ð

NEWBORNTRANSITIONANDNEONATALRESUSCITATION

LIMPOPOINIATIVEFORNEWBORNCARE2017

1

2

TABLEOFCONTENTS

INTRODUCTIONTOTHECOURSEONNEWBORNTRANSITIONANDNEONATALRESUSCITATION 4

COURSEOVERVIEW 4HOWTHECOURSEWORKS 4COURSEDEVELOPERSANDFACILITATORS 4

MODULE1:NEWBORNTRANSITIONANDRESUSCITATION 6

MODULE1:PREPARINGFORTHEBIRTH 9

STEP1:PREPAREANEMERGENCYPLAN 9STEP2:HANDWASHING 9STEP3:PREPARETHEMOTHERANDBIRTHCOMPANIONFORTHEDELIVERY 11STEP4:PREPARETHEAREAFORDELIVERY. 11STEP5:PREPAREFORRESUSCITATIONANDCHECKTHEEMERGENCYEQUIPMENT. 11SELFASSSEMENTQUESTIONS:MODULE1 15

MODULE2:ROUTINECAREATBIRTH 16

DRYTHOROUGHLY 16CHECKIFTHEBABYISCRYING,CHECKBREATHING,KEEPWARM 16CLAMPANDCUTTHECORD. 16ROUTINECAREOFBABIESBORNBYCAESAREANSECTION 17ROUTINECAREOFPRETERMBABIES 17MONITORBABYWITHMOTHERANDINITIATEBREASTFEEDING 18RAPIDLYASSESSTHEBABYIMMEDIATELYAFTERBIRTH 18SELFASSESSMENTQUESTIONS:MODULE2 21

MODULE3:HELPTHEBABYWHOISNOTBREATHINGWELL 22

3.1CLEARTHEAIRWAYANDSTIMULATEBREATHING. 223.2VENTILATEWITHBAGANDMASK 233.3IMPROVEVENTILATIONIFTHEBABYISSTILLNOTBREATHINGWELL 24SELFASSESSMENTQUESTIONS:MODULE3 25

MODULE4.ADVANCEDRESUSCITATION 26

4.1PATHOPHYSIOLOGYOFBIRTHASPHYXIA 264.2ADVANCEDCARE:HEARTRATE 274.3ENDOTRACHEALINTUBATION 304.4UMBILICALVEINCATHETERISATION 334.5WHENTOWITHHOLDORDISCONTINUELIFESUPPORT 344.6POSTRESUSCITATIONCAREOFTHENEONATE 35SELFASSESSMENTQUESTIONSMODULE4 35REFERENCES 37CLINICALPRACTICESESSIONS 39

3

4

INTRODUCTIONTOTHECOURSEONNEWBORNTRANSITIONANDNEONATALRESUSCITATION

COURSEOVERVIEW

Thecourse is fordoctors,midwivesandclinicalassociatesworking indistrictandregionalhospitals inSouthAfrica.Thecoursecoversthe immediatecareofthenewbornduringtransition inthedeliveryroomaswellasallneonatalresuscitation prior to the transfer of both mother and baby to the postnatal or neonatal ward. This course iscomplimentary to theHelpingBabiesBreathe (HBB) course, an iniativeof theAmericanAcademyofPediatricsandpartners.AllmidwivesinSouthAfricaarerequiredtoundergotheHBBcourse.ThiscoursefollowsthesamestepsasHBB and then incorporates advanced resuscitation, resuscitation of the preterm newborn, care of the newborndeliveredbycaesareansectionandtheimmediatepostresuscitationcareofallnewborns.

HOWTHECOURSEWORKS

Thecourseconsistsof4modules,eachfollowedbyanassessment.Eachmoduleincorporatesreading,chartreviews,videosandassessmentquestions.Alistofadditionalreadingmaterialwillbeprovided.

Thecoursecanbedoneinanumberofways.

1. Pre-reading andattendanceataplannedcourse inyourdistrict.Read thismaterialandwatch thevideo’swhichareavailableonthewebsitewww.lincare.co.zabeforeattendingacourseinyourdistrictorprovince.AtthestarttothecoursethefacilitatorwillbegiveyoutheMCQ’stodobeforegoingontotheclinicalskillssessions.

2. Ase-learning.Youcanenrol for thee-learningcourse.Gotothewebsitewww.lincare.co.zaandfollowtheinstructionsonthee-learningtab.Thee-learningishostedbytheUniversityofLimpopoontheBlackboardlearnplatform.YoucandownloadtheBlackboard learnAPPonyoursmartphone.Aspartofthee-learningyouwillbeassignedafacilitator;thiswillusuallybeaPaediatricianorseniorclinicianworkinginyourfacility,district or region. Your facilitator will host a discussion forum with a group of participants, and may setadditionaloptionaltasks.Yourfacilitatorandgroupwilldecideonadatefortheclinicalskillssession.

ParticipantswhoworkinLimpopoandotherparticipatingprovinceswillbeinvitedbytheirfacilitatortoenrolina2–3hourskillssession.

CEUpointswillbeavailableonsuccessfulcompletionoftheon-siteande-learningcourse.

Youarewelcometoreadthismaterialandwatchanddownloadthevideo’s.WewillhowevernotbeabletoprovideyouwithCEUpointsunlessyouenrolonaformalcourse.

COURSEDEVELOPERSANDFACILITATORS

ThecoursedevelopersareDrAnneRobertsonandDrRienkBaarsma.

Dr Anne Robertson is the Provincial Paediatrician in the Limpopo Province, Department of Health and jointlyappointedwiththeUniversityofLimpopo.SheisinvolvedinseveralinitiativestoimprovepaediatricandchildhealthinLimpopoProvinceandSouthAfrica.

DrRienkBaarsmaisaNeonatologistfromtheNetherlands,withextensiveexperienceinclinicalneonatology,generalpaediatrics, teaching and research. He worked in Mankweng Hospital, Limpopo Province from 2012-2015, as aNeonatalogist.

Acknowledgements

5

Thevideo’swereproducedbyDrRienkBaarsmawiththeassistanceofMsLollyMashao(LimpopoProvincialNeonatalcoordinator)andDrGlenroseRikhotso.(PaediatricRegistrar,UniversityofLimpopo)

DrDelinaManzini(Paediatrician)hasassistedwitheditinganddevelopingfurtherassessmentmaterial.

MrAndrewScholtz(Educationaltechnologist)hasadvisedontheeducationmethodologyandhasdevelopedandsetuptheon-lineplatformande-learningcourse.

Coursefacilitators

Youwillbeassignedacoursefacilitatorwithwhomyoucaninteractanddiscuss.YourfacilitatorwillusuallybeaPaediatricianorseniorclinicianinyourfacility,districtorregionalhospital.

6

MODULE1:NEWBORNTRANSITIONANDRESUSCITATION

Thetransitionfromafoetustoanewborn isaphysiologicalprocessthatbegins inthe latterpartofpregnancyandcontinues throughout labour. At around 28weeks gestation, the alveolar cells begin to secrete surfactant on thesurfaceoffluid-filledlungs.Duringlabour,fluidisclearedfromthelungs,andwiththefirstbreathoutsidethewomb,airfillsthepreviouslyfluid-filledlungs.Thetransitionfromfoetaltonewborncirculationoccurswiththecessationofthe placental circulation as the umbilical cord is cut or the placenta is removed. There is a decrease in pulmonaryvascularresistanceandanincreaseinpulmonarybloodflowthatiscausedbytheincreaseinarterialoxygentensionafter the baby starts breathing, thus the gaseous exchange via the placenta ceases and the lungs take over thisfunction. Cortisol and catecholamines prepare the foetus for the birth process and support the multi – organtransitionfromintrauterinetoextrauterinelife.Initiatingbreastfeedingsoonafterbirthformspartofthetransition.

Themajorityofnewbornsdonotencounteranyproblemswiththetransition.Abnormalitiestoadaptationaremorefrequentlyfoundfollowingpretermdelivery;deliverybycaesareansectionordeliveryfollowingfoetaldistress.

Thevastmajorityofbabiesbornattermbreathespontaneouslywithin10–30secondsofbirth.Anestimated5-10%respond to drying and stimulation, airway clearing or positioning to breathe. Only 3 – 6% of all newborns requireassistedventilationwithabagandmasktohelpthembreathe.Lessthan1%ofnewbornsrequirechestcompressionand drugs to assist with transition and establish breathing. We will refer to the need for drugs and chestcompressions as requiring advanced resuscitation. In several large studies, only ~0.1% of newborns required chestcompression and/or drugs as part of resuscitation. These numbers vary in different places in theworld: in a largeSwedish study, less than 1% of babies needed any resuscitation at all, including not requiring bag and maskventilation.TwolargestudiesdoneinGautengprovince,SouthAfrica,showedthat4,7/1000and8,5/1000newbornsneededhelpwithbreathingatCharlotteMaxekehospitalandChrisHaniBaragwanthhospital,respectively.Veryfew0,1% newborns needed cardiac compression and only 0,04% newborns required adrenaline as part of advancedresuscitation.Theprognosisofthosewhodidrequirecardiaccompressionandadrenalinewasgenerallypoor.

