Intact Survival Blog

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Intact Survival Blog

  1. 1. INTACT SURVIVAL STARTED FROM BIRTH M.Sholeh Kosim Chairman of Perinatology Working Group Indonesian Society of Pediatrician (UKK Perinatologi IDAI) Presented in 13 rd National Congress of Child Health Bandung Indonesia July 6, 2005
  2. 2. Introduction <ul><li>Human Life Cycle : </li></ul><ul><ul><li>Started from intrauterine life </li></ul></ul><ul><ul><li>Result of reproductive system. </li></ul></ul><ul><ul><li>Survival of the human species depends </li></ul></ul><ul><ul><li>upon the female and male reproductive systems </li></ul></ul><ul><ul><li>Functioning and control : dependent on the </li></ul></ul><ul><ul><li>neuro-endocrine system </li></ul></ul>
  3. 3. LIFE CYCLE
  4. 4. Stages of Human Life Cycle after being a new born : <ul><li>Infancy : 0 – 1 year </li></ul><ul><li>Childhood : 1 year --- adolescence </li></ul><ul><li>Adolescence : Body becomes sexually mature. </li></ul><ul><li>- Changes were happened due to hormonal and </li></ul><ul><li>physically origins. </li></ul><ul><li>Adulthood : Body slowly slows down </li></ul><ul><ul><li>- Certain changes such as hair falling out and physical activity are decreasing </li></ul></ul>
  5. 5. <ul><ul><li>Survive after a period of birth and continue to next steps of the cycle by growing up optimally and healthy. </li></ul></ul><ul><ul><li>Belong to babies who have no prominent malformation or congenital anomaly : </li></ul></ul><ul><ul><ul><li>especially central nerve system malformation </li></ul></ul></ul><ul><ul><ul><li>born as preterm or term but not immature or extremely low birth weight babies </li></ul></ul></ul>Human Life Cycle is being to occur successfully
  6. 6. Human is such different species <ul><li>Characteristics : </li></ul><ul><ul><li>Separate the Human Organism from Lower species </li></ul></ul><ul><ul><li>Enhance `survivorship' of the species: </li></ul></ul><ul><ul><ul><li>Intra-uterine development </li></ul></ul></ul><ul><ul><ul><li>Post-natal nutrition of the newborn through lactation by the mother; </li></ul></ul></ul><ul><ul><ul><li>Development of the limbic portion of the brain </li></ul></ul></ul><ul><ul><ul><li>Development and expression of homeostatic mechanisms </li></ul></ul></ul>
  7. 7. Birth Period or Intrapartum <ul><li>Most important times within Human Life Cycle. </li></ul><ul><li>“ The critical minutes and the critical days”. </li></ul><ul><li>Failure to prevent or treat  affect : </li></ul><ul><ul><ul><li>child’s growth </li></ul></ul></ul><ul><ul><ul><li>physical and mental abilities, </li></ul></ul></ul><ul><ul><ul><li>School performance. </li></ul></ul></ul><ul><li>Increased burden and strain on </li></ul><ul><ul><ul><ul><li>Family </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Community </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Various social institutions. </li></ul></ul></ul></ul>
  8. 8. Birth Asphyxia as Starting Disasters <ul><li>Major cause of neonatal death, stillbirth </li></ul><ul><li>Significant of severe neurological disability. </li></ul><ul><li>In industrial countries : reduced </li></ul><ul><li>In developing countries : still high </li></ul><ul><li>Case fatality rates for neonatal encephalopathy may 40% higher </li></ul>
