Only suction a neonate who shows clear signs that suctioning is appropriate:
 An increase in CO2
 Increased oxygen needs
 Bradycardia and apnea
 Audible breathing, gasping, or wheezing
 Visible secretions, or obvious difficulty clearing the airway
 Aspiration
 blue or gray color around eyes, mouth, fingernails, or toenails
 tachycardia or tachypnea
 a "gurgle" sound of secretions
 you feel "rattling" on the infant's chest or back
 infant seems anxious or restless, or cries and cannot be comforted
 nostrils flare (open wider when breathing in)
 retracting (chest or neck skin pulls in with each breath)

Potential Complications of Suctioning

 Hypoxia
 Bronchospasm
 Tracheobronchial mucosal trauma resulting in potential pulmonary hemorrhage
 Contamination of airway leading to nosocomial infection
 Atelectasis (loss of ciliary function / glottis closure)
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.
  Right upper lobe collapse (excessive suction pressures) (Boothroyd et al. 1996)
 Pneumothorax (Morrow and Argent 2008)

Essential Equipments Needed:

 Bulb syringe
 Oxygen source / oxygen mixer for preterm / neonates
 Monitoring equipment – oxygen saturation, heart rate and blood pressure
 Portable or wall suction
 Connecting tube
 Appropriately sized suction catheters/ Suction Kit
 Sterile gloves
 Clean gloves
 Disposable plastic apron
 PPE (face shield, face mask, goggles)
 Alcohol
 Sterile Irrigating Solution
 Sterile basin
 Tissue

Guidelines on Return Virtual Return Demonstration

Procedure
1. Upon delivery of the new born, comprehensive
assessment. Use APGAR scoring system.
2. Explain the procedure to the mother or significant
other
3. Obtain consent form the mother or significant other
4. Place pulse oximeter on infant’s foot. Take reading and
leave pulse oximeter in place.
5. Gather all the equipment’s needed
Suctioning with a bulb syringe (A bulb syringe is used to clean the nose or to remove mucus that has been coughed up. Most
suctioning can be done this way. You may use this method as often as needed.)
6. Perform hand hygiene
7. Wear clean gloves.
8. Swaddle the infant (wrap snugly in a blanket) while placed
on a warmer.
9. Hold the tip of the bulb between your middle finger and
forefinger. The bulb should touch the palm of your hand.
Before inserting the tip into your baby’s nose, use your
thumb to push out the air until it is collapsed.
10. Insert the tip of the bulb into the mouth first, then slowly Suction is created as your thumb releases pressure on the bulb.
release your thumb.
11. Remove the bulb syringe from the infant’s mouth. Use
your thumb to push mucus or fluids out of the bulb syringe
onto a tissue or paper towel.
12. Repeat the procedure, but now insert the bulb syringe into
each nostril of the infant.
Rationale
-To assess the need for suctioning.
-Health assessments of the newborn start right away. One of
the first checks is the Apgar test. The Apgar test is a scoring
system to evaluate the condition of the newborn at 1 minute
and 5 minutes after birth.
To minimize anxiety and stress.
Promoting advocacy to the newborn and to protect the nurse
Provides baseline SpO2 to determine client’s response to
suctioning.
To ensure effectiveness of procedure and minimize risk of
complications
Reduces transmission of microorganisms.
Suctioning using bulb syringe does not require sterile glove
use.
To prevent the infant from wiggling when you suction.
Collapsing the bulb before inserting in inside the nose or
mouth will prevent trauma.
This will remove the mucus or fluid from the infant’s mouth. •
In newborns, always suction the mouth before the
nose, because suctioning the nose first may trigger a reflex
gasp, possibly leading to aspiration if there is mucus in the
posterior throat.
Remove mucus and fluid from the bulb syringe every after
suction to prevent pushing back the mucus back to the infant.
Follow mouth suctioning with suction to the nose, because the
nose is the chief conduit for air in newborns.

