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HELPING BABIES

BREATHE….THE WHY
BEHIND EACH STEP

VANESSA BOOYSEN
UNIVERSITY OF THE FREE STATE
HELPING BABIES BREATHE
UNDER 5, INFANT AND NEONATAL MORTALITY
RATES IN SOUTH AFRICA

Rapid Mortality Surveillance report 2012


CAUSES IF NEONATAL DEATHS < 28 DAYS
Diarrhea 1%

Other 6%
Sepsis 8%

Congenital Pneumonia
anomalies 13% 8%
Tetanus 1%

Asphyxia 22%

Prematurity 41%

)
WHY DO BABIES DIE OF BIRTH ASPHYXIA IN SA?

• Primary Obstetric causes (PPIP)


• Intrapartum labour related
• Meconium aspiration in utero
• Cord prolapse
• Cord around neck
• Neonatal causes (PPIP)
• Inadequate resuscitation
• Persistent foetal circulation
7 INTERVENTIONS ACCOUNT FOR 90% OF
NEONATAL LIVES SAVED
Other 8% Antenatal
Clean postnatal corticosteroids for
practices 5% preterm labor 22%
Neonatal
resuscitation
6%

Promotion of
breastfeeding 10%

KMC -
Kangaroo
mother care
Case management 18%
of severe neonatal
infection 13%

Labour and
delivery
management 18%
TRAINING ALL PROVIDERS REDUCES DEATHS

• Training ALL birth attendants in SKILLS based


neonatal resuscitation may result in
• 30% of deaths of full term babies with intrapartum
events
• 5 – 10% of deaths due to prematurity
And
• There will also be a decrease stillbirths!
RESULTS OF HBB TRAINING

• Results so far from Tanzania

• 47% reduction in early neonatal death rate

• 24 % reduction in fresh
stillbirths
How many babies need resuscitation at
birth?
Some of the new evidence includes

– Not using oxygen for initial bag and mask


ventilation

– Approach to the management of meconium


aspiration

– Delayed Cord clamping


HBB is not just resuscitation
• Includes KEY strategies that improve neonatal
outcomes
– Good communication with mother and other health
workers
– Preparedness
– Hand washing
– Drying the baby and keeping warm - hat
– Immediate skin-to-skin contact
– Delayed cord clamping
– Breastfeeding
Key: The Golden Minute
Baby breathes • Clear the
spontaneously airway and
with in a minute
stimulation
OR
OR
Help the Baby
to breathe
within the
• Start bag and
GOLDEN mask
minute ventilation
Action Plan
3 Colours – levels of help
– Grey – preparation
– Green – Routine care
– Yellow – The golden minute
– Red – Continue, advanced
Evaluation–Decision-Action
Evaluate
Crying? Breathing? Heart rate?
• Decision
– Crying, not crying
• Action
– Drawing of action
PREPARE FOR A BIRTH IDENTIFY A HELPER
AND REVIEW THE EMERGENCY PLAN
Prepare the birth companion or another skilled helper to
assist if the baby does not breathe.
- A birth companion can help the mother and call for
another helper.
- A second skilled helper can assist in caring for the baby.
- The emergency plan should include communication and
transportation to advanced care.
WASH HANDS.

• Good hand washing helps


prevent the spread of
infection.
• Wash hands thoroughly with
soap and clean water or use
an alcohol-based cleaner
before and after caring for a
mother or a baby
• Gloves protect you from
infections carried by blood
and body fluids.
VIRGINIA APGAR INVENTED THE APGAR
SCORE IN 1952
APGAR scoring
A = Appearance
(skin color)
P = Pulse (heart
rate)
G = Grimace (reflex
irritability)
A = Active (muscle
tone)
R = Respiration
(breathing)
Activity
• Baby Smit was born 1 minute ago. His heart rate is 124
beats per minute and he is crying. Furthermore he is lying
with his limbs slightly flexed and he pulls a face if you tick
his feet with your finger. His body is pink, but his hands
and feet appear to be blue.