  9. 9. Asphyxia-related sequellae ‘ Birth asphyxia’ Not breathing at birth Intrapartum Stillbirth Lawn J, et al 2005 Neurological Disability Severe Mild Other factors, e.g., preterm birth Intrapartum factors Pre-delivery factors Asphyxia-related neonatal death Not resuscitable Healthy development Neonatal Encephalopathy Severe Moderate Mild
  10. 10. www.thelancet.com March, 2005
  11. 11. Recent estimates... Lawn J,et al 2005 Cases/year not specified 7,565,000 years of life disabled Methods not yet published 691,000 Not assessed WHO GBOD I version 2 2001 (around 2000) Not assessed 1.6 million [40% of 3.9 Million stillbirths] WHO RHR 2001 Not assessed 1.16 million (Of 4.0 million neonatal deaths, 29% due to birth asphyxia) Not assessed WHO RHR 2001 (around 1999) Not assessed 1.6 million [32% of 5.0 million neonatal deaths] Not assessed WHO RHR c 1996 (1990 data) Cases/year not specified 3,525,000 years of life disabled 770,000 Not assessed WHO GBOD I 1996 (1990 data) ‘ at least an equal number’ to the 800,000 neonatal deaths 800,000 Not assessed WHO a 1991 Asphyxia-related neonatal disability Asphyxia-related neonatal deaths Intrapartum stillbirths Source Date
  12. 12. www.thelancet.com March, 2005 Indonesia 82 2% 18
  13. 13. Lawn J et al (2005) <ul><li>Intra partum-related neonatal death annually </li></ul><ul><ul><li>+ 0.94 million ~ 23% of the global total of 4 million. </li></ul></ul><ul><li>Intra partum stillbirths 1.02 million (0.66–1.48 million) occur annually, comprising 26% of global stillbirths </li></ul><ul><li>Intra partum-related neonatal deaths account for almost 10% of deaths in children aged under 5 years </li></ul><ul><li>Intra partum stillbirths are a huge and invisible problem, but are potentially preventable. </li></ul><ul><li>Programmatic attention and improved information are required </li></ul>
  14. 14. Perinatal hypoxic-ischemic brain injury <ul><li>+ 10% to 20% of all cases of Cerebral Palsy ( CP ) </li></ul><ul><li>Most distinctive sequelae : intrapartum asphyxia. </li></ul><ul><li>Magnitude of the changes in the blood gas (term infant) remains unclear.: </li></ul><ul><ul><ul><li>would necessitate knowledge about: </li></ul></ul></ul><ul><ul><ul><ul><ul><li>fetal Cerebral Blood Flow (CBF) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>and cerebral metabolism. </li></ul></ul></ul></ul></ul><ul><li>Severe asphyxia  Residual neurologic sequelae </li></ul>
  15. 15. FACTORS INFLUENCING CEREBRAL BLOOD FLOW ( CBF) IN ASPHYXIA NEWBORN <ul><li>: </li></ul><ul><li>. </li></ul>Asphyxia Insult Maintaining cerebral perfusion <ul><li>Systemic adaptation </li></ul><ul><li>Cerebral circulatory response </li></ul>
  16. 16. Responses <ul><li>Biochemical response </li></ul><ul><li>Autoregulation response </li></ul><ul><li>Circulatory response </li></ul>
  17. 17. <ul><li>Major priority in perinatal medicine : </li></ul><ul><ul><li>Early and accurate identification </li></ul></ul><ul><ul><li>Highly relevant clinical issue : newer therapies were investigated to reduce subsequent hypoxic-ischemic cerebral injury and long-term neurologic deficits. </li></ul></ul>
  18. 18. Major Adverse Outcome Related To Birth Asphyxia <ul><li>Stillbirth </li></ul><ul><li>Neonatal death </li></ul><ul><li>Severe neurological disability. </li></ul><ul><li>Birth trauma. </li></ul><ul><li>Brain hypoxic – ischemic injury </li></ul>To define specific outcomes for estimation of the burden more precise epidemiological case definition is required.