7

Figure1.Newbornsrequiringneonatalresuscitation

“Neonatalresuscitation,whenimplementedsystematicallybypersonnelusingstandardguidelinesandcompetency-based training, has the potential to avert 30% of intrapartum-related neonatal deaths per year.” (2) Furthermoreresuscitation may avert 5 – 10% of deaths due to the complications of preterm birth. This is the premise forsimplifying and increasing access to skills based training in neonatal transition and resuscitation for all health careworkers.

ThechartbelowistheactionplansourcedfromtheHelpingBabiesBreathecoursematerial,(6)whichyoumayhavealreadydone.Reviewthestepsinthechart.Thestepsintheactionplanofferasystematicapproachtothecareofthenewborninfant,whichifcorrectlyappliedareeffectivewithinoneminute:THEGOLDENMINUTESM

(References1–8)

85%ofbabiesbreathespontaneouslywithin10-30secondsofbirth

Approximately5-10%ofpalentssimplyrequireslmulalonanddryingatbirthtohelpthembreathe

Approximately3-6%requirebasicresuscitalon(bagandmaskvenllalon)

<<1%requireadvanced

resuscitation<0.1%require

chestcompression<0.05%require

8

Figure2:HelpingBabiesBreatheActionChart(8)

9

MODULE1:PREPARINGFORTHEBIRTH

Planandpreparefortransitionbyfollowingthese5steps.

STEP1:PREPAREANEMERGENCYPLAN

Identifysomeonetohelpwith transition forEVERYbirth.Supportduring transitionatbirthor resuscitationmayberequiredwithanydeliverybut ismorelikely ifthebabyis lessthan35weeksgestation,deliveredbyanemergencycaesarean section or has documented foetal distress. Arrange for a healthworker to assist if normal transition isanticipatedorfortwohealthworkerstoassistifadvancedresuscitationisanticipated.Fourhealthworkersshouldbeavailableatatwindelivery.Reviewtheemergencyplaninyourfacility;includingwhomtocall,howtocommunicate,andhowtotransportthebabyshouldneonatalwardcareortransferberequired.

STEP2:HANDWASHING

Everyonewhoattendsadeliverymustwashhisorherhands.This includesthemother, father,orbirthcompanion.Goodhandwashinghelpstopreventthespreadofinfection.Handsmustbewashedthoroughlywithsoapandcleantepidwater. An alcohol-based cleanermaybeused afterwashing. For thehealthcareworker, thismust bedonebefore checking theemergencyequipment aswell asbeforeandafter caring for amotheror ababy. In addition,sterileglovesmustbewornwhenassistingthenewbornwithtransition.Glovesprotectyoufrominfectionscarriedbybloodandotherbodyfluids.

10

Figure3:HandWashingandcleaningchart(8)

11

STEP3:PREPARETHEMOTHERANDBIRTHCOMPANIONFORTHEDELIVERY

Explaintothemotherandbirthcompanionwhatwillhappen if thebabyhasanormal transition,andwhatwillbedoneshouldthebabyrequiresupportfortransition.Ifyouexpectanormaltransition,explaintothemotherandbirthcompanionthatthebabywillbeplacedskintoskinonthemothersabdomenimmediatelyafterbirth,andkeptskintoskininordertofacilitatetheinitiationofbreastfeeding.

STEP4:PREPARETHEAREAFORDELIVERY.

The area where the baby is to be born must be clean, warm and well lit. Eliminate draughts from fans, airconditioners,openwindowsanddoors.Warmthebirthingroomortheatreto23–25oCandusearadiantwarmertowarmthearea forventilation should thisbe required. If thegestationalageof thebaby is less than28weeks thetemperatureofthedeliveryroomortheatreshouldbe>25oC.Itistheresponsibilityofthepersonpreparingforthedeliverytoensurethattheareaiscomfortableforthebaby.

STEP5:PREPAREFORRESUSCITATIONANDCHECKTHEEMERGENCYEQUIPMENT.

Prepare the resuscitation surface before every delivery. This should be a flat padded surface with an overheadwarmer,goodlightingandatimer.Havingwashedhandsthoroughly,checkthatallequipmentandsuppliesarereadyforuse.Basicequipmentisrequiredateachdeliverysite.Additionalequipmentmaybestoredonamobiletrolleyincleanplasticbagsor inabox,usedonly forthispurpose.Thetablebelowprovidesachecklistofall theequipmentthatisrequired.

12

Table1:NeonatalResuscitationequipment

BasicneonatalResuscitationequipment(ateachbedside)

NeonatalResuscitationstation,trolleyorbox,atleast1per4deliverybedsand1intheatre

General ! Firmpaddedresuscitationsurface! Overheadwarmer! Lightforthearea! Clockwithtimerinseconds! Warmreceivingtowels! Stethoscope! HeadCaps/hats

! Firmpaddedresuscitationsurface! Overheadwarmer! Lightforthearea! Clockwithtimerinseconds! Warmreceivingtowels! Stethoscope! HeadCaps/hats! Pulseoximeterwithneonatalprobe! Transportincubator! Sterilegloves

AirwayManagement

! PortableSuctionDevicelikePenguin

! Suctionapparatus! Suctioncatheters6F! Suctioncatheters8F! Suctioncatheters10F

! OrophayngealairwaysSize0! OrophayngealairwaysSize00! Laryngoscopehandle

! MillerBlade00! MillerBlade0

! Spareworkingbatteries! Spareworkingbulb! ETTintroducer/stylet! SuppliesforfixingETT! McGillforceps(paediatricsize)! ETTuncuffed2.5

! ETTuncuffed3.0! ETTuncuffed3.5

Breathingsupport

! Bagvalvemaskventilator(e.g.LaerdalNeonatalVentilationBag)

! MaskforventilationbagSize0! MaskforventilationbagSize1

! Bagvalvemaskventilator(e.g.Laerdal)! Maskforventilationbag! Size0! Size1! Sourceofoxygenwithflowmeter! Oxygentubing

Circulationsupport

! UmbilicalvenouscatheterSize3.5F! UmbilicalvenouscatheterSize5F! IVcannula24G! Skinprepe.g.Webcol! Tapes/devicestosecureUVC/IVcannula! Syringesandneedles(assortedsizes)! 2X3waytaps! UmbilicalVeinCatheterisationsterilepack

Drugsandfluids

! Adrenaline1:1000! WaterforInjection! (Naloxone)! NormalSaline0,9%! Neonatolyteor10%glucose! 60drops/mindripset! Buretol! Dial-a-flow! 3waytap! Glucoseteststripsandglucometer! VitaminK(Konakion)! Chloramphenicol(Chloromax)eyeointment

Documentation

! Equipmentchecklist! Neonatalexaminationticksheet

13

WatchLINCVideo:EmergencyEquipment.

Testthefunctionoftheventilationbagandmask.

Figure4:Bagvalvemaskventilatorfornewborns

14

1.Squeezethebagandlookforthevalveinthepatientoutletopenasyousqueeze.Thisshowsthedeviceisreadytodeliverairtothepatient.

2a.Sealthemasktightlytothepalmofyourhandandsqueezehardenoughtoopenthepressurereleasevalve.Thisshowsthatair,whichcannotbedeliveredthroughablockedairway,willescapethroughthepressurereliefvalve.

2b.Ifonsqueezingthebag,noairpopsoutofthesafetyvalve,opentheobstructedoutlettoallowairtoescapethroughthesafetyvalve.Ifthisdoesnothappen,useanotherbag.

3.Checkthemaskrimforanydamagethatmaypreventanairtightmasksealontheface.

Figure5:Testneonatalventilationbagandmask(8)

WatchLINCVideo:ChecktheNeonatalBag-valve-mask

CLEANINGEQUIPMENT

Disinfectallusedequipmentandkeepitclean.Checktheequipmentlisttwiceaday,witheachchangeinnursingshift.Repairorreplaceanyequipmentthatisdamagedordoesnotfunction.Correctaproblemwhenitoccurs.

Tocleanequipment:

• Disassembletheventilationbagandmask,suctiondeviceortubing.• Washtheequipmentinwarmsoapywatertoremovevisibleblood,secretionsandothercontaminated

matter• Disinfectallpartsbyimmersioninanappropriatedisinfectantsolution(accordingtothemanufacturer’s

instructionsthenrinseinboiledwater.Alternativelyboiltheequipmentinwaterfor10minutes.• Allowallpartsoftheequipmenttoairdrybeforereassembly.• Reassembleaccordingtomanufacturer’sinstructions.• Placeinacleanplasticbag• Wipethebloodandsecretionsfromthelaryngoscopebladeandpaddedsurfacewithadampcloth,followed

byanalcoholordisinfectsolution.

Disposeofcontaminatedsuppliesandhandlelinen.Restockcleanlinenandsupplies.

