newborn resuscitation and care international normal newborn care

Newborn Resuscitation and Care

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Normal Newborn Care


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Introduction

• 4 million neonatal deaths per year• 2/3 of neonatal deaths occur in 1st week of life• Must improve maternal education in basic

newborn care and recognition of danger signs• Improve training in neonatal resuscitation and

recognition and management of sick neonates


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Main Causes of Infant Mortality

7%15%

9%1%

29%

24%

10% 5%

Neonatal tetanus 7%

Pneumonia 15%

Sepsis/Meningitis 9%

Diarrhea 1%

Birth asphyxia and trauma 29%

Prematurity 24%

Congenital anomalies 10%

Others 5%

Main Causes of Mortality


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Essential Care for Newborn Health

• Care of future mothers

• Care during pregnancy

• Care at time of birth

• Care after birth


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Immediate Care of the NewbornAt birth, ask yourself the four following questions. If any answer is NO, THE BABY

REQUIRES RESUSCITATION

•Breathing or crying?

•Good muscle tone?

•Color pink?

•Term gestation?

Routine care

-Warmth

- Dry

IF YES

IF NO

-Provide warmth

-Position; clear airway

-Dry, stimulate

Evaluate:

-Respirations

-Heart rate

-Color

RAPID INTERVENTION…for resuscitation


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Apgar Scores

• A tool used to document the clinical status of the newborn

• NOT used to identify newborns that require resuscitation

• A score of 0 to 10 is assigned at 1, 5, and 10 minutes


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Sign Score

0 1 2

Heart rate Absent Slow (< 100 beats/minute)

=> 100 beats/min

Breathing Absent Slow, irregular Good, crying

Muscle Tone Limp Some flexion Active motion

Reflex irritability

No response Grimace Cough, sneeze

Color Blue or pale Pink body with blue extremities

Completely pink

Apgar ScoringApgar Scoring


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Cleanliness for the Newborn

• Clean hands, perineum and delivery surface

• Immediate tying and clean cutting of cord

• Clean cloth to wrap baby in after delivery

• Clean cord care- nothing applied to cord stump- cord stump to be left uncovered to dry


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Thermal Protection of the Newborn

• Warm delivery room• Immediate drying• Skin to skin contact• Breastfeeding• Delay weighing and bathing• Appropriate clothing and bedding• Keep mother and newborn together• Warm transportation and

resuscitation


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Newborn ResuscitationNewborn Resuscitation


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•Be prepared for resuscitation – 10% of babies require resuscitation

•30-40% of babies that require resuscitation are a surprise


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What is Necessary to Prepare for Resuscitation?

• Appropriate equipment

• Skill to use equipment

• Learn to recognize which baby needs resuscitation


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At birth, ask yourself the four following questions. If any answer is NO, THE BABY REQUIRES RESUSCITATION

Breathing or crying?Good muscle tone?Color pink?Term gestation?

- Provide warmth- Position; clear airway- Dry, stimulate

Evaluate:- Respirations- Heart rate- Color

Supportive care

Provide breathing assistance

RAPID INTERVENTION…for resuscitation

HR > 100 & pink

Abnormal respirations or HR < 100

Routine care- Warmth- Dry

IF NONormal breathing


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MeconiumBabies (10 – 12%) may be born through meconium stained

amniotic fluid

Meconium can plug the airway

A vigorous baby is:

- breathing or crying

- heart rate > 100 bpm

- good tone

If baby not vigorous then clearing the airway by intubating and suctioning of the trachea may be life saving.


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How to Assess a Baby in a Health Care Facility

Breathing or Crying :

-Watch babies chest rise

-Normal rate 40-60/bpm

- A vigorous indicates breathing

Abnormal breathing may be:

- absence of breathing

- shallow respirations, poor chest movement

- gasping respirations – extreme effort to inhale associated with a slow respiratory rate


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Muscle tone - healthy term babies have a flexed position

Color – Normal is pink lips and mucous membranes. A dusky blue hue of lips and mucous membranes indicates central cyanosis.

Term gestation – by history

Heart rate – normal heart rate 120 – 160 bpm determined by auscultation of the heart.

