1. Chapter 3Problems of the neonate and young infant -Birth Asphyxia

2. Case study: Baby boy of Ruth Baby of Ruth is a boy born at term. He is blue and has poor muscle tone. He doesn't cry.

3. Dry and stimulate baby with clean cloth and place where the baby will be warm Look for: • Breathing or crying • Good muscle tone • Colour pink Assessment of newborn at delivery NO NO NO

4. YES Start the resuscitation now! Remember: A,B,C Airway, Breathing Circulation NO Early Essential Newborn Care Does baby of Ruth need resuscitation? Assessment of newborn at delivery

5. (Ref. WHO pocket book p.47)

6. Neonatal resuscitation (A=Airway) • Open airway by positioning the head in the neutral position (Ref. p. 47) • Clear airway and suction, if necessary • Stimulate, reposition • Give oxygen, as necessary Ruth’s baby is still blue and not breathing.

7. Neonatal resuscitation (B = Breathing) • Use a correctly fitting mask: • If the baby is still not breathing (Ref. p. 47) : • Check position and mask fit • Continue to give breaths at rate of 40 breaths per minute • Use oxygen if available • Every 1-2 minutes stop and • see if the pulse or breathing has improved • Observe the baby closely!

8. Neonatal resuscitation (C=Circulation) • You check the heart rate (HR) • What steps would you take next?

9. Early Essential Newborn Care • Immediate and thorough drying with a clean cloth • Maintain skin-to-skin contact • Give the baby to mother as soon as possible, on chest or abdomen • Cover the baby to prevent heat loss • Properly time cord clamping • Wait for up to 1 - 3 mins or until pulsations stop. Keep umbilical cord clean and dry. • Breastfeeding and non-separation • Initiate within the first hour keeping mother and baby together Further Management after 1hr: • Give vitamin K (phytomenadione), according to national guidelines 1 ampoule IM once • Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once (prophylaxis), according to national guidelines • Full examination and weight

10. History Baby boy of Ruth was born at term. He came out not crying, blue and with poor muscle tone. He was resuscitated for 2 minutes. Rupture of membranes happened at home, contractions were regular. His mother, Ruth, G1 P1, was in labour for a long period of time, but progressed to normal delivery in hospital. No chronic illness and no pre-eclampsia were diagnosed before.

11. Examination after stabilisation After 2 minutes bag-mask resuscitation baby was breathing well, muscle tone has increased. He was crying. Vital signs: pulse: 120/min, RR: 50/min Weight: 3.2 kg Chest: air entry was good bilaterally and there were no added sounds, no chest indrawing Cardiovascular: both heart sounds were audible and there was no murmur Abdomen: soft, bowel sounds were active Neurology: muscle tone improved, no focal signs

12. What supportive care and monitoring are required?

13. Monitoring • The baby has to be monitored frequently • Pay attention to colour, breathing, muscle tone and ability to suck

14. Monitoring (continued) • In the days after birth asphyxia the baby may develop following problems (Ref. p. 51-52): • Convulsions • check glucose • treat with phenobarbital • Apnoea • oxygen by nasal prongs • resuscitation with bag and mask • Inability to suck • feed with milk via a nasogastric tube Treat only if the problems arise

15. Supportive Care • If no evidence of birth asphyxia at delivery provide normal care for newborn: • Give the baby to mother as soon as possible, place on chest or abdomen • Cover the baby to prevent heat loss • Encourage initiation of breastfeeding within the first hour • Keep umbilical cord clean and dry • Give vitamin K 1 ampoule IM single dose • Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once (prophylaxis) (Ref. p. 46, p. 50) • Take care of the mother

16. Breastfeeding support Early and exclusive breastfeeding is important for all newborns Breastfeeding support: • Encouragement • Breastfeeding friendly environment • Breastfeeding assessment and counselling (Ref. p. 295)

17. Progress Ruth’s baby’s motor tone recovered well in the first hour. After some difficulties at the beginning he was sucking well. Before he was discharged home he also received hepatitis B and BCG vaccines.

18. Follow-up Baby should receive regular MCH follow-up to monitor: • Growth and development • Nutritional intake • Immunization status • Detection of other illnesses or problems

19. Summary • Be prepared for resuscitation at every delivery • Don’t need oxygen in most cases, bag-mask ventilation will stimulate the baby to breathe on its own • Prognosis for the baby with perinatal asphyxia can be predicted by recovery of motor function and sucking ability • The prognosis is good for babies who respond quickly to resuscitation • Learn all steps of neonatal resuscitation, practice and teach others