15

SELFASSSEMENTQUESTIONS:MODULE1

Answer the multiple choice or true / false questions below. If you do not get the questions correct, review thematerialbeforeansweringthequestionsagain.Onceyouhavesuccessfullycompletedthequestionsyoumaymovetothenextsection.

1.1 Tickthestatementthatiscorrectregardingneonatalresuscitation.Thereisonly1correctanswer.

☐About3-6%ofbabieswillrequireassistedventilationwithtrachealintubation

☐Mostbabieswillnotneedanyneonatalresuscitationtobreathe(CORRECT)

☐About75%ofbabiesrequirebasicsupportsuchasdryingandstimulation

☐1%ofbabiesrequirecardiaccompressionanddrugsinneonatalresuscitation

1.2Preparationforhelpingababybreathebeforebirthincludesthefollowing:

1 Identifyahelperandgoingthroughtheemergencyplan

2 Checkingtheequipment

3 Washinghands

4 Communicatingwiththemother

Whatisthecorrectsequence?

☐1,2,3,4

☐3,2,1,4

☐1,3,4,2

☐1,4,3,2(CORRECT)

1.3 Neonatal resuscitation, when implemented systematically using standard guidelines and competency based

training

☐Haspotentialtoavert30%ofintrapartumrelateddeaths(CORRECT)

☐Haspotentialtoavert70%ofintrapartumrelateddeaths

☐Haspotentialtodecreasepretermmortalityby30-35%

☐Haspotentialtodecreasepretermmortalitybe50-55%

16

MODULE2:ROUTINECAREATBIRTH

Assoonasthebabyisborn:

DRYTHOROUGHLY

Check the timeofbirthad thendry thebaby thoroughly.Drying thoroughly involvesgently rubbing thebody, legs,armsandheadwithawarmcloth.Dryinghelpskeepthebabywarmandclean,andalsostimulatesbreathing.Blottingor patting does not stimulate breathing. Awet baby can easily become cold, and a cold baby can have difficultybreathing.Dryingalsoremovesblood,bodyfluidsandstoolsofthemother. Removethewetcloth.Placethebabyskin-to-skinonthemother’sabdomen,coverwithadryclothandplaceacaponthehead.

A note about suctioning andmeconium: Babiesdonot require routine suctioningatbirth,evenifthereismeconium.Meconiumintheamnioticfluidmaybeasignoffoetaldistress, especially if there is thick meconium. While these babies may be at risk ofMeconium Aspiration Syndrome (MAS), recent randomised control trials have foundtheretobenoreductioninMASwhenthesebabiesareroutinelysuctionedondeliveryorwithroutineintubationandsuctioningofthevigorousbabywithmeconium.(7)

If at birth the baby has very poor tone and does not breathe, youmay immediatelyvisualise the cords with direct laryngoscopy. If meconium is seen through the cords,intubateandthenapplysuctionandremovetheETtube.Thisprocedureshouldnottakelonger than15seconds,andventilationshouldneverbedelayed if thiscannotbedoneimmediately.

CHECKIFTHEBABYISCRYING,CHECKBREATHING,KEEPWARM

Check if thebaby iscryingandbreathing.Ifthebabyiscrying,thenbyimplication,thebabyisbreathingandhasaheartratethatisusuallyabove100beatsperminute.Inthissituation,itisnotnecessarytophysicallychecktheheartrateimmediately.IfthebabyisNOTcrying;checkingwhetherthebabyisbreathingnormallyisthefirstpriority.Lackofbreathingoranabnormalpatternofbreathingwarrantsimmediateinterventionasdiscussedinmodule3)

Keep babywarm. The babywho is cryingor breathingwell should be placed skin-to-skin, proneon themother’sabdomenwith the baby’s head cranially and turned to the side. This keeps the babywarm andhelps the baby tobreatheandfacilitatesearlyinitiationofbreastfeeding.Keepthebabycoveredwithawarmclothandwiththecaponthehead.

Recheckbreathing.Continuetocheckthebaby’sbreathingwhilethebabyisonthemother’sabdomen.Mostbabieswhocryatbirthcontinuetobreathewell.Somebabieshavealargeamountoffluidintheirmouthandnose.Positionthesebabiesontheir side tohelpdrain the fluid.Thebaby’sneckshouldbe in theneutralposition–not flexedorhyperextendedtofacilitatedrainageofexcessfluidfromthemouthandnoseaswelltofacilitatebreathing.

CLAMPANDCUTTHECORD.

Delayclampingandcuttingofthecordfor1-3minutesinthenewbornwhoisbreathingwell.Delayingcordclampingforatleastoneminuteoruntilthecordstopspulsatingimprovestheironstatusofthebabyfornext3–6months.Inpreterm infants, delayed cord clamping to 3minutes improves blood pressure and results in a lower incidence ofintra-ventricular haemorrhage, periventricular leukomalacia, late onset sepsis and fewer blood transfusions.Randomized control trials found that there was NO correlation between delayed cord clamping and hyper-bilirubinaemia.(10,11,12)

17

Keepthenewbornonthemother’sabdomenorattheleveloftheperineumwhilewaitingtocutthecord.Tocutthecord,placetwoclampsonthecord,withthefirstclampplacedtwofingersawayfromthebaby’sabdomenandthesecondclampthreefingersawayfromthefirstclamp.Usesterilescissorstocutthecordbetweentheclamps.Keepthebabyskintoskinandencouragebreastfeedingandroutinecare.

Watch Global Health Media Video, Routine care in the first hour of birth:https://globalhealthmedia.org/videos/

ROUTINECAREOFBABIESBORNBYCAESAREANSECTION

BabiesbornbyCaesareansectionrequirethesameinitialstepsofcare,butusuallyrequireassistancewithtransitionmorefrequently:

PREPARATION

• Find out why themother is having a Caesarean section, the gestational age and condition of the foetus, anymaternal illness that may affect the baby, and whether steroids were given to the mother in the case of apretermdelivery.

• Prepareforthetransitionandresuscitation.o Identifysomeonetoassistwiththetransition,andanadditionalpersontohelpwithresuscitationo Discussthefollowingwiththesurgeonandanaesthetist

§ Thepossibilityofdelayedcordclampingormilkingthecord§ Ifthebabymaybekeptskintoskinwithmomordadafterbirth§ Timingofinitiationofbreastfeeding

o Preparethetheatre,checkthetheatretemperatureandeliminateanydraughtso Preparetheemergencyandtransportequipmento Speaktothemotherandbirthcompanionaboutwhattoexpect

TRANSITION

• Drythebabythoroughly,placeacapontheheadandkeepwarm• Ifthebabydoesnotneedhelpwithbreathing,andthemother’sconditionallows,clampandcutthecordafter1

–3minutes,otherwiseclampandcutthecordimmediatelyandinitiateresuscitation.• Keepthebabywarm,eitherskin-to-skinwiththemotherorfather,orunderapre-warmedradiantwarmerorin

awarmedtransportincubator.• Monitor thebabytoensurethebaby isbreathingwell,andkeepthetemperatureof thebabybetween36.5oC

and37.5oC.

ROUTINECAREOFPRETERMBABIES

Preparefortheprematurebabyinthesameway,butanticipatethatthebabymayneedassistanceinbreathing,andmayneedextrasupporttomaintainwarmth.

Babieswhoare<32weeksgestationor<1,5kgareatahigherriskofhypothermia.Inordertopreventthiscomplicationofpretermdelivery,thesebabiescanhavetheirbodyplacedinapolyethylenewrappingoropenbagwhilestillwet(beforedrying)andthenbeplacedunderaradiantheater.DONOTcovertheface.Theheadmayhoweverbewrappedinpolyethylene.Monitorthebabyclosely.Ifyouarenotabletocarefullyapplythisprocedureandmonitorthebaby’stemperature,itmaybesafertodrythebabyandthenplaceskintoskinwiththemotherorfathertokeepthebabywarmortoplacethebabyinatransportincubatorpre-warmedto35,5oC.

18

MONITORBABYWITHMOTHERANDINITIATEBREASTFEEDING

Aftercuttingthecord,movethebabyclosertothemothers’breasts,andmonitortoensurethatthebabyisactiveandbreathingwell.

RAPIDLYASSESSTHEBABYIMMEDIATELYAFTERBIRTH

Rapidlyassessthebabyimmediatelyafterbirth.Reviewthechart“B.RapidlyAssessBabyImmediatelyAfterBirth.”SourcedfromtheEssentialNewbornCareChartBook.

Explain to themother and birth companion that you are rapidly assessing that the baby for any serious illness orabnormality,andifnonearefoundthatthebabywillhaveamorethoroughassessmentinthepostnatalward.

Inordertoassessthebaby,ask,listenandfeel

• ChecktheApgarscoreat1and5minutesanddocumentyourfindings.IstheApgar<8at5minutes?

• Observethebreathing:isthereanyfastbreathing,cyanosis,gruntingorchestin-drawing?

• Observethebaby’stoneandmovement:Isthebabyhypoorhypertonicandisthebabyactiveandmovingalllimbswell?