• Five minutes after birth his heart is 140 beats per minute
and he is calm but is breathing well. He is moving his arms
and legs actively and pulls his feet away when you shoot
them. His whole body now appears to be pink.
Record his “OLD” APGAR count in the
following table
APGAR: 1 min 5 min
Heart rate
Breathing attempt
Muscle tone
Reaction on stimulus
Colour
Total:
APGAR ACCORDING TO HBB STEPS
VIRGINIA APGAR HBB
Activity
• Baby Smit was born 1 minute ago. His heart rate is 124
beats per minute and he is crying. Furthermore he is lying
with his limbs slightly flexed and he pulls a face if you tick
his feet with your finger. His body is pink, but his hands
and feet appear to be blue.

• Five minutes after birth his heart is 140 beats per minute
and he is calm but is breathing well. He is moving his arms
and legs actively and pulls his feet away when you shoot
them. His whole body now appears to be pink.
APGAR ACCORDING TO HBB STEPS
Record his HBB APGAR count in the following
table
APGAR: 1 min 5 min
Breathing attempt
Heart rate
Colour
Muscle tone
Reaction on stimulus
Total:
MECONIUM IN THE AMNIOTIC FLUID
• If there is meconium in the amniotic
fluid, clear the airway before
drying. If the baby has passed stool
before birth, there is meconium in
the amniotic fluid.
• Meconium inhaled into the lungs can
cause breathing problems.
• Suction the mouth and nose
immediately after delivery.
• Use a bulb suction device, a tube and
reservoir suction device, or a cloth to
remove fluid.
• Dry the baby thoroughly after
clearing the airway
HYPOTHERMIA
DRY BABY ON MOTHERS ABDOMEN FOR FUNDAL
RUBBING AND INVOLUTION OF THE UTERUS
Heat loss in a term
baby, >3,5kg,
0.9°C / 15 min.
Hypothermia

Hypoglycemia

Acidosis
DEATH !!!
Warming,
feeding and
protection
behaviours are
intricately, inseparably
linked to the right place.
(Alberts 1994)
SKIN-TO-SKIN CONTACT
BREAST- VAGAL
MOTHER FEEDING (PSNS) GROWTH

OTHER PROTEST- STRESS SURVIVAL or


DESPAIR (SNS)

SEPARATION
Separated neonates experience
STRESS…….UNSTABLE… FREEZE
& DISSOCIATION.
HOW DOES SKIN TO SKIN WORK?
Autonomic Nervous System

Sympathetic Nervous Parasympathetic Nervous


System System (Vagal Nerve)

• Fight or flight • Regulates digestive tract


• Survival • Promotes growth
• Not conducive to growth • Promotes neurodevelopment
•  stress •  stress

Hypothesis: Vagal Nerve Stimulation


VAGAL NERVE STIMULATION
Skin-to-skin contact & suckling causes vagal stimulation

Stimulation back of palate Skin-to-skin care


SENSATIONS THAT WIRE BRAIN

SEES Ear HEARS


Mum’s eyes Mum’s voice

SMELLS
Mum’s milk MOVES
with Mum
TASTES
Mum’s milk Back FEELS
Mum’s arm
Hand TOUCH holding
Mum’s skin WARMED on
Skin-to-skin
CONTACT Mum’s front
MOTHER
is the KEY for
NEURODEVELOPMENT
Or
breathing
• A baby who does not cry needs help to breathe. Babies
who do not cry may not be breathing at birth.
• A baby who is not breathing is limp and does not move.
The skin may be pale or bluish.
• A baby who is breathing shallowly, gasping, or not
breathing at all needs help to breathe.
• Prompt attention will increase the chance of a good
response.
• If no help is given to a baby who is not breathing,
that baby may die or experience serious brain
damage.
CLEAR THE AIRWAY
• Clear the mouth and then the nose with a clean suction device or wipe.
• Clear the mouth first to remove the largest amount of secretions before the
baby gasps or cries. Suctioning the nose first may cause gasping and inhaling
of secretions.

