Newborn Resuscitation and Care

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Normal
Newborn Care

Newborn Resuscitation and 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 Mortality

Neonatal tetanus 7%

Main Causes of Infant Mortality

Pneumonia 15%
Sepsis/Meningitis 9%

10%

5%

7%
15%

24%

9%
1%
29%

Diarrhea 1%
Birth asphyxia and trauma 29%
Prematurity 24%
Congenital anomalies 10%
Others 5%

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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 Newborn

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

IF NO
Breathing or
crying?

-Provide warmth

Good muscle
tone?

-Dry, stimulate

-Position; clear airway

Evaluate:
-Respirations
-Heart rate
-Color

Color pink?
Term
gestation?
IF YES
Routine care
-Warmth
- Dry

RAPID INTERVENTIONfor 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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Apgar Scoring
Sign

Score
0

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

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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 Resuscitation

Newborn Resuscitation and Care

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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?

IF NO
Normal breathing
- Provide warmth
- Position; clear
airway
- Dry, stimulate

Evaluate:
- Respirations
- Heart rate
- Color

HR > 100 &

pink

Abnormal respirations or HR < 100

Routine care
- Warmth
- Dry

Provide breathing assistance

RAPID INTERVENTIONfor resuscitation

Supportive
care

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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.

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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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How to Assess a Baby in a Health Care Facility

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.

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How to Assess a Baby in the Community

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 babys heart rate
should be more than your own heart rate.
All other assessments are similar to health facility

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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
- babys body can be wrapped in a towel and then covered by plastic.
Ensure babys 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

Facility
Technique:
- 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 airway
and 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 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 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

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Recognition and Management

of Problems Following
Resuscitation or Presenting
During 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

Newborn Resuscitation and Care

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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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Not feeding well

General

Risk of infection

(<6 feeds/day)

DANGER
SIGNS

Skin

Respiratory
Cardiac

Other
Neurologic

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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

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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

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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 SIGNS
Skin

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 SIGNS
Asphyxia

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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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

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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

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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

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MANAGEMENT
Asphyxia/seizures

treat the seizures with phenobarbital

antibiotics (see severe infection)
nutrition/prevention of hypoglycemia
temperature control
transfer if possible

Newborn Resuscitation and Care

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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