  19. 19. Major conditions or sequel associated with birth asphyxia <ul><li>Intra partum stillbirth </li></ul><ul><li>Birth Asphyxia </li></ul><ul><li>Newly born live infant who can not be resuscitated </li></ul><ul><li>Neonatal encephalopathy </li></ul><ul><li>Neonatal death as a consequence of an asphyxia-related condition </li></ul><ul><li>Neurological disability </li></ul>
  20. 20. Birth as an Additive or Potentiating factor in Hypoxic injury <ul><li>Process of birth : </li></ul><ul><ul><li>Perinatal Hypoxic – Ischemic injury </li></ul></ul><ul><ul><li>Profound alteration of biochemical and physiological homeostasis: </li></ul></ul><ul><ul><ul><li>Transient hypoxemia and hypercapnea, variable in severity and duration are consistence occurrences. </li></ul></ul></ul><ul><ul><ul><li>Transient disturbances in cerebral blood may also occur </li></ul></ul></ul><ul><ul><li>Whether biochemical state of the brain is affected the major systemic alteration that take place at birth ? </li></ul></ul>
  21. 21. Biochemical mechanisms of neuronal death with Hypoxic – Ischemia <ul><li>Principal biochemical mechanisms of cell death with hypoxemia, ischemia and asphyxia are presumably very similar, </li></ul><ul><ul><li>initiated with oxygen deprivation </li></ul></ul><ul><li>Current concepts concerning the mechanism for cell death : </li></ul><ul><ul><li>the disturbances of brain glucose and energy metabolism </li></ul></ul>
  22. 22. Characteristics Of Hypoxic-Ischemic Brain Damage <ul><li>An evolving process </li></ul><ul><li>Begins : during insult and extends into the recovery period (reperfusion interval). </li></ul><ul><li>Tissue injury takes the form of selective neuronal necrosis or infarction, </li></ul><ul><ul><li>the latter with destruction of all cellular elements including neurons, glia, and blood vessels. </li></ul></ul><ul><li>When infarction occurs, area surrounding the infarct (penumbra) consists of neurons : </li></ul><ul><ul><li>necrosis or apoptosis (programmed cell death). </li></ul></ul><ul><li>Penumbral area that appears most amenable to reversal of cellular injury through therapeutic intervention </li></ul>
  23. 23. Risk Factors During Intrapartum Period <ul><li>Kind of delivery </li></ul><ul><li>Respiratory morbidity </li></ul><ul><li>Titapant V and Sirimai K, 2002 : </li></ul><ul><ul><li>Low education level </li></ul></ul><ul><ul><li>Past history of previous delivery </li></ul></ul><ul><ul><li>Past history of preterm delivery </li></ul></ul><ul><ul><li>No antenatal care, unawareness of symptoms of true labor and present preterm delivery </li></ul></ul><ul><ul><li>The risk factors : should have further study to get more information that can apply to control birth before arrival </li></ul></ul><ul><li>Born at night and during weekends and holidays </li></ul>
  24. 24. Survival Condition <ul><li>Most likely importance factors which influence the </li></ul><ul><li>survival of neonates after having experience of birth </li></ul><ul><li>asphyxia actually depend on: </li></ul><ul><li>Gestation period, </li></ul><ul><li>Birth weight </li></ul><ul><li>Proper and prompt management. </li></ul>
  25. 25. <ul><li>If neonates could survived and most of them will be suffered from disabilities. </li></ul><ul><li>Recent International Consensus ( ICIDH-2, WHO 1999 clarified terminology for disability by outlining three components of disablement : </li></ul><ul><ul><ul><li>Impairment : defined as “ any loss or abnormality of psychological, physiological and anatomical structure or function “ </li></ul></ul></ul><ul><ul><ul><li>Activity limitation </li></ul></ul></ul><ul><ul><ul><li>Participation restriction </li></ul></ul></ul>
  26. 26. Categories of impairment <ul><li>Motor function ( Cerebral palsy ) </li></ul><ul><li>Visual function ( Blindness) </li></ul><ul><li>Hearing ( deafness) </li></ul><ul><li>Mental ability ( Intelligence Quotion < 70 ) </li></ul>
  27. 27. Vanhaesebrouck