• Isthereamajorabnormality?Istheheadlarge?Ifsomeasuretheheadcircumference?Isit>39cm?

• Whatisthegender?Isthebabyaboyorgirlorareyouunsure?

• Estimatethebaby’sweight,isit<2kg?

• Isthemotherdiabeticordoesthebabyweighmorethan4,5kg?

Inawellbaby,theApgarscorewillbemorethan8at5minutes.Thebabywillalsobebreathingwellwithgoodtone;nomajorabnormalities;withdistinctmaleor femalegenitaliaanda weightof 2-3,9kgandhavebeenborn toanotherwisehealthymother.

Thereafter

• Keepthebabyskintoskinwiththemother.Thisisimportantformanyreasons,includingkeepingthebabywarmandbreathing,supportingbondingandenablingbreastfeedinginthefirsthour.

• Youwillseehowababycancrawltobreastfeedandwillbeabletoprovidesupporttothemothertoenablefeeding.

• Aftertheinitialfeed,weighthebaby,measurethelengthandtheheadcircumference,anddocumentyourfindingsandthecareyouprovide.

• AdministerVitaminK1mgIMandChloramphenicoleyeointmentintobotheyes.

• Checkifthemotherisdiabeticorifthebirthweightis>4.5kg,ifsochecktheglucosehourlyforthefirst6hours and breastfeed hourly or give 3ml/kg of breastmilk or replacement feed every hour for the first 6hours.

19

• Check if themother is HIV positive, if sowhat treatment she is getting and initiate the first dose of ARVprophylaxistothebabyaccordingtothecurrentPMTCTstandardguideline.

• Identifythebabywiththemotherandplacethenametagsonthebaby’sankle.

• Keepthebabywiththemotherandmaintainskintoskincontactwiththemotherifherconditionallowsit,otherwiseplacethebabyinawarmtransportincubatorandmonitorthecondition.

• Ifthemotherandbabyarewelltransferthemotherandbabytothepostnatalward.Babieswhosemothershavehadacaesareansectionbutwhoarewellshouldreceivecarewiththeirmother,andnotbetransferredtotheneonatalunit.

Ifanyoftheabnormalsignsarefound,thebabyrequiresintervention.Checkthebloodglucose,oxygensaturationandfullyassessthebaby.Keepthebabywarmandmanagethebabyforhypoglycaemia,hypoxia,hypothermiaifthisisfound.IfthebabyisnotwellorissmalltransferthebabytotheNeonatalunitinatransportincubator,afterinitiatinganynecessarycareforhypothermia,hypoglycaemiaorhypoxaemia.

Ifthebabyweighs<2kgortheheadcircumferenceismorethan39cm,thebabywillneedcareintheneonatalunit,butthebabycanremainskintoskinwiththemotherifthereisnootherimmediatecarethatisrequired.

AlltheseguidelinesarefoundintheEssentialNewbornCareChartBook.(15)

20

Figure6:RapidlyAssessBabyimmediatelyafterbirth(10)

WatchGlobal HealthMedia Video: Breastfeeding in the first hour for healthworkers:https://globalhealthmedia.org/videos/

21

SELFASSESSMENTQUESTIONS:MODULE2

Answertheassessmentquestionsbeforecontinuingtothenextmodule.Ifyoudonotgetthequestionscorrect,re-reviewthematerialbeforeansweringthequestionsagain.Onceyouhavesuccessfullycompletedthequestionsyoumaymovetothenextsection.

2.1WhenthebabyisdeliveredbyCaeseriansection

☐SuctionallbabiesdeliveredbyCaeseriansection

☐Thecordmustalwaysbecutimmediatelybythesurgeon

☐Thesebabiesrequireadmissiontotheneonatalunit

☐Requirethesameinitialstepsofcare(TRUE)

2.2Babieswhoare<32weeksgestationor<1,5kgareatahigherriskofhypothermia.Whichofthefollowingstatementsiscorrect?

☐Hypothermiacanbepreventedbydryingthebabyandthenwrappingthebabyinpolyethelinewrappingwithoutcoveringtheface.

☐Thedeliveryroomtemperatureshouldbe>25oC.

☐Skintoskincontactdoesnotworkforpretermbabies

☐Suctionallbabiesdeliveredpreterm

ReadthefollowingCasestudyandthenanswerthequestionbelow,

Youareonduty for theatreandare informedaboutanemergencycaeseriansectionforanotherwisewellmother,withfoetaldistress. Youmakeallthenecessarypreparationsandawaitdeliveryofthe infant. Upondelivery,thickmeconiumismixedwiththeliquorandthebabyhasverypoortoneanddoesnotbreathe.Whichofthestatementsbelowiscorrect?

2.3

! Thebabyrequiresvigoroussuctioningthroughthemouthandthenthenoseuntilnomeconiumisvisibleinthemouthorthenose

! Thebabyneedsstimulationtobreatheimmediately! Waitfor1minutetoavoidoverstimulatingthebabyandtoseeifthebabywillbreathespontaneously! Visualizethecordsandsuctiononceforanymeconiumseenbelowthevocalcordswithin20secondsbefore

thebabytakesabreath.(TRUE)

22

MODULE3:HELPTHEBABYWHOISNOTBREATHINGWELL

3.1CLEARTHEAIRWAYANDSTIMULATEBREATHING.

If the baby is not crying or breathing well after drying, help the baby breathe in the first minute. This is a veryimportanttimeandiscalledTheGoldenMinute©byHelpingBabiesBreathe©.

1.CLEARTHEAIRWAY.

Ifafterdrying,thebabyisstillnotcryingorbreathing,positionthebabyonthesideandensurethattheneckisintheneutralpositiontokeeptheairwayopen.Whenthebabyisintheneutralpositionthenosewillbemoreprominentthanboththeforeheadorthechin.Repositionasnecessarytoopentheairway.

If thebabystilldoesnotbreathe,gently suction themouthand then thenosewitha suctiondevice.Themouth issuctioned first to remove secretions closest to the airway. Insert the suction tubing into the side of the mouthadvancingforapproximately3–4cmintothemouth,whilestillvisualisingthetipofthesuctiontubing.Suctioningfortoolongcandamagethemucosaandcausebradycardiaduetovagalstimulation.

2.STIMULATEBREATHING.

Ifaftersuctioningtheairwaythebabyisstillnotbreathing,gentlystimulatethebabyagainbyrubbingthebackfirmly.Donotliftthebabyup,slapthebabyorinjurethebabyinanyway.

IFTHEBABYDOESSTARTBREATHINGAFTERSTIMULATION,CONTINUETOOBSERVETHEBREATHINGTOMAKESURETHATADEQUATEBREATHINGISSUSTAINED.

3.PLANFURTHERCARE

Somebabieswillhave shallow, irregular, slow,noisyorabsentbreathing immediatelyafterbirth.Othersmayhavechestindrawingandgrunting.Thesebabieswillrequirefurthercare.

Thereare3categoriesofbabiestoconsiderandmakeplansforfurthercare.

Ifthebabyisnotbreathingatallorisgasping,youwillneedtobeginventilationwithabag-valve-maskimmediately.Quickly clampand cut theumbilical cordbeforemoving thebaby to the area for resuscitation (clean, flat surfaceunder a radiantwarmer,with good lighting, prepared and checked prior to the birth) to begin BVM ventilation. Adelayinventilationmayresultinapreventabledeathorbraindamage.Inthisscenario,ventilationclearlyhaspriorityoverdelayinclampingoftheumbilicalcordandisdescribedindetailbelow.

Ifthebabyisbreathingbutiscyanosed,breathingtoofast(>60breathsperminute)orgruntingwithchestindrawing,takethebabytotheresuscitationareaandassesswhetherthebabyneedsoxygenandfurthercareornot.Beginbychecking theoxygen saturationof thebaby,using apulseoximeterwithaneonatalprobe, and then checking thesaturationagainsttheageofthebabyinminutes(table2).Ifthesaturationisbelowthetargetrange,oxygenshouldbe adminstrered by face mask or nasal prongs. Generally, if saturation is less than 90%, oxygen should beadministered.

Ifthebabyisprematureorweighslessthan2000gandhasrespiratorydistress,hemayneedearlyinitiationofnasalCPAP,whichisbest,administeredintheneonatalunitassoonaspossible.

All such babies will require referral to the neonatal unit for close monitoring including monitoring of oxygensaturation.Donotforgettospeaktothemotherandthebirthcompanionaboutthebaby’sconditionandtoexplaintheplanforthebaby’sfurthercare.

23

.

Table2:Targetoxygensaturationimmediatelyafterbirth

Timefrombirth Targetoxygensaturations1minute 60–70%2minutes 65–85%3minutes 70–90%4minutes 75–90%5minutes 80–90%10minutes 85–90%

Term>24hrs >96%Preterm>24hrs >90%

3.2VENTILATEWITHBAGANDMASK

Ventilationwithabag-valve-maskdeviceisforbabieswhostillhavenotinitiatedbreathingafterstimulation.Ventilationhelpscarryairintothelungsandinsodoing,initiatethetransitionneededtoallowspontaneousbreathing.Delayinstartingventilationcanresultinseriousinjurytothebrainastheresultoftissueanoxia.Aimtoinitiateventilationwithin60secondsofbirth,orwithinthe“goldenminute℠”.

