Skilled Birth Attendant

Neonatal Resuscitation Training Program

1
 National and State goals in the MDG context

Key India M.P 10th FY NPP MDG

Indicators Plan 2010 2015
2007

IMR 55 72 45 <30 27
(2008) (2008)
SRS SRS

NMR 39 45 26 <20* <20*

NFHS-III NFHS-III

U5MR 74 94 - - 41
NFHS-III NFHS-III
 
 Child Health Services in Madhya Pradesh

Trend in I.M.R. …
110 India
97 Madhya Pradesh
98 Linear (India)
100 Linear (Madhya Pradesh)
88 85
90
79
75
80 72 72
68 74 72
70
63 58
57
60
57 55
50

40
1996

1998

2000

2002

2004

2006

2007

2008
Source: SRS, India
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 Lesson 1
Overview and
Principles of Resuscitation
Content:
• Resuscitation risk factors
• Physiologic changes at birth
• Normal transition
• Abnormal transition
• Premature infants at higher risk
• How to prepare for resuscitation

2
 Basic Steps in Resuscitation

Always Assess baby’s response at birth

100%
needed
Dry, warm, clear airway, and
stimulate
Needed less Ventilation with 10%
frequently bag and mask
Chest
compressions
Rarely Needed 1%
Meds
3
ABC’s of Resuscitation

Airway
Position and clear
Breathing
Stimulate to breathe
Circulation
Assess heart rate

4
Risk Factors Associated with the
Need for Resuscitation

Maternal Risk Factors Before Birth:

• Ruptured membranes over 18 hours
• Pre-eclampsia and eclampsia
• Maternal infection – malaria, HIV, etc.
• Premature labor
• Multiple births
• Others
6
Risk Factors Associated with the
Need for Resuscitation
Risk Factors During Labor:
• Excessive bleeding
• Breech presentation
• Meconium
• Abnormal fetal heart tones
• Prolapsed or nuchal cord
• Rapid, hard labor
• Foul smelling fluid
• Prolonged labor
• Shoulder dystocia 7
 Normal Transition

• No meconium
• Breathing/crying
• Good muscle
tone
• Term

12
Abnormal Transition

• Gasping, ineffective or no breathing

• Poor muscle tone
• Central cyanosis (blue)
• All need assisted ventilation!

13
 Apgar Score
Parameter 0 1 2

Respiratory Effort Absent Gasping Good Cry

Heart Rate Zero <100/min >100/min

Colour (cyanosis) Central Cyanosis Peripheral Pink

Cyanosis

Muscle tone Flaccid Partial Flexion of Complete flexion

the extremities

Reflex (response None Grimace Sneeze

to nasal catheter)

It should be calculated at 1 minute and 5 minutes after birth

Normal more than 7
 Premature Infants at
Higher Risk

• Immature lungs – increased respiratory distress

• Increased heat loss and poor temperature control
• Possible infection
• Prone to bleeding in the brain
• Feeding problems 14
 Prepare for a Delivery

• Basic equipment:
• Heat source
• Blankets
• Suction
• Bag and mask
• A person trained in neonatal
resuscitation

15
At every delivery,
there should be at least one
person whose primary
responsibility is the baby
and who is capable of
performing resuscitation.

16
 Initial Steps
The First 30 Seconds

Content:
• Manage meconium if present
• Provide warmth
• Open the airway
• Clear mouth and nose
• Dry, stimulate, and reposition head
• Evaluate

17
Management of Meconium
Meconium

•Immediately
Initial Yes After delivery ask:
No clear mouth
and nose
Steps Is baby active
and breathing?
•Continue with
initial steps

19
 Provide Warmth

Place baby in warm location:

• Warm surface, warm blankets
• Away from draft
• Heat lamp
• Overhead warmer, if available
• Skin to skin, if routine care

20
 Positioning the Airway

Correct and incorrect head position for resuscitation 21

 Clear the Mouth and Nose
Bulb syringe:
• Suction mouth first, then
nose
(“m” before “n”)

No bulb syringe:
• Clear secretions with clean,
dry cloth

No deep suctioning with bulb

syringe or catheter!

Bradycardia (slowing of the heart

rate) can result from deep
suctioning

22
Drying the Infant

23
 Tactile Stimulation

Acceptable ways to stimulate a baby to breathe 24

 Do NOT Stimulate By:

• Slapping the back

• Squeezing the rib cage
• Forcing thighs into the abdomen
• Dilating anal sphincter
• Hot or cold compresses or baths
• Shaking

25
 How to Prioritize Actions
Evaluation is based on:
• Respirations (breathing/crying)
• Heart rate
• Color

26
 Evaluate Respirations

YES
• Unlabored breathing/crying
• Listen with stethoscope

NO
• If shallow breathing, gasping,
or not breathing at all, give
positive-pressure ventilation