13. Repeat as needed. Allow the infant to recover and breathe

This will allow the infant to rest and gain proper breathing in
between each suction attempt. Gently wipe your child’s
between suctioning to prevent hypoxia.
nose with a tissue as needed.
14. When finished, clean the bulb syringe using a bowl of Cleaning the bulb after use will help prevent the spread of
soapy water, pulling the soapy water into the bulb and germs. It is impossible to completely clean the inside of the
squeezing it out. Let the bulb syringe air dry. With your bulb; therefore, it is recommended that you replace the bulb
thumb compressing the bulb, place the tip into the bowl of syringe after 24 hours of use.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.
 warm water and then release your thumb to pull the water
into the bulb syringe. Push the bulb with your thumb to
push out the dirty water into the sink or another bowl. Do
not push out the dirty water into the clean water.
15. Wash your hands. To prevent spread of microorganisms after suctioning.
Suctioning with a catheter
5. Decontaminate hands prior to procedure. Put on PPE Maintenance of asepsis and prevention of cross infection.
(goggles, facemask, face shield) Protection of practitioner.
6. Calculate the appropriate size of the suction catheter

To ensure effectiveness of procedure and minimize

risk of complications. To guarantee maximum of 50% of
internal diameter which creates less negative pressure and
prevents hypoxia and right upper lobe collapse / atelectasis. It
also limits the risk of mucosal trauma. Too big a suction
catheter has been demonstrated to reduce the tidal volume to <
10%.

7. Open suction kit or catheter with the use of aseptic

Prepares catheter and prevents transmission of
technique. If sterile drape is available, place it on the over
microorganisms. Provides sterile surface on which to lay
bed table. Do not allow the suction catheter to touch any
suction catheter between passes, if needed.
non-sterile surfaces.
8. Unwrap or open sterile basin and place on bedside table.
This solution is used to irrigate the catheter in between
Fill basin or cup with approximately 100ml of sterile
suctions.
normal saline irrigating solution.
9. Turn on suction device. Ensure the correct suction pressure
High negative suction pressures and deep suctioning may cause
is set:
right upper lobe collapse in children. Also, high pressures may
 Neonate 50 – 80mmHg
damage respiratory mucosa and cause destruction of epithelial
 Pediatric 80 – 100mmHg
cilia of the airways.
 Older Child 100 – 120mmHg
10. Suction Airway.
A. Oropharyngeal Suctioning
i. Apply clean disposable glove to dominant hand. Suction or oral cavity does not require sterile glove use.
ii. Attach suction catheter to connecting tubing.
Remove oxygen mask if present.
iii. Insert catheter into the infant’s mouth. With suction
applied, move the catheter around the mouth, Take care not to allow suction tip to invaginate oral mucosa
including pharynx and gum line, until secretions are surfaces with continuous suction.
cleared.
iv. Suction irrigating solution from the basin through Clearing secretions before they dry reduces probability of
catheter until catheter is cleared of secretions. transmission of microorganisms and enhances delivery of
preset suction pressures.
v. Place catheter in a clean dry area for reuse with Facilitates prompt removal of airway secretions when
suction turned off on client’s bedside. suctioning is needed in the future.
B. Nasopharyngeal Suctioning
i. If indicated, increase supplemental oxygen therapy to
30% above infant’s baseline oxygen requirements or Preoxygenation assist in reducing suction-induced hypoxemia.
as ordered by the physician.
ii. Open lubricant. Squeeze small amount onto open Prepares lubricant while maintaining sterility. Water-soluble
sterile catheter package without touching the lubricant is used to avoid lipoid aspiration pneumonia.
package. Excessive lubricant can occlude catheter.
iii. Apply sterile glove to each hand, or apply nonsterile
Reduces transmission of microorganisms and allows nurse to
glove to nondominant hand and sterile glove to
maintain sterility of suction catheter.
dominant hand.
iv. Pick up suction catheter with dominant hand without
touching nonsterile surfaces. Pick up connecting
Maintains catheter sterility.
tubing with nondominant hand. Secure catheter to
tubing.
v. Check that equipment is functioning properly by
suctioning small amount of normal saline solution Ensures equipment function.; lubricates catheter and tubing.
from basin.
vi. Lightly coat distal 6 to 8 cm of catheter with water-
Lubricates catheter for easier insertion.
soluble lubricant.
vii. Remove oxygen delivery device, if applicable, with Application of suction pressure while introducing catheter into
nondominant hand. Without applying suction and nasopharyngeal tissues increases risk of damage to mucosa.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.
 using dominant thumb and forefinger, gently insert
catheter into naris during inhalation.
viii. Follow natural course of naris; slightly slant catheter
downward and advance to back of pharynx. In
infants 4 to 8 cm (2 to 3 inches). Rule of thumb is to
insert catheter distance from tip of nose (or mouth) to
the base of earlobe.
ix. Apply intermittent suction by placing and releasing
nondominant thumb over catheter vent. Slowly
withdraw catheter while rotating it back and forth
between thumb and forefinger.
C. Nasotracheal Suctioning
viii. Follow natural course of naris and advance catheter
slightly slanted and downward to just above entrance
into trachea. Quickly insert catheter during inhalation
about 8 to 14 cm (3 to 5 ½ inches).
ix. Apply intermittent suction for up to 10 seconds by
placing and releasing nondominant thumb over vent
of catheter and slowly withdrawing catheter while
rotating it back and forth between dominant thumb
and forefinger. Replace oxygen device, if applicable.
x. Rinse catheter and connecting tubing with normal
saline until cleared.
xi. Assess for need to repeat suctioning procedure.
Allow adequate time between suction passes for
ventilation and oxygenation.
11. Disconnect catheter from connecting tubing. Roll catheter
around fingers of dominant hand. Pull glove off inside so
that catheter remains in glove. Pull off other glove over
first glove in same way to contain contaminants. Discard
into appropriate receptacle. Turn off suction device.
12. Reposition newborn as indicated by condition (side-lying).
13. If indicated, readjust oxygen to original level because
client’s blood oxygen level should have been returned to
baseline.
14. Discard remainder of normal saline into appropriate
receptacle. If basin is reusable, rinse and place in soiled
utility room.
15. Remove and discard PPE, and perform hand hygiene.
16. Place unopened suction kit on suction machine table or at
head of bed.
17. Compare client’s vital signs and O2 saturation before and
after suctioning.
18. Observe airway secretions.
19. Document the procedure and all the data observed.
When advanced into trachea, suction could
damage mucosa and increase risk of hypoxia.
Proper placement ensures removal of pharyngeal secretions.
Intermittent suction safely removes pharyngeal secretions.
Ensures catheter will be inserted into trachea with minimum
stress to client. Insert catheter during inhalation, especially if
inserting catheter into trachea because epiglottis is open. Do
not insert during swallowing or catheter will most likely enter
esophagus. Never apply suction during insertion. If infant gags
or becomes nauseated, catheter is most likely in esophagus and
must be removed.
Intermittent suction and rotation of catheter prevent injury to
mucosa. If catheter “grabs” mucosa, remove thumb to release
suction. Suctioning longer than 10 seconds can cause
cardiopulmonary compromise, usually hypoxemia or vagal
overload.
Removes secretions from catheter. Secretions that remain in
suction catheter or connecting tubing decrease suctioning
efficiency.
Observe alterations in cardiopulmonary status. Suctioning can
induce hypoxemia, dysrhythmias, laryngospasm, and
bronchospasm. Repeated passes clear the airway of excessive
secretions but can also remove oxygen and may induce
laryngospasm.
Reduces transmission of microorganisms. Clean equipment
should not be touched with contaminated gloves.
Proper positioning based on client’s condition promotes
comfort, encourages drainage, and reduces risk for aspiration.
Solution is already contaminated.
Reduces transmission of microorganisms.
Provides immediate access of suction catheter and equipment
in the event of an emergency or for the next suctioning
procedure.
Identifies physiological effects of suction procedure to restore
airway patency.
Provides data to document presence or absence of respiratory
tract infection.
Documentation is very important, because what is not
documented is not done.

Summary

If the infant fails to respond to the stimulation of drying, then the infant must be actively suctioned to clear
airways. Although not done routinely, if a newborn appears to have a great deal of mucus in the mouth following birth,
the primary care provider can suction this from the infant’s mouth by a bulb syringe before the infant is laid on the
mother’s abdomen in order to prevent aspiration of the secretions. If the infant continues to have an accumulation of
mucus in the mouth or nose after these first steps, you may need to suction further after the baby is placed under a
warmer. Use a bulb syringe or a soft, small suction catheter. The suctioning techniques include oropharyngeal,
orotracheal/ nasotracheal suctioning. In newborns, always suction the mouth before the nose, because suctioning the
nose first may trigger a reflex gasp, possibly leading to aspiration if there is mucus in the posterior throat. Follow
mouth suctioning with suction to the nose, because the nose is the chief conduit for air in newborns.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.
 These techniques are based on common principles. Because oropharynx and trachea are
considered sterile, sterile technique is used for suctioning. Frequency of suctioning is determined by client assessment
and need.

Readings and References

• Fundamentals of Nursing 8th Edition by Potter and Perry

• Maternal and Child Health Nursing (Care of the Child Bearing and Child Bearing Family) 7 th Edition by
Adele Pillitteri

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing,
uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU,
is strictly prohibited.