Ventilationwithbagandmaskisthemostimportantandeffectivewaytohelpthebabywhoisnotbreathingorisgasping.Ventilationopensthelungswithair.

INITIATEVENTILATIONWITHABAG-VALVE-MASKStandbehindthebaby’shead.Thisenablescontroloftheheadpositionandvisualisationofchestmovementwithventilation.Selectthecorrectmask.Themaskshouldcoverthebaby’schin,mouth,andnose,butnottheeyes.Themaskshouldmakeatightsealonthefacesothatairwillenterthebaby’slungsandnotescapesunderthemask.Amaskthatistoolargewillnotsealwellontheface.Airwillescapeunderthemask.Amaskthatistoosmallwillnotcoverboththemouthandnoseandmayblockthenose.Airwillnotenterthelungsfreely.Asageneralguide,atermbabyusuallyrequiresamasksize1andapretermbabyamasksize0.Positiontheheadintheneutralposition(avoidover-extension).Helpkeepthebaby’sairwayopenbypositioningtheheadintotheneutralpositionandsupportingthechin.Positionthemaskontheface.Positiontherimofthemasktorestonthetipofthechin,andthenplacethemaskovermouthandnose.

Formafirmsealbetweenthemaskandthefacewhilesqueezingthebagtoproduceagentlemovementofthechest.Holdthemaskonthefacewiththethumbandindexfingerontopofthemask.Usethemiddlefingertoliftthechinuptowardthemask.Usethe4thand5thfingersalongthejawtoliftitforwardandhelpkeeptheairwayopen.Formatightsealbypressinglightlyonthetopofthemaskandgentlyholdingthechinuptowardthemask.Ifthesealisnottight,youwillnotmoveairintothelungsasyousqueezethebag.Theairwillescapeundertherimofthemask.Donotpushthemaskdownontotheface.Thismaychangetheheadpositionandinterferewithaerationofthelungs.

24

Figure7:Twopointholdoffacemask

Ventilatebysqueezingthebagtoproduceagentlemovementofthechest,asifthebabyweretakinganeasybreath.Makesurethereisnoleakbetweenthemaskandthebaby’sface.Squeezethebagharderifyouneedtodelivermoreairwitheachbreath.Forthefirst5breaths,maintaintheinflationpressurefor2–3seconds.Thiswillaidlungexpansion.Thereafterventilateatarateofabout30-40breathsperminute.Thiscanbeachievedbycountingaloud;“Bag…two…three…Bag…two…three…….”Ifyousqueezethebagasyousay,“Bag,”andreleasewhileyousay,“two…three,”youwillventilateatthecorrectrate.

Ventilatethebabywithroomairandnotoxygen.Theefficacyoftheventilationcanbeseenbyarapidincreaseintheheartrateandobservingchestrisingandsomeabdominalrising.

EVALUATETHEBABYDURINGVENTILATIONBYASKING:ISTHEBABYBREATHINGWELL?

Mostbabiesrequiringventilationatbirthwillrespondwithin30secondsofventilation,andthenbeginbreathingwell.Stopventilationwhenthebabystartstobreathewell.

Otherbabiesrequirecontinuedventilationwithbagandmask.Suchbabiesmayhavegaspingrespirationseenasasingledeepfutilebreathingmovement,followedbyalongpauseorseveraldeep,irregularbreathingmovementsfollowedbyapause.Continueventilationwithbagandmaskinthisscenario.

.

3.3IMPROVEVENTILATIONIFTHEBABYISSTILLNOTBREATHINGWELL

Ifthebabyisnotbreathing,continueventilationandcallforhelp.

Inthemeantime,checkthatventilationbreathsproducemovementofthechestasifthebabywerebreathingnormally.Takestepstoimproveventilationifthechestisnotmoving.

Mouth:- Checkthemouth,thebackofthethroat,andthenoseforsecretions,andclearasnecessary.- Openthebaby’smouthslightlybeforereapplyingthemask.- Reattemptventilation

Head:

- Reapplythemasktothefacetoformabetterseal.- Repositiontheheadwiththeneckintheneutralposition.Inordertoachievethis,onecanplaceacloth

underthebaby’sshoulders.

25

- Reattemptventilation

Consideranalternativeairway-Insertanoralairway,oranasopharyngealtube,orintubate.

Anairleakunderthemaskorincorrectpositionoftheheadisacommonreasonforpoorchestmovement.Ifyoustilldonotseegentlemovementofthechest,trytofindtheproblemandrepeatthenecessarystepstoimproveventilation.Recheckthefunctionoftheventilationbag.Replaceitifanotherbagisavailable.

WatchtheLINCvideo:Bagandmaskventilationavailableonwww.lincare.co.za

WatchtheLINCvideo:Improveventilationavailableonwww.lincare.co.za

SELFASSESSMENTQUESTIONS:MODULE3

3.1 The one most important skill that is required by health workers to help a baby breathe is (choose 1 correctanswer)

☐Correctlyapplynasalprongsforoxygenadministration

☐Intubation

☐Bagandmaskventilation(CORRECT)

☐Cardiaccompression

3.2Toensurethatallbabiesbreathewithin1minuteofbirth(GOLDENMINUTE),whichstepiscorrecttotake?

☐Cuttheumbilicalcordimmediately

☐Ifbabydoesnotcryimmediatelystimulate,positionairwayandcheckbreathing(CORRECT)

☐Ifbabydoesnotbreathecommencebagandmaskventilationby2minutes

☐Administeroxygenviaendotrachealtubeifbabydoesnotbreatheby60seconds

3.3Tosuccessfullybagandmaskventilatethebabydothefollowing,exceptfor

☐Standorsitatthebaby’sheadandselectthecorrectmask

☐Positionthemaskonthebaby’sface,makeafirmsealbetweenthemaskandthefaceandgentlysqueezethebag

☐Ventilatethebabyatabout20breathsperminute(FALSE)

☐Watchthechest/abdomenformovement

26

MODULE4.ADVANCEDRESUSCITATION

Ifthebabyisstillnotbreathingafterbagandmaskventilationandcheckingthatthisiseffective,youwillneedtostartadvancedresuscitation.Advancedresuscitationreferstotheadditionofchestcompressionsanddrugstohelpthebabytorecover.Beforeproceeding,takesometimetoreviewthepathophysiologyonbirthasphyxia.

4.1PATHOPHYSIOLOGYOFBIRTHASPHYXIA

If subjected tohypoxia inutero, the foetuswill start gasping. If thehypoxic insult is sustained, the foetuswill loseconsciousness. The neural centres controlling the breathing efforts ultimately cease to function because of lack ofoxygen.Asaresult,thefoetusthenentersaperiodknownasprimaryapnoea.Theheartrate,whichwasunchangeduptothispoint,nowdecreasestoabouthalfthenormalrateandthemyocardiumrevertstoanaerobicmetabolism.Thecirculationtonon-vitalorgansisreducedinanattempttopreserveperfusionofvitalorgans.Lacticacid,theresultofanaerobicmetabolismofglucoseisproduced,andcausesmetabolicacidosis.

If the insult continues, the primitive basal gangliainitiategaspsatarateofabout12gaspsperminute.If the foetus is still in utero, or if for some otherreasonthesegaspsfailtoaeratethelungs,thegaspsgradually fade away until the foetus enters a periodknownassecondary,or terminal,apnoea.Untilnow,the circulation has been maintained, however, asterminalapnoeaprogresses,therapidlydeterioratingbiochemical milieu begins to impair circulation byhinderingcardiacfunction.Thehearteventuallyfails,in both frequency of contraction and contractility.Without effective intervention, the baby dies. In aterm newborn, the entire process takesapproximately20minutes.

It is important to note that, in the face of asphyxia,the baby is able maintain an effective circulation.From the period of primary apnoea, through thegaspingphase,andevenforawhileaftertheonsetofterminal apnoea, circulation ismaintained. Thus, themosturgentrequirementofanyasphyxiatedbabyatbirth iseffectiveaerationof the lungs.Provided thebaby’s circulation is sufficient, oxygenatedbloodwillbeconveyedfromtheaeratedlungstotheheart.Theheartratewillincreaseandthebrainwillbeperfusedwith oxygenated blood. Following this, the neuralcentresresponsiblefornormalbreathingwill,inmanyinstances, function once again and the baby willrecover.

Figure8:Sequenceofeventsfollowingbirthasphyxia(1)

27

ReviewFigure8.ThisfiguresummarisesthechangesinHR,BP,pHandthepatternofgaspingrespirationattheonsetofasphyxia.Thefigurealsodemonstratestherecoverywiththeinitiationofresuscitation.