• When using a bulb suction, squeeze the bulb before inserting the tip in the
mouth or nose and release before withdrawing the bulb.
• Stop suctioning when secretions are cleared, even if the baby does not
breathe.
• Suctioning too long, too vigorously, or too deeply can
cause injury, slow heart rate, and prevent breathing.
BULB SUCTION DEVICE
• When using a suction device with a tube and reservoir,
insert the tube into the side of the baby’s mouth no
more than 5 cm beyond the lips.

• Apply suction while withdrawing the tube.

• Insert the suction tube 1 to 2 cm into each


nostril and apply suction while withdrawing the tube.
STIMULATE BREATHING.

• Gently rub the back once or twice.


• Do not delay or stimulate longer.
• Move quickly to evaluate breathing and decide if
ventilation is needed.
• Drying, clearing the airway, and stimulating
breathing should take less than 1 minute.
• Your actions in The Golden Minute can help
many babies begin to breathe.
BREATHING, WARMTH……… IF
BREATHING, CUT CORD
BENEFITS OF SKIN TO SKIN TO THE BABY

• REDUCES
INFECTION !!!!
INFANT GUT COLONISATION WITH MATERNAL GUT
BACTERIA

A major factor behind the


expansion of the immune
system of the newborn is the
exposure to normal maternal
intestinal flora
IMMUNITY AT DELIVERY

Delivery of baby
(IgG from mother)

Exposure to mother's intestinal bacteria


(delivered next to the mother's perineum & anus)

Expansion of immune system

Specific Immunity: Production of IgG/IgM Innate Immune system:


Occurs over weeks maternal enteric flora
• Misplaced hygienic measures to prevent
exposure of the newborn to the mother’s
faeces at delivery as well as the family’s
normal bacterial flora have resulted in
that neonates have to trace their
intestinal flora from the mother’s skin,
hospital staff etc*
*Hanson et al. Pediatrics International 2002;44:347
IMMUNITY EXPANSION: VAGINAL VERSUS CAESAREAN
SECTION
Immunity expansion: Type of delivery

vaginal delivery Delivery by Caesarean section

exposure: vaginal flora exposure: mother's skin

exposure: enteric bacteria on perineum exposure: hospital staff

Administration of antibiotics
THE NATURAL CAESAREAN - VAGINAL SEEDING
https://www.youtube.com/watch?v=m5ricak98yg
DELAYED versus early umbilical cord clamping

Umbilical cord blood is a baby’s life blood until


birth and during transition phase.
It contains many wonderfully precious cells,
like stem cells, red blood cells and white blood
cells (including cancer-fighting T-cells) to help
fight disease and infection.
It makes sense that delayed cord clamping is a
great option for newly born babies.
ERASMUS DARWIN 1801
• “Another thing very injurious to the
child, is the tying and cutting of the
navel string too soon; which should
always be left till the child has not only
repeatedly breathed but till all pulsation
in the cord ceases. As otherwise the
child is much weaker than it ought to
be, a portion of the blood being left in
the placenta, which ought to have been
in the child.”
• Erasmus Darwin, Zoonomia, 1801. [3]
• At the moment of birth, 30 to 50%
of the baby’s blood volume is in the
placenta, and immediate clamping
deprives the baby of that blood.

Adults are in perilous danger of hypovolemic


shock and receive blood transfusions at 15 to 30%
blood loss.
DELAYED CORD CLAMPING
1-3 min after birth or
until pulsations have stopped
Delayed cord clamping
 Reduces infection
 Baby still gets oxygen via the placenta
 Reduces Paediatric anemia first 5 years of life
 Babies grow better
 Cardiac size is larger if we wait for the first breath
 Baby gets stem cells
NEONATAL RESUSCITATION
 With birth :
Transition from
intra uterine to
extra uterine
life…
Physiology of Respiration