27
 Evaluate Heart Rate
• Feel pulse at base of
umbilical cord or listen
with stethoscope
• Count for 6 seconds
and multiply by 10
Example:
If you counted 13
pulsations in 6 seconds the
baby’s heart rate would be
13 x 10 = 130
• Heart rate <100 requires
positive-pressure
ventilation 28
 Evaluate Color
• Peripheral cyanosis (a bluish color):
– Pink centrally: assess lips and gums
– Bluish color of hands and feet
– Requires no further action
• Central cyanosis:
– Bluish color of the trunk and limbs
– Bluish color of lips and gums
– Use free-flow oxygen, if available, or
positive-pressure ventilation
29
 Free-flow Oxygen
• If the infant is breathing
but there is persistent
central cyanosis, give
free-flow oxygen.
• Flow rate at approximately
5-10 L/min
• If not available, use
positive-pressure (bag and
mask) ventilation

30
Newborn Resuscitation Flowchart
Initial Steps
Clear meconium,
if present

 Provide warmth

30 seconds
 Position; clear airway
 Dry and reposition
 Stimulate if necessary

Is the baby breathing?

What is the heart rate?
What is the color?

31
If the Evaluation is NOT Normal

Is the baby breathing?

What is the heart rate?
What is the color?

30 seconds
•Not breathing, or
•Heart rate <100, or
•Poor color

 Provide positive-pressure ventilation

 Check for increasing heart rate
 Correct problems
 Give oxygen if available

32
Evaluate These Newborns

33
 Positive-Pressure Ventilation
The Second 30 Seconds
Content:
• When to ventilate
• Self-inflating bag and mask
• Important characteristics of face mask
• Testing bag and mask
• Preparing for positive-pressure
ventilation
• What if the baby does not improve
34
 Ventilation

Ventilation of the lungs

is the single most
important and effective
step of resuscitation.

35
 When to Ventilate

Is the baby breathing?

What is the heart rate?
What is the color?
•Not breathing, or

30 seconds
•Heart rate <100, or
•Poor color

 Provide positive-pressure
ventilation
 Check for increasing heart rate
 Correct problems
 Give oxygen if available

36
Basic Parts of Bag and Mask

90-100% O2 to infant

37
Room Air May Be Used for
Resuscitation

Room air to infant

40% O2 to infant

38
 Operation of Bag and Mask

Pressure determined by 3 factors:

1. How hard the bag is squeezed
2. Any leaks between mask and face
3. Set point of pressure-release
(pop-off) valve

39
 Face Mask Size

Correct: Covers
mouth, nose, and chin

Incorrect:
Too large - covers eyes
and extends over chin

Too small - does not

cover nose and mouth
40
 Testing Bag and Mask

• Pressure against
your hand?

• Pressure-release
valve opens?

41
 Face Mask Placement

• Correct positioning:
cover mouth, nose,
and tip of chin, but
not the eyes

• Correct position for

assisted ventilation

42
Preparing for Positive-Pressure
Ventilation
• Select correct-sized
mask
• Clear airway
• Position head
• Position yourself at

side or head of baby

43
 Effective Use of Bag
• The primary sign of good ventilation is an
increase in heart rate
• Apply enough pressure to create
noticeable, gentle rise and fall of the chest
• Bilateral breath sounds
• Improvement of color and heart rate
• Initial breaths may require higher
pressures
• If baby appears to be taking a very deep
breath, too much pressure is being used
44
How Often Should You
Squeeze the Bag?
40-60 breaths per minute
Count out loud: “Breathe—two—three”

45
 Signs of Improvement

1. Increasing heart rate (>100)

2. Improving color

3. Spontaneous breathing or crying

4. Improving muscle tone

46
 Inadequate Chest Expansion
PROBLEM ACTION

Inadequate seal Reapply mask to face, check size,

remove vernix

Blocked airway Reposition head

Check for secretions and suction if

present

Not enough pressure Ventilate with newborn’s mouth

slightly open

Increase pressure until there is an

Equipment malfunction easy rise and fall of the chest

Fix or use backup equipment 47

 Is Adequate Oxygen Being
Administered?
If available, is 100% oxygen being given?
• Oxygen tubing attached to the bag and the oxygen source?
• Gas turned on?
• Oxygen reservoir attached?
• Oxygen in the tank?

If supplemental oxygen is not available, give

positive-pressure ventilation using room air!

48
 Newborn Resuscitation Flowchart
Remove meconium,
if present

30 seconds
 Provide warmth
 Position; clear airway
 Dry and reposition
 Stimulate if necessary

Is the baby breathing?

What is the heart rate?
•Breathing What is the color?

30 seconds
•Heart rate > 100, •Not breathing, or
•Color improving •Heart rate < 100, or
•Poor color
 Supportive Care
 Keep Warm  Provide positive-pressure ventilation
 Check for increasing heart rate
Evaluate again in  Correct problems
TWO minutes  Give oxygen if available 49
Key to Success

Establishing
effective ventilation
is the key to nearly
all successful
neonatal
resuscitations!

50