1. Newborn Resuscitation and Care International Normal Newborn Care

2. Newborn Resuscitation and Care International Introduction 4 million neonatal deaths per year 2/3 of neonatal deaths occur in 1 st 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

3. Newborn Resuscitation and Care International Main Causes of Mortality

4. Newborn Resuscitation and Care International Essential Care for Newborn Health Care of future mothers Care during pregnancy Care at time of birth Care after birth

5. Newborn Resuscitation and Care International Immediate Care of the Newborn 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? Routine care -Warmth - Dry IF YES IF NO -Provide warmth -Position; clear airway -Dry, stimulate Evaluate: -Respirations -Heart rate -Color RAPID INTERVENTION…for resuscitation

6. Newborn Resuscitation and Care International 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

7. Newborn Resuscitation and Care International SignScore 012 Heart rateAbsentSlow (< 100 beats/minute) => 100 beats/min BreathingAbsentSlow, irregularGood, crying Muscle ToneLimpSome flexionActive motion Reflex irritability No responseGrimaceCough, sneeze ColorBlue or palePink body with blue extremities Completely pink Apgar Scoring

8. Newborn Resuscitation and Care International 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

9. Newborn Resuscitation and Care International 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

10. Newborn Resuscitation and Care International Newborn Resuscitation

11. Newborn Resuscitation and Care International Be prepared for resuscitation – 10% of babies require resuscitation 30-40% of babies that require resuscitation are a surprise

12. Newborn Resuscitation and Care International What is Necessary to Prepare for Resuscitation? Appropriate equipment Skill to use equipment Learn to recognize which baby needs resuscitation

13. Newborn Resuscitation and Care International 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 NO Normal breathing

14. Newborn Resuscitation and Care International Meconium Babies (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.

15. Newborn Resuscitation and Care International 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

16. Newborn Resuscitation and Care International 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

17. Newborn Resuscitation and Care International 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

18. Newborn Resuscitation and Care International How to Provide Resuscitation in a Health Care Facility Warmth - warmer - warm delivery room - temperature – 25 o C to 28 o C (77 – 82.4 o 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

19. Newborn Resuscitation and Care International 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

20. Newborn Resuscitation and Care International 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

21. Newborn Resuscitation and Care International 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

22. Newborn Resuscitation and Care International 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

23. Newborn Resuscitation and Care International Breathing Assistance in a Health Care Facility Technique: - connect O 2 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 airway and continue bag and mask ventilation

24. Newborn Resuscitation and Care International 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

25. Newborn Resuscitation and Care International 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

26. Newborn Resuscitation and Care International Successful Resuscitation BABY SHOULD BE: WARM PINK BREATHING COMFORTABLY

27. Newborn Resuscitation and Care International Preventative Care for the Newborn

28. Newborn Resuscitation and Care International 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

29. Newborn Resuscitation and Care International Proper Latch

30. Newborn Resuscitation and Care International 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%

31. Newborn Resuscitation and Care International Other Measures Vitamin 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

32. Newborn Resuscitation and Care International Recognition and Management of Problems Following Resuscitation or Presenting During the First Week of Life

33. Newborn Resuscitation and Care International 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

34. Newborn Resuscitation and Care International 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.

35. Newborn Resuscitation and Care International 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

36. Newborn Resuscitation and Care International DANGER SIGNS Not feeding well (<6 feeds/day) Respiratory Cardiac Other Neurologic Skin Risk of infection General

37. Newborn Resuscitation and Care International NEONATAL DANGER SIGNS Not 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

38. Newborn Resuscitation and Care International DANGER SIGNS Respiratory 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

39. Newborn Resuscitation and Care International DANGER SIGNS Neurologic seizures hypotonia hypertonia jitteriness, tremors irritability lethargy poor suck weak cry or high pitch cry bulging fontanel, depressed fontanel

40. Newborn Resuscitation and Care International DANGER SIGNS Skin jaundice pustules pus from the umbilicus redness around the umbilicus purulent eye discharge Other abdominal distension, diarrhea vomiting bleeding

41. Newborn Resuscitation and Care International CLINICAL SIGNS Not feeding well (with risk of hypoglycemia) irritability seizures jitteriness temperature instability respiratory distress poor colour jaundice

42. Newborn Resuscitation and Care International CLINICAL SIGNS Sepsis /meningitis all the danger signs Pneumonia RR>60 retractions, nasal flaring grunting cough

43. Newborn Resuscitation and Care International CLINICAL SIGNS Asphyxia abnormality of muscle tone lethargy, poor activity, irritability seizures, jitteriness, tremors poor sucking reflex poor respiratory effort poor colour

44. Newborn Resuscitation and Care International 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

45. Newborn Resuscitation and Care International MANAGEMENT Not 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

46. Newborn Resuscitation and Care International MANAGEMENT Severe 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

47. Newborn Resuscitation and Care International MANAGEMENT Local 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

48. Newborn Resuscitation and Care International MANAGEMENT Asphyxia/seizures treat the seizures with phenobarbital antibiotics (see severe infection) nutrition/prevention of hypoglycemia temperature control transfer if possible

49. Newborn Resuscitation and Care International MANAGEMENT LBW/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