Chapter 3 Problems of the neonate and young infant - Birth Asphyxia

Case study: Baby of Ruth Baby of Ruth is a boy born at term. He is blue and has poor muscle tone. He doesn't cry.

Assessment of newborn at delivery Dry and stimulate baby with clean cloth and place where the baby will be warm Look for: Breathing or crying Good muscle tone Colour pink NO Call for Help, check HR, attach sats probe if available Remember A, B, C - added

Airway, Breathing Circulation Assessment of newborn at delivery YES NO Start the resuscitation now! Early Essential Remember: A,B,C Newborn Care Airway, Breathing Circulation Does baby of Ruth need resuscitation? Call for Help, check HR, attach sats probe if available Remember A, B, C - added

(Ref. WHO pocket book p.47) NEW SLIDE Moved from chapter 3 Highlighted A B C

Neonatal resuscitation (A=Airway) Open airway by positioning the head in the neutral position (Ref. p. 47) Clear airway and suction, if necessary Stimulate, reposition Give oxygen, as necessary Ruth’s baby is still blue and not breathing.

Neonatal resuscitation (B = Breathing) Use a correctly fitting mask: If the baby is still not breathing (Ref. p. 47) : Check position and mask fit Continue to give breaths at 40 breaths per minute Use oxygen if available Every 1-2 minutes stop and see if the pulse or breathing has improved Merged slide 5/6 – Give the baby 5 slow ventilations with bag (Ref. p. 47-49) Check the heart rate

Neonatal resuscitation (C=Circulation) Check the heart rate (HR) What steps would you take next?

Early Essential Newborn Care Immediate and thorough drying with a clean cloth Maintain skin-to-skin contact Give the baby to mother as soon as possible, on chest or abdomen Cover the baby to prevent heat loss Properly time cord clamping Wait for up to 1 - 3 mins or until pulsations stop. Keep umbilical cord clean and dry. Breastfeeding and non-separation Initiate within the first hour keeping mother and baby together Further Management after 1hr: Give vitamin K (phytomenadione), according to national guidelines 1 ampoule IM once Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once (prophylaxis), according to national guidelines Full examination and weight

History Ruth’s baby was born at term. He came out not crying, blue and with poor muscle tone. He was resuscitated for 2 minutes. Rupture of membranes happened at home, contractions were regular. Ruth, G1 P1, was in labour for a long period of time, but progressed to normal delivery in hospital. She had no chronic illness and no pre-eclampsia.

Examination after stabilisation After 2 minutes bag-mask resuscitation baby was breathing well, muscle tone has increased. He was crying. Vital signs: pulse: 124/min, RR: 46/min, SpO2 93% Weight: 3.2 kg Chest: mild chest indrawing, breath sounds heard over both sides, no added sounds Cardiovascular: both heart sounds were audible and there was no murmur Abdomen: soft, bowel sounds were active Neurology: muscle tone improved, no focal signs

What supportive care and monitoring are required?

Monitoring The baby has to be monitored frequently Pay attention to colour, breathing, muscle tone and ability to suck

Monitoring (continued) In the days after birth asphyxia the baby may develop following problems (Ref. p. 51-52): Convulsions check glucose treat with phenobarbital Apnoea oxygen by nasal prongs resuscitation with bag and mask Inability to suck feed with breast milk via a nasogastric tube Treat only if the problem arises

Supportive Care If no evidence of birth asphyxia at delivery provide normal care for newborn: Give the baby to mother as soon as possible, place on chest or abdomen Cover the baby to prevent heat loss Encourage initiation of breastfeeding within the first hour Keep umbilical cord clean and dry Give vitamin K 1 ampoule IM single dose Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once (prophylaxis) (Ref. p. 46, p. 50) Take care of the mother

Breastfeeding support Early and exclusive breastfeeding is important for all newborns Breastfeeding support: Encouragement Breastfeeding friendly environment Breastfeeding assessment and counselling (Ref. p. 295)

Progress The baby’s motor tone recovered well in the first 4 hours. After some difficulties at the beginning he was sucking well. Before he was discharged home he also received hepatitis B and BCG vaccines.

Follow-up Baby should receive regular MCH follow-up to monitor: Growth and development Nutritional intake Immunization status Detection of other illnesses or problems

Summary Be prepared for resuscitation at every delivery Don’t need oxygen in most cases, bag-mask ventilation will stimulate the baby to breathe on its own Prognosis for the baby with perinatal asphyxia can be predicted by recovery of motor function and sucking ability The prognosis is good for babies who respond quickly to resuscitation Learn all steps of neonatal resuscitation, practice and teach others