Resuscitation of the newborn baby

Learning objectives To assess a newborn baby at birth To perform basic resuscitation of a newborn baby using standard equipment Resuscitation in special situations: meconium stained liquor and preterm birth To learn principles of aftercare for a baby who requires resuscitation at birth NH- 2 Teaching Aids: ENC

Resuscitation: Key words Anticipation Preparation Help Record Fast Gentle Warmth Hygiene Mother NH- 3 Teaching Aids: ENC

Check if all equipments are in working order Preparing for birth Wash your hands Draught free, warm room - temperature >250C Clean, dry and warm delivery surface Radiant heater Two clean, warm towels/clothes A folded piece of cloth Self inflating bag - newborn size Infant masks in two sizes - normal and small newborn Suction device Oxygen (if available) Clock Check if all equipments are in working order NH- 4 Teaching Aids: ENC

Assessment at birth Assess breathing while drying Deliver the baby on to mother’s abdomen Note and call out time of birth Thoroughly dry the baby Use a warm towel Discard wet towel after drying Wrap the baby in another warm cloth Keep the baby warm Assess breathing while drying NH- 5 Teaching Aids: ENC

Care of the baby at birth Assess breathing: Assessment Decision Baby is crying No need for resuscitation or suctioning; Start skin-to-skin contact and breastfeeding Baby is not crying, but breathing at 30 to 60 times per minute No need for resuscitation or suctioning Baby is gasping Start resuscitation immediately Baby is not breathing NH- 6 Teaching Aids: ENC

Scenario 1 A mother arrived at your maternity hospital and delivered a baby girl as soon as she reached the labor ward. The placenta followed the baby and mother was not bleeding. The baby was pale. He was breathing and heart rate was 120/min. What is the Action? NH- 7 Teaching Aids: ENC

Dry the baby immediately after birth NH- 8 Teaching Aids: ENC

Immediate skin-to-skin Contact & Breastfeeding (routine care) NH- 9 Teaching Aids: ENC

Message 1 ONLY Routine care is required for a baby who is crying or breathing normally; Even routine suctioning is not required for these normal babies NH- 10 Teaching Aids: ENC 10

Scenario 2 A baby girl is born at your clinic after second stage of 60 minutes. The umbilical cord is short. You see that the skin is pale .She is not breathing. Heart rate is over 100/min. What is the Action? NH- 11 Teaching Aids: ENC

Steps of resuscitation If the baby is not breathing or gasping Call for help! Cut cord quickly, transfer to a firm, warm surface [under a radiant heater] Inform the mother that baby has difficulty breathing and you will help the baby to breathe Start newborn resuscitation NH- 12 Teaching Aids: ENC

Position, clear airways Steps of resuscitation Position, clear airways NH- 13 Teaching Aids: ENC

Position, clear airways Steps of resuscitation Position, clear airways √ NH- 14 Teaching Aids: ENC

Suction: Do not exceed duration of 20 sec Steps of resuscitation Position, clear airways (if needed) Suction: Do not exceed duration of 20 sec NH- 15 Teaching Aids: ENC

Steps of resuscitation Dry, stimulate, reposition NH- 16 Teaching Aids: ENC

Steps of resuscitation Dry, stimulate, reposition NH- 17 Teaching Aids: ENC

Steps of resuscitation Dry, stimulate, reposition NH- 18 Teaching Aids: ENC

Steps of resuscitation Ventilate (if still not breathing) Selecting Bag & Mask equipment Size of bag: 240-750 ml Oxygen capability: Oxygen source, reservoir Safety feature: Pop off valve, pressure gauge (optional) NH- 19 Teaching Aids: ENC

Steps of resuscitation Ventilate Use the CORRECT size face mask that covers: The nose The mouth The tip of the chin but not the eyes NH- 20 Teaching Aids: ENC

Steps of resuscitation Fitting a face mask: A face mask that is too LARGE Covers the eyes Extends over the tip of the chin A face mask that is too SMALL Does not cover the nose Does not cover the mouth effectively NH- 21 Teaching Aids: ENC