Merelyaeratingthelungsissufficientforrecoveryinthevastmajorityofcases.Althoughlungaerationisvital,thereareafewcasesinwhichcardiacfunctionwillhavedeterioratedtosuchanextenttoresultininadequatecirculation.Aninadequatecirculation(identifiedbyaslowheartrateoflessthan60beatsperminute)cannotconveyoxygenatedblood from the aerated lungs to the heart. In this scenario, a brief cycle of chest compressionmay be necessary.Furthermore,inveryfewcaseslungventilationandchestcompressionalonemaynotbesufficient,withtheneedfordrugs to restore the circulation. The outlook in this small group of infants is generally poor. Themanagement ofbabieswhorequirechestcompressionsanddrugsoverandaboveeffectivebagmaskventilationisdiscussedindetailbelow.

WatchtheLINCvideo:Pathophysiologyofperinatalasphyxia.www.lincare.co.za

4.2ADVANCEDCARE:HEARTRATE

Thealgorithmforadvancedresuscitationbeginswithassessmentoftheheartrateinababywhohasbeenventilatedeffectively,butfailstobreathespontaneouslyand/orfailstorestoreheartratetomorethan60beatsperminute.Ifababydoesnotbegintobreathespontaneouslyafter1minuteofeffectiveventilation(withchestmovement),evaluatetheheartratetodecideifventilationaloneissufficient.Askyourselfthequestion:Istheheartratenormalorslow?

Toevaluatetheheartrate,palpateforumbilicalcordpulsationorlistenforaheartbeatwithastethoscope.Palpateorlistenjustlongenoughtorecognizeiftheheartrateisnormalorslow.Iftheheartrateisfasterthanyourown,itismostlikelynormal.Iftheheartrateisslowerthanyourownpulse,thenitisslow.

Intheresuscitationsetting,itisimportanttocommunicateinformationabouttheheartratequickly.Asanaide,feelforapulseintheumbilicalcordorauscultateandthen“tapwhatyoufeel”onahardsurfacetogetabettersenseofthepulserate

WatchtheLINCvideo:Checkthepulserate.www.lincare.co.za

IFTHEHEARTRATEISNORMAL

If theheart rate is normalwhile youprovideeffective ventilation; continue to ventilateuntil thebaby isbreathingspontaneously.Graduallyreducetherateofventilationwhileobservingthebaby’sbreathing.Iftheheartrateremainsnormalasthebabybreathesspontaneouslyandregularly,stopventilation.

Ventilation canbe stoppedwhen thebaby isbreathing spontaneouslyand regularlywhilstmaintaininganormaltheheartrate(morethan100beatsperminute).

Iftheheartrateisnormalandthebabystilldoesnotbreathe,checkwhetherthemotherreceivedpethidineoranyopioids,inthepreceding4hours.Ifpethidineoranyopioidsweregivenandthebabyisnotbreathing,thebabymayneednaloxone (Narcan®). Ababywhohasanormalheart ratebutdoesnotbreatheneedscontinuedventilation.Slowly decrease the rate of ventilation over several minutes to see if there is a return of normal, spontaneous

28

breathing.Ifthebabystilldoesnotbreathe,continueventilationandconsultaspecialistwiththeviewofinsertinganalternativeairway.

Ifthebabyisbreathing,butbecomesbluewheneffectiveBVMventilationisdiscontinuedorifthebabyisbreathingandlookscyanosed,checktheoxygensaturationandifnecessarygivesupplementaloxygen.Supplementaloxygencanbeadministeredthroughaheadbox,nasalprongsorcatheter.

Assessthenewbornsresponsetooxygenbymeasuringthepre-ductalsaturation.Pre-ductalsaturationismeasuredbyputting thepulseoximeterprobeon therighthandof thebaby. Targetoxygensaturations fornewborns fromthetime of birth are presented in table 2. Regardless of gestation, the goal of oxygen administration is an oxygensaturation resembling that of a healthy term newborn. High concentrations of oxygen have been associated withincreasedmortality,anddonotimproverecoveryfromasphyxia;infact,thecontrarymightbetruewithdelayintimeofonsetofspontaneousrespiration.Provideaslittleoxygenaswillbenecessarytokeepthesaturationat90%.Youcan add a venturi (60%, 40%, and 28%) to modify the percentage of oxygen provided. Compare the pre-ductalsaturation with the post-ductal saturation, as a difference in saturation of more than 15% may be indicative ofpersistent pulmonary hypertension of the newborn. Reduce or stop oxygen if the newborns oxygen saturation isabove90%atanypointinthefirst10minutes.

Ifthebabyhasseverechestin-drawing,veryfastbreathing,grunting,orfrequentpausesinbreathing(longerthan15to20seconds)thebabyrequiresnasalCPAPtosupporttheaerationofthelungs.TransferthebabytotheNeonatalunitwherethiscarecanbeinitiated.

Ofnote: If thebabyshowsregularbreathing,andhas lowoxygensaturation,anddoesnot improveonoxygen(i.e.thereisnoincreaseinsaturation),thebabymayhaveacongenitalheartlesionwitharight-to-leftshunt.

Allbabieswhohaverequiredbagandmaskventilationwillrequireclosemonitoringintheneonatalunitafterwards.

Speaktomotherandthebirthcompanionaboutthebabyandtheplanofcare.

ADVANCECARE:SLOWHEARTRATE,CHESTCOMPRESSIONANDDRUGS

Iftheheartrateisslow,makesurethatyouhavetakenallthestepstoimproveventilation.Aslowheartrateisasignof hypoxaemia, which ismost often the result of inadequate ventilation. If the chest is notmovingwell youmayconsideranalternativeairway,orintubation.

Ifventilationseemsadequateandthechestismovingwell,withaslowheartrate,youwillneedtoprovidecirculatorysupport.Startchest compression, to improve thecirculation. Ifyouaregoing toadministerchestcompression it isusuallybesttointubatethebabyfirstandventilateviatheendotrachealtube.

CHESTCOMPRESSION

Circulatory support with chest compressions is only effective if the lungs are successfully inflated. Give chestcompressionsiftheheartrateislessthan60beatsperminute.Forthistobesuccessful,oneneedsaskilledhelper.

Therearetwotechniquesforchestcompression.Firstly,youmayusethe2-fingerorsecondlythe2-thumbmethod.The2-thumbmethodisthemosteffective:gripthechestinbothhandsinsuchawaythatthetwothumbscanpressonthelowerthirdofthesternum,justbelowanimaginarylinejoiningthenipples,withthefingersoverthespineattheback.(Figure9)

Compressthechesttoadepthof1/3theAPdiameterofthechest. Count1,2,3Bag,1,2,3Bag(3compressionstoeachbreath).Asateam,onehealthcareproviderwillcompressthebagtoprovideventilationandtheotherhealthcare providerwill do chest compression. By definition, the leader is the health care providerwho is bagging andshouldthereforebetheoneresponsibleforcounting.

29

Chest compressions move oxygenated blood from the lungs back to the heart. Allow enough time during therelaxationphaseofeachcompressioncycle for theheart to refillwithblood.Ensure that thechest is inflatingwitheachbreath.Continuechestcompressionsforatleastoneminuteandthenevaluateheartrateagain.Ifthereisstillbradycardia,thencontinuechestcompressions,andpreparetoadministeradrenalin.

In less than one per thousand births, effective ventilation and effective chest compression will be insufficient toproduceaneffectivecirculation.Inthisscenario,administeringdrugsmaybehelpful.

Figure9:Chestcompression,a)2-thumbandb)2-fingermethod

IFHEARTRATESTILLSLOW,GIVEADRENALINE

Bradycardiausually followshypoxiadue to inadequateventilationandoxygenationof thebrainstem,with resultingapnoea.Establishingadequateventilationisthemostimportantinterventiontoimproveheartrate.If,however,theheartrateremains lessthan60beatsperminutedespiteadequateventilation,administeringadrenaline isthenextmostimportantsteptoimproveheartrate.

Adrenaline is to be administered if the heart rate is less than 60 beats per minute after oneminute of effectiveventilationwithchestcompression.Adrenalinisbestadministeredviaanumbilicalvenouscatheter.Seethesectionbelowoninsertingofanumbilicalvenouscatheter.Alternativeaccessisviaanendotrachealtube,peripheralvein,orintraosseousline.

Prepareadrenalinbymixing1mlof1 in1000adrenalinewith9mlofSalinetoget1 in10000Adrenalinesolution.Administer 0.01-0.03mg/kg (equates to 0.1-0.3mL/kg of 1 in 10 000 adrenaline).Give as a rapid bolus followedby0.9%SodiumChlorideflushofequalvolume.

Alternatively,ifresuscitatingatermbaby,drawup1mLofAdrenalineandadministeritallintravenously.Ifthebabyis 27–32weeks gestation, thengive0.25ml, if 33–37weeks give0.5ml and if 38–43weeks thengive1mlofadrenalinperCPRcycleof1-2minutesduration.