How to Assess a Baby in a Health Care Facility


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Heart rate Hold the base of the umbilical cord with your

thumb and index finger. The cord pulsations felt are the

heart rate of the baby. The baby’s heart rate should be more than your own heart rate.

All other assessments are similar to health facility

How to Assess a Baby in the Community


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How to Provide Resuscitation in a Health Care Facility

Warmth - warmer

- warm delivery room

- temperature – 25oC to 28oC (77 – 82.4o F)

- no fans or draughts

- warm linen including 2 blankets/sheets, cap and clothing for baby

-Dry baby immediately and remove wet linen

- kangaroo care: even premature babies can maintain temperature with skin to skin contact


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How to Provide Resuscitation in a Health Care Facility

Suction - suction mouth and nostrils before delivery of baby- suction mouth and nostrils after delivery of baby. Remember mouth is to be suctioned before the nose

Stimulate – If the baby is not breathing provide:- tactile stimulation by gently rubbing the back- stroking the feet- drying also provides tactile stimulation


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How to Provide Resuscitation in the Community

Warmth - deliver baby in a room that is warm and has no draughts - may need heating.

- dry baby immediately and remove wet linen

- warm linen including 2 blankets/sheets, cap and clothing for baby

- baby’s body can be wrapped in a towel and then covered by plastic. Ensure baby’s head is not covered by plastic.

- kangaroo care: even premature babies can maintain temperature with skin to skin contact


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How to Provide Resuscitation in the Community

Suction if you do not have a suction catheter or bulb syringe then wipe the

mouth gently with a cloth

- deep suctioning may cause bradycardia

Stimulate - If the baby is not breathing provide:

- tactile stimulation by gently rubbing the back

- stroking the feet

- drying also provides tactile stimulation


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Breathing Assistance in a Health Care Facility

Bag and Mask Ventilation

Indication:- not breathing- heart rate < 100 bpm

Equipment:- self inflating bag with oxygen reservoir- infant mask


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Breathing Assistance in a Health Care FacilityTechnique:

- connect O2 to reservoir- cover mouth and nostrils with mask- squeeze bag 40-60 times/minute

WATCH for chest movement. If no movement:- check for seal

- reapply mask-reposition head- check for blocked airwayand continue bag and mask ventilation


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Breathing Assistance in the Community

- If you have a self inflating bag and mask, follow instructions in health care facility section.

- You may use a tube and mask:• - get a good seal covering the mouth and nostrils

• - breathe 40 times/minute into the tube by blowing into the tube - make sure the chest rises


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When does the baby require continuing observation and additional attention?

Danger signs:- ineffective breathing/labored respiration – respiration rate > 60/min- heart rate < 100 bpm- cyanosis- pale, mottled or gray- abnormal tone- jitteriness- seizures- cool/warm baby- not feeding- at risk for infection


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Successful Resuscitation

BABY SHOULD BE:• WARM• PINK• BREATHING COMFORTABLY


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Preventative Care for the

Newborn


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Breastfeeding

• Within one hour of birth• Feed on demand to stimulate milk production• 8 to 12 feeds in 24 hours• Feeding is appropriate if: 6-8 wet diapers per day,

frequent bowel movements and weight gain• No supplements needed• Empty breast completely to use hind milk• Mother must increase caloric and fluid intake


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Proper LatchProper Latch


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Eye Care• Helps prevent infectious conjunctivitis

in 85 to 90% of newborns• Clean eyes in all newborns within 1

hour of birth• Prophylactic agents:

• Silver nitrate 1% solution (2 drops per eye)• Tetracycline ointment 1%• Erythromycin ointment 0.5%• Provilodone solution – iodized 2.5%


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Other MeasuresVitamin K

• 1 mg IM to prevent haemorrhagic disease

Cord Care• Keep stump clean and uncovered• No traditional medicines, herbs, etc

Immunizations• BCG if at risk of TB• One dose of oral polio vaccine (OPV) <2 wks after birth

• Hepatitis B if available


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Recognition and Management Recognition and Management of Problems Following of Problems Following

Resuscitation or Presenting Resuscitation or Presenting During the First Week of LifeDuring the First Week of Life


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IMPORTANT PRINCIPLES• Training

• neonatal resuscitation

• post resuscitation management

• prompt recognition of danger signs

• prompt management of danger signs

• Maternal education• Urgency of assessment and

management of a sick newborn


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DANGER SIGNS• A danger sign is a sign or a symptom identified

from history (mother, pregnancy, delivery, baby) as well as physical exam of the baby, which indicates that he/she is at risk for, or is in trouble and needs urgent evaluation.