 In Utero:
 Alveoli consists of fetal lung fluid
 30% of the breathing time is rapid panting
 During these passive movements the fetus
‘breaths’ +/- 600ml of amniotic fluid daily
FIRST BREATH

 Vaginal delivery puts pressure on the neonates


thorax and tracheal fluid gets forced out of the
lungs
 Stimulation of lights, cold, noise, handling,
gestational age and asphyxia, all have an effect on
the first breath
 Circulation adapts from intra uterine circulation to
extra uterine circulation
 Lung fluid is forced out
 Increase in blood and lymph flow through the
lungs
Assurance of an open air passage
Initiation of gas exchange:
Perfusion of alveoli
Blood circulation after birth
• Lung vessel relaxation &  Systemic blood flow
  pulmonary blood flow
  ductus arteriosus blood flow
DELAYED versus early umbilical cord clamping
Yet common practice is to quickly cut off this source of valuable cells
at the moment of birth.
Three reasons for this are:
• Carers who believe that there is little or no benefit in
delayed cord clamping, despite numerous studies and
recommendations
• Carers who believe that delayed cord clamping can cause
complications, despite numerous studies and
recommendations
• Carers being in a hurry to finish the birth… despite
numerous studies and recommend -
Delayed cord clamping (30 – 120 seconds)
was associated with:
• Fewer transfusions for anaemia (three trials, 111
infants; relative risk (RR) 2.01, 95% CI 1.24 to 3.27)

• Fewer infants with low blood pressure (two trials, 58


infants; RR 2.58, 95% CI 1.17 to 5.67)

• Less IVH (five trials, 225 infants; RR 1.74, 95% CI 1.08 to


2.81) than early clamping
IVH and late onset sepsis with delayed and
immediate cord clamping*

ICC = immediate cord clamping


DCC = delayed cord clamping, 30 to 45 seconds and lowering the infant

*Mercer et al. Pediatrics 2006;117;1235-1242


Gender differences in IVH, late onset sepsis and NEC among
infants with immediate and delayed cord clamping*

ICC = immediate cord clamping


DCC = delayed cord clamping

*Mercer et al. Pediatrics 2006;117;1235-1242


INNITIATE BREASTFEEDING WHEN
BREATHING WELL, DIRECTLY AFTER BIRTH
INTEGRATION OF CHILD
SURVIVAL PROGRAMS……
ESMOE

HBB
MBFI
TEN STEPS TO SUCCESSFUL BREASTFEEDING

1. Have a written breastfeeding policy that is routinely communicated to all health care
staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4.Help mothers initiate breastfeeding within a half-hour of


birth. HBB THIS STEP IS NOW: “Place babies skin to skin contact with their
Slide 3.84

mothers immediately following birth for at least an hour” = KMC


PROTECTION OF INFANT GUT BY HUMAN MILK
GLYCANS (LACTOFERRIN, OLIGOSACCHARIDES,
ETC.)

Newburg et al. Pediatric Res 2007;61:2-8


FORMALDEHYDE-FIXED SECTIONS FROM THE DISTAL INTESTINE OF
CLINICALLY HEALTHY PIGLETS FED COLOSTRUM (A–C)

A milk-derived film was detected along the


dense villous surface (A)

Only a few microcolonies of bacteria were


attached to tissues from colostrum-fed piglets (red
arrows)

Clostridium perfringens (green arrows) were present in


the lumen or along the villous surface in 2 out of 10
tested colostrum pigs (C)
Gastroenterology 2006;130:1776–1792
FORMALDEHYDE-FIXED SECTIONS FROM THE DISTAL
INTESTINE OF CLINICALLY HEALTHY PIGLETS FED
FORMULA MILK (D–F)
All formula fed piglets diagnosed with
NEC showed intense bacterial overgrowth (red
arrows)
Bacteria were present around a markedly atrophic
mucosa

Bacteria were also present deep into a severely


necrotic mucosa (E) red arrows

In some piglets with NEC, colonisation was


dominated by Clostridium perfringens (F; green
arrows)
Gastroenterology 2006;130:1776–1792
EFFECTS OF COLOSTRUM ON GUT