IfadrenalinistobegiventhroughtheETtube,thedosesofadrenalinemustbe3timeshigherthantheintravenousdoses. Follow administration of ET tube adrenalinwith positive pressure ventilation to ensure that the AdrenalinedoseisventilatedintothelungsandisnotleftintheETTortheadaptor!.

Repeatevery1-2minutes,iftheheartrateremainslessthan60beatsperminute.Seesectionorwhentodiscontinueorwithhold lifesupportbelow. (Andcontinue forhow long?)IfanETTdose isadministeredwith inadequateeffect,giveanIVdoseassoonasvascularaccessisobtained

30

WHENWOULDYOUGIVEAFLUIDBOLUS?

If,inaterminfant,thereissuspectedbloodlossortheinfanthasclinicalsignsofshock(pallor,poorperfusion,weakpulse, increased capillary refill time) and has not responded adequately to other resuscitation measures, thenconsidergivingabolusof fluid.Givean initialbolusof10ml/kgofNormalSaline intravenously. Ifeffective, itmayneedtoberepeatedtomaintainimprovement.Inpretermbabies,volumeexpansionisrarelyneeded,andhasbeenassociatedwithintraventricularandpulmonaryhaemorrhages.

WHENWOULDYOUUSEBICARBONATE

There is insufficient data to recommend the routine use of bicarbonate in the resuscitation of the newborn.Bicarbonate is not recommended during brief Cardio Pulmonary Resuscitation (CPR). It may be considered duringprolonged cardiac arrests unresponsive to other therapy. It should only be given after adequate ventilation andcirculationisestablishedwithCPR.TheuseofbicarbonateshouldbelimitedtocaseswhereanABGhasbeendonetoguidecorrectdosingofbicarbonate.

4.3ENDOTRACHEALINTUBATION

Asdiscussed inthe introductiontothiscourse, bagandmaskventilation isusuallyadequatetoventilatethebaby.However insomecircumstances,ET intubation isunavoidable. Endotracheal intubation is indicatedwhenthebabyneedsadvancedcarewithchestcompressionsandadrenalinorwheneffectiveventilationwithbagandmaskfails.

In summary, a decision to perform endotracheal intubation will depend on the newborn’s gestation, degree ofrespiratorydepression,responsetofacemaskventilation,and,ofcourse,theskillandexperienceoftheresuscitator.

Only clinicians with appropriate training and experience in the procedure should attempt neonatal endotrachealintubation. If successful intubation cannot be achieved within 20 seconds, then continued positive pressureventilation(PPV)viaafacemaskisrecommended.

Ifthereisnohealthcareproviderskilledinintubationpresent,continuepositivepressureventilationviaafacemask,andwaitforaskilledhelper.

INDICATIONS

• Trachealsuctioninginanon-breathingandfloppynewbornexposedtomeconiumstainedliquor*• Unsuccessfulventilationviaa facemask(e.g.heartrateremainsslow,oxygensaturationfallingor failingto

riseorprolongedapnoea)• Administrationofendotrachealmedications(e.g.adrenalineorartificialsurfactant)• Expectedneedforcontinuedorprolongedventilationandchestcompression

WHATISNEEDED

• Straightbladedlaryngoscopewithabrightlightthathasbeencheckedo Millerbladesize00orsize0

• Suctionapparatusthathasbeenchecked• ETtube

o sizes2.5to3,5(see:table1)o Donotusesize2.0tubesorshoulderedtubes.

• McGillforcepswithlubricatingjellyfornaso-trachealintubation• Guidewirefororo-trachealintubation(makesurethattheguidewiredoesnotprotrudeoutsidethetube,as

thismaycausetrachealperforation).

31

• Strappingsforsecuringthetube

POSITIONINGOFTHEBABY

• Placethebabyontheresuscitairewiththeheadtowardsyou.• Ensurethehead is inneutralposition.Flexion,andhyperextensionblockvisualisationofthevocalcords.A

smallclothplacedundertheshoulders,orundertheneck,mayhelpwithadequatepositioning.

TECHNIQUE• Toobtaingoodvisualisation,theoropharynxshouldbegently,albeitadequately,suctioned.• Fornasalintubation,introduceETtube,afterlubrication,intoonenostrilandadvanceittoapositionbeyond

thepalate.• Holdingthelaryngoscopeinyourlefthand,introducethebladeintotherightsideofthemouth,movingthe

tonguetotheleftasthetipofthebladeisadvancedintothevallecula.Thevalleculaisthespacebetweentheepiglottisandthebaseofthetongue

• Gentleverticalpressureofthe laryngoscope,witha littlepressureonthecricoid,willbringthevocalcordsintoview.

• VisualizetheETtubeandgrabitwiththetheMcGillforcepsbeforeadvancingthetubeapproximately1cmbeyondthecordsintothetrachea.

• Verifyequalandbilateralairentrybyauscultatingbothaxillaewhileventilatingwithabagandmask.• SecuretheETtubepositionwiththehelphelpofanotherhealthcareprovider.• Ventilatingwithaventilationbag.

Figure10:NeonatalIntubation

32

ETTTUBESIZE

ETTsizeandinsertionlengtharebasedonthenewborn’sweightandcorrectedgestation.ETTinternaldiametercanbecalculatedusingtheformulaofgestationalageinweeksdividedby10.

ApproximateETTinsertiondepthfromthemiddleoftheupperlipcanbecalculatedusingtheformulaofweightinkg+6cmandfornasotrachealintubation,weightinkg+1cm.

Table3:ETTtubesizeandlength

Weightinkg ETTmarkatupperlip(cm)

ETTinsidediameter(mm)

ETTsuctioncathetersize(F)

<1kg 6.0 2.5 5or61.1–1.9 7.0 3.0 6or82.0–3.0 8.0 3.5 8>3kg 9.0 3.5 8or10

POSITIONVERIFICATIONo ETT insertion depth must always be checked by comparing the markings on the tube with the formula or

tabulatedfindings.o Primarily,correctETTpositionisconfirmedbyeffectiveventilationasdemonstratedby:

o Chestrisewitheachinflationo Heartrateincreasingtoabove100bpmo Improvingoxygenation(oximetryismoreaccuratethanvisualassessment,althoughfalsenegativesmay

occurinnewbornsifthereisveryloworabsentpulmonarybloodflow)

Onlyperformintubationforthepurposeofsuctioningmeconiumfromthetracheainnewbornswithdecreasedmuscletone,immediatelyafterbirthandbeforetheonsetofbreathing or crying. An experienced clinician should be the one to perform theprocedureandeventhen,onlyifalltheequipmentrequiredisimmediatelyavailable.In this scenario, suctioning should only be done once followed by rapidcommencementofresuscitationasrequired

WatchLINCvideo:Endotrachealintubation(www.lincare.co.za)

33

4.4UMBILICALVEINCATHETERISATION

Whenintravenousaccessisrequiredintheemergencysituation,insertionofanumbilicalveincathetercanfacilitaterapidaccess

INDICATIONS

• Duringresuscitationifquickivaccessisindicatedforexamplefor:o Toadministerabolusoffluidsforvolumeexpansiono Toadministeradrenalineo Topreventor,correctseverehypoglycaemia

• Ifivaccessisdifficult• Inpreparationforanexchangetransfusion

WHATYOUWILLNEED

Ideally,asterilepackcontaining

• Size5FGsterilenasogastrictubeorumbilicalveincatheter• Sterileswabs• Sterilescalpelandblade• Umbilicalcordties• Strapping• NormalSalineampoule• 5mlsyringe• Arteryforceps

STERILEUMBILICALVEINCATHETERISATION

• Positiontheinfantunderaradiantwarmerwithgoodlighting• Putonamask,washyourhandsthoroughlyandputonsterilegloves.• Attachthecatheter/nasogastrictubetoasyringecontainingsalineandflushit(alsoeliminateanyfreeair)• Cleantheumbilicalcordareawithspirits• Placeasteriletowelaroundtheumbilicus• Placetheumbilicaltape1cmabovetheabdominalskinandtieloosely• Cutthecord2cmabovetheskin• Identifytheumbilicalvein:thereisoneumbilicalveinandtwoumbilicalarteries,withtheveinsituatedat

thetop(towardsthebaby’shead)andthetwoarteriesbelow.• Insertthetipofthesalinefilledcatheterornasogastrictubeintotheveinandadvancewhileaspiratinguntil

blood return is seen. Inserting the catheter 1-2cm beyond this point is an appropriate position for theemergencyusewithoutradiographicconfirmationofposition.