Steps of resuscitation Ventilate Squeeze bag with 2 fingers or whole hand, 2-3 times Observe for rise of chest IF CHEST IS NOT RISING: Check seal Reposition the head Squeeze harder Once good seal and chest rising, ventilate at 40 squeezes per minute Observe chest rise Check heart rate after 30 seconds NH- 22 Teaching Aids: ENC

Message 2 Bag and mask ventilation is required for a baby NOT BREATHING or GASPING NH- 23 Teaching Aids: ENC 23

Steps of resuscitation When to stop ventilating? If baby is crying; If breathing >30/min, and NO chest in-drawing: If the skin between the ribs is ‘sucked’ inwards and the ribs are prominent, the baby has chest ‘in-drawing’ NH- 24 Teaching Aids: ENC

Steps of resuscitation After stopping ventilation Put the baby in skin-to-skin contact on mother’s chest Monitor every 15 minutes for breathing and warmth Tell the mother the baby will probably be well Encourage the mother to start breastfeeding as soon as possible NEVER leave the baby alone NH- 25 Teaching Aids: ENC

Steps of resuscitation When to continue ventilating? If the baby is breathing at a rate of <30/min, is gasping has severe chest in-drawing Arrange for immediate referral NH- 26 Teaching Aids: ENC

Steps of resuscitation Referral Explain to the mother what happened, that her baby needs help with breathing Ventilate during the referral Record the event on a referral form and labour record If the baby is NOT breathing even after 20 minutes, STOP ventilating NH- 27 Teaching Aids: ENC

Scenario 3 Baby girl born at 38 weeks following thick meconium stained amniotic fluid is noted to be limp and not breathing . The baby is blue. She was not breathing and heart rate was 80/min. What is the Action? NH- 28 Teaching Aids: ENC

No need for intrapartum suction Nonvigorous: any parameter abnormal Birth: assess HR, breathing and tone Vigorous: HR>100 good breathing Good tone Nonvigorous: any parameter abnormal Initial steps Tracheal suction NH- 29 Teaching Aids: ENC

Message 3 Meconium stained depressed baby needs endotracheal suction prior to B&MV Routine suction of oro-pharynx is not recommended before delivery of shoulder NH- 30 Teaching Aids: ENC 30

Scenario 4 Mother admitted in maternity unit delivered a baby boy at 32 week gestation on bed. The baby is limp and not breathing. The baby is pale. He is not breathing and HR is 80/min. What is the Action? NH- 31 Teaching Aids: ENC

Steps of resuscitation Special considerations for preterm Be gentle Use small size resuscitation bag and give small tidal volumes to move chest Avoid 100% oxygen , use blenders and oxygen saturation monitors Avoid rapid fluid bolus May need intubation, chest compression, medications Keep CPAP back up ready NH- 32 Teaching Aids: ENC 32

Message 4 Preterm births need special precautions before and during resuscitation NH- 33 Teaching Aids: ENC 33

Post resuscitation management Principles Keeping normal temperature Maintaining oxygenation Maintaining physiological milieu- fluids , glucose Maintaining perfusion Treating seizures Monitoring organ function NH- 34 Teaching Aids: ENC 34

Care after resuscitation Place baby in skin-to-skin contact with mother Keep the baby warm Monitor every 15 minutes Start breastfeeding as soon as possible Discuss what has happened with the parents - be positive! Do not separate the mother and baby unless the baby has difficult breathing NH- 35 Teaching Aids: ENC

Summary: Steps of resuscitation 1. Keep the baby warm: Place under the radiant heater 2. Open the airway: - Position baby’s head so it is slightly extended - Suction the mouth and then the nose 3. If still not breathing: VENTILATE 4. If breathing or crying begins: STOP VENTILATION

Summary: Steps of resuscitation 5. If breathing at <30 breaths per minute or there is severe chest in-drawing: CONTINUE VENTILATION 6. If no breathing or gasping after 20 minutes of ventilation: STOP VENTILATION 7. Explain events to the mother and document