• The villous structure and the absorptive


area*** shows a 50 - 80% increase in mass
within 24 - 48 hours of colostrum feeding*

• Breast milk stimulates lactase activity in


preterm infants***
*McGuire et al. Arch Dis Child Fetal Neonatal Ed 2003;88:F11
**Weaver et al. Gut 1991;32:1321
***McClure et al. Acta Paediatr 2002;91:292
Colostrum ingested in first 24 hours: 15 ± 11 ml (4 – 26ml)
J Pediatr 2010:156
Even brief periods of positive pressure
ventilation, such as during resuscitation in
the delivery room, can cause bronchiolar
epithelial and endothelial damage in the
lung, setting the stage for progressive lung
inflammation and injury

Manual Ventilation with a Few Large Breaths at Birth Compromises the Therapeutic Effect of Subsequent Surfactant
Replacement in Immature Lambs. Björklund et al. Pediatric Res 1997;42:348-355
NEONATAL RESUSCITATION

 B-BREATHING
 Oxygen

 21 vs 100% O2
Pulse oximetry for
monitoring oxygen
saturation of
infants in the
delivery room
NEONATAL RESUSCITATION
 B-BREATHING
 Targeted Preductal Sats
Minutes after birth Saturation
1 min 60 – 65%
2 min 65 – 70%
3 min 70 – 75%
4 min 75 – 80%
5 min 85 – 95%
10 min 85 – 95%
Oxygen saturation (SpO2) measurements
in infants with asphyxia randomised to
resuscitation with air or 100% oxygen

*Pulse oximetry for monitoring infants in the delivery room: a


review
Dawson et al. Arch Dis Child Fetal Neonatal Ed.2007;92:F4–F7
NEONATAL RESUSCITATION
 B-BREATHING
 Provide positive pressure
ventilation
 Rate of 30-60 breaths/min
BREATHE WALTZ

 Breathe 2-3
 Breathe 2-3

 Breathe 2-3
 The requirements of medicalized neonatal
resuscitation are warmth, a firm surface, suction and
access to the umbilicus.
 Other priorities include comfortable position for staff
and the ability to draw umbilical blood for cord gas
analysis.
 A warm firm surface can be the bed or surface
where baby is born.
 In a poll of 34 midwives from around the world, most
reported that they perform resuscitation with the
cord intact using the bed, side of a pool designed for
waterbirth, part of an adult human body (mother or
midwife) or a portable board with a warm pack.
 If the cord is left intact, then fluids are
already being provided.
 Drugs are rarely required for
resuscitation, and it’s likely they would
be required far less often if cords were
intact.
 Since extensive resuscitation is rarely
required, can we not be uncomfortable
once in a while, bending over the baby
rather than performing resuscitation at
our standing height?
• A heart rate of 100 beats per minute or more is
normal.
• A heart rate of less than 100 beats per minute is
slow.
• If the heart rate sounds faster than your own,
it is probably normal. If the heart rate sounds
slower than your pulse, it is slow.
SKIN-TO-SKIN CONTACT
BREAST- VAGAL
MOTHER FEEDING (PSNS) GROWTH

OTHER PROTEST- STRESS SURVIVAL or


DESPAIR (SNS)

SEPARATION
Separated neonates experience
STRESS…….UNSTABLE… FREEZE
& DISSOCIATION.
SKIN-TO-SKIN CONTACT

HUMANITY FIRST
TECHNOLOGY SECOND
Summary

• Immediate drying
• Immediate skin to skin care
• Assess breathing continuously
• Early introduction of exclusive breast
milk feeding
• Whatever you do….don’t clamp and cut
the umbilical cord immediately
NEONATAL RESUSCITATION

 E – EXIT
 No sign of life after 10
minutes of resuscitation
 Poor response after
20 min …..DISCONTINUING
RESUSCITATION

 No oxygen to the brain


 Baby will be severely
handicapped
Thank you