• Signs and symptoms are non-specific in the neonatal period.


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HISTORICAL DANGER SIGNS

maternal history• maternal fever• incomplete maternal immunization status• maternal HIV, TB, syphilis, malaria

delivery history• prolonged rupture of membranes• prolonged labor• unclean delivery• bleeding, foul amniotic fluid• need for neonatal resuscitation


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DANGER SIGNS

Not feeding well

(<6 feeds/day) Respiratory

Cardiac

Other

Neurologic

Skin

Risk of infection

General


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NEONATAL DANGER SIGNSNot feeding well

• After first day of life, a healthy baby should be feeding 8-12 times a day. He/she should wake up for feeding and show interest in feeding.

General appearance• low birth weight <2500g

• premature <34 weeks

• twins or triplets

• dysmorphism

• temperature abnormalities

- hypothermia <35.5 °C axillary

- hyperthermia >37.5 °C axillary


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DANGER SIGNSRespiratory

• tachypnea RR>60, irregular breathing, apnea

• labored breathing, grunting, retractions

• cyanosis

• cough

• requiring bag and mask ventilation

Cardiac• tachycardia HR>200, bradycardia HR<100

• pale, mottled, capillary refill>3sec

• cyanosis


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DANGER SIGNS

Neurologic• seizures• hypotonia• hypertonia• jitteriness, tremors• irritability• lethargy• poor suck• weak cry or high pitch cry• bulging fontanel, depressed fontanel


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DANGER SIGNSSkin

• jaundice

• pustules

• pus from the umbilicus

• redness around the umbilicus

• purulent eye discharge

Other• abdominal distension, diarrhea

• vomiting

• bleeding


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CLINICAL SIGNS

Not feeding well (with risk of hypoglycemia)• irritability• seizures• jitteriness• temperature instability• respiratory distress• poor colour• jaundice


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CLINICAL SIGNS

Sepsis /meningitis• all the danger signs

Pneumonia• RR>60• retractions, nasal flaring• grunting• cough


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CLINICAL SIGNSAsphyxia

• abnormality of muscle tone

• lethargy, poor activity, irritability

• seizures, jitteriness, tremors

• poor sucking reflex

• poor respiratory effort

• poor colour


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CLINICAL SIGNS

LBW/prematurity• BW<2500g• physical immaturity• risk of respiratory problems, especially the premature

infant• difficult temperature control (risk of hypothermia)• poor feeding• higher risk of infections• higher risk of jaundice


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MANAGEMENTNot feeding well with no other

danger signs• evaluate

- milk production

- feeding technique

- sucking ability of the baby

• spoon feeding of extracted milk or formula

• treat oral thrush with gentian violet


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MANAGEMENTSevere infection (pneumonia, sepsis,

meningitis)• antibiotics: Septra PO for 10 days, and Gentamicin

IM for 7 days

• temperature control

• nutrition

• transfer (with mother) to a hospital, if feasible


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MANAGEMENTLocal infection

• Eyes: IM Cefotaxime or Ceftriaxone, 1dose, or Penicillin for 7 days

• Umbilicus:- if mild redness not extending: observation- if redness extending or pus draining, or other danger signs:

see severe infection• Skin:

- hygiene and oral cloxacillin- if not improving with oral treatment, or other danger signs

present: see severe infection


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MANAGEMENTAsphyxia/seizures

• treat the seizures with phenobarbital

• antibiotics (see severe infection)

• nutrition/prevention of hypoglycemia

• temperature control

• transfer if possible


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MANAGEMENTLBW/Premature baby

• handle with care• temperature control• early and frequent feedings• spoon feeding of expressed colostrum/breast milk if

unable to suck• close observation for signs of infection• check skin for jaundice

newborn resuscitation and care international normal newborn care

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