• Securelystraptheumbilicalcatheterinplace.Rugbypoststrappingworkswell.• Youcanreplacethesyringewithanintravenousgivingsetor3waytapifyouneedtogivemedications

PRECAUTIONS

• Bleedingifthebaseofthecordisnotsecuredtightly• Ensurenot toallowair tobe introduced into thecatheter, this iswhyyou fill thecatheterwithsalineand

leavethesyringeattached.Ifyouseeairinthecatheter,withdrawontheenduntilthereisnoairandreplacesyringe

34

• Don’tgivehypertonicsolutions(e.g.50%glucoseand8%sodabicarbonate)throughthecatheter• Portalveinthrombosismaycomplicateumbilicalveincatheterization• Donotinsertanumbilicalveincatheterifitispossibletoinsertaperipheralveininfusion

Figure11:Umbilicalvenouscatheterisation

4.5WHENTOWITHHOLDORDISCONTINUELIFESUPPORT

The decision towithhold or discontinue life support is not an easy one. The decision largely depends on theavailabilityofresourcesandonyourexpectationofthefunctionalsurvivalofthebabybeingresuscitated,giventheresourcesintheregioninwhichyouwork.Thedecisionisnoteasy,andonemustbeawarethattheparentsmaywanttobeinvolved.Themostseniorhealthworkeravailableshouldassistwiththedecisionmaking. Youmaywanttoconsultthepaediatricianatyourreferralhospital.Thefollowinggeneralguidelinesmayassist:

• If the baby has no heart rate after 10 minutes of ventilation it is appropriate to consider stoppingresuscitation,asdisabilityfreesurvivalisunlikely.

• Whenthepossibilityoffunctionalsurvivalishighlyunlikelysuchaso Extremeprematurityo AbnormalitiessuchasanencephalyorTrisomy13or18

• Ifthereisnobreathingeffortwhatsoeverafter20minutes,oronlygaspingrespirationafter30minutes.

Whenwithholdingorwithdrawingresuscitation,talkrespectfullytothefamilyofthebabyandprovidecomfort.

35

4.6POSTRESUSCITATIONCAREOFTHENEONATE

Ifthebabyhasrequiredbagandmaskventilationoradvancedresuscitation,thebabyneedsfurtherimmediatecareandmonitoringandshouldbeadmittedtotheneonatalunitforobservationandfurthercare.

StabilisethebabypriortotransfertotheNeonatalunit

1. Checkbloodglucose.Ababywhohashadasphyxiaandrequiredresuscitationwillneedmaintenanceglucoseandpossiblyadditionalglucose.Establishaperipheralintravenousline,orputupanumbilicalline.Ifthereishypoglycaemia administer 2ml/kg of 10% glucose IV slowly, and in all babies put up Neonatolyte or 10%glucose iv at 2.5 – 3.0 ml/kg/hr. as maintenance. Monitor the fluid intake with an infusion controller orBuretrolandinlineflowregulatingdevice.

2. Keepwarm.Ensurethatthebaby’stemperatureiskeptinthethermoneutralrange.Ifthebabyisprematureensurethebaby’stemperature isbetween36.5and37.5oC. If thebaby isatermbabywithbirthasphyxiakeep the temperature between 35 and 36 oC. Transfer the baby in a temperature regulated transportincubator.

3. If the baby has respiratory distress (central cyanosis, fast breathing, chest – in-drawing, grunting) and theoxygen saturation is less than 90% give supplemental oxygen by nasal prong or face mask. If the babyrequiresoxygen,provideoxygenevenduringtransfer.

Transfer the baby to theNeonatal Unit,where the babywill have a full assessment and receive further care. TheassessmentandcarearedescribedintheNewbornCareCharts:Managementofthesickandsmallnewborn(MSSN).Ane-learningcourseonMSSNisindevelopment.TheNewbornCareChartsareavailablefromwww.lincare.co.za

SELFASSESSMENTQUESTIONSMODULE4

4.1Oxygenadministration(indicatewhichonestatementiscorrect)

☐Isimportantforallbabieswhodonotinitiatebreathingontheirown

☐Isnotnecessaryforinitialbagandmaskventilation,useroomair(CORRECT)

☐Isgiventoallbabieswithmeconiumaspiration

☐Isnecessaryforallpretermbabies

4.2Ifthebabyhasaslowheartrateandisnotbreathing,dothefollowingexcept

☐Intubateimmediatelyandgiveadrenaline(ALLEXCEPTTHIS)

☐Improveventilationwithbagandmaskventilation

☐Ifventilationadequateinitiatechestcompression

☐Ifheartrateremainsslowdespiteadequateventilationandchestcompressiongiveadrenaline

36

4.4.Discontinuelifesupporttothebabyif(choosetheincorrectstatement)

☐Thebabyhasnoheartrateandnobreathingaftergivingventilationfor10minutes

☐Thereisnobreathingeffortafter20minutes

☐Thereisonlygaspingafter30minutes

☐After45minutesifthebabyis“precious”(INCORRECT)

4.5Aftersuccessfulresuscitationwithbagandmaskventilation,youdecidetoadmitababytoneonatalwardforthefollowingmonitoringand/ortreatment,exceptfor:

☐Oxygensaturation

☐Glucose

☐Temperature

☐Antibiotics

37

REFERENCESANDRECOMMENDEDREADING

1. ErsdalHL,MdumaE,SvensenE,PerlmanJM.Earlyinitiationofbasicresuscitationinterventionsincludingfacemaskventilationmayreducebirthasphyxiarelatedmortalityinlow-incomecountries.Aprospectivedescriptiveobservationalstudy.Resuscitation83(2012)869–873

2. PerlmanJM,RisserR.Cardiopulmonaryresuscitationinthedeliveryroom.Associatedclinicalevents.ArchPediatrAdolescMed1995;149:20-25

3. WallSN,LeeAC,NiermeyerS,etal.Neonatalresuscitationinlowresourcesettings:what,whoandhowtoovercomechallengestoscaleup?IntJGynecolObstet2009;107:47–64

4. LeeACC,CousensS,WallSNetal.Neonatalresuscitationandimmediatenewbornassessmentandstimulationforthepreventionofneonataldeaths:asystematicreview,meta-analysisandDelphiestimationofmortalityeffect.BMCPublicHealth2011,11(Suppl3):S12http://www.biomedcentral.com/1471-2458/11/S3/S12

5. KattwinkelJ.Addressinghighinfantmortalityinthedevelopingworld.AGlimmerofhope.Pediatrics.http//paediatrics.aappublications.org/content/early/2013/01/15/peds2012-3171

6. PadayacheeN,BallotDE.OutcomesofneonatewithperinatalasphyxiaatatertiaryacademichospitalinJohannesburg,SouthAfrica.SAJCH2013,7(3):89–94

7. Bruikman,E.K,IntrapartumAsphyxiaandHypoxicIschaemicEncephalopathyinaPublicHospital:Incidenceandpredictorsofpooroutcome.MMEDThesis,Wits18May2015

8. HelpingBabiesBreathe,ProviderGuide,Secondedition.(2016)AmericanAcademyofPediatrics;http://www.helpingbabiesbreathe.org/.

9. WyllieJ,BruinenbergJ,etal.EuropeanResuscitationCouncilGuidelinesforResuscitation2015.Section7.Resuscitationandsupportoftransitionofbabiesatbirth.Resuscitation2015;95:249–263

10. WyckoffMH,AzizK,EscobedoMBetal.Part13:NeonatalResuscitation:2015AmericanHeartAssociationGuidelinesUpdateforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.Circulation.2015Nov;132(18Suppl2):S543-60

38

11. Delayedumbilicalcordclampingafterbirth.Committeeopinionno684.AmericanCollegeofGynecologists.ObstetGynecol2017;129e5–10

12. Weineretal,Part15:NeonatalResuscitation:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCareM.Circulation.2010;122:S909-S919http://circ.ahajournals.org/content/122/18_suppl_3/S909

13. NewbornLifeSupport,ResuscitationCouncil(UK)2010ResuscitationGuidelines

14. NeonatalResuscitation:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.http://pediatrics.aappublications.org/content/early/2010/10/18/peds.2010-2972E.citation

15. EssentialNewbornCare2013.NDOH.LimpopoInitiativeforNewbornCare.www.lincare.co.za

16. SinghalN,LockyerJ,FidlerH,etal.HelpingBabiesBreathe:Globalneonatalresuscitationprogramdevelopmentandformativeeducationalevaluation.Resuscitation2011

17. MsemoG,MassaweA,MnbandoDetal,NewbornMortalityandFreshStillbirthratesinTanzaniaafterHBBtraining.PediatricsDOI:10.1542/peds.2012-1795.

18. Little,GA,KeenanWJ,NiermeyerS,SinghalN,LawnJE.NeonatalnursingandHBB:Aneffectiveinterventiontodecreaseglobalneonatalmortality.Newbornandinfantnursingreviews.June2011VolIIno2.www.nainr.com

39

CLINICALPRACTICESESSIONS

Onceyouhavecompletedthereading,arrangeforafacilitatortotakeyouthroughthefollowingdemonstrationsandskillssessions.Yourfacilitatorwilldemonstrateeachstepandyouwillthenpracticeinpairs,beforedoingthefinal2OSCE’s.Satisfactoryperformancesonalltheskillsstationsarerequired.Preparationforbirth

1. Routinecare2. Stimulateandclearairwayifnotbreathing3. Bagandmaskventilation4. Howtoimproveventilation5. Endotrachealintubation6. Chestcompression7. Administrationofdrugsandfluids8. Umbilicalcatheterinsertion9. OSCE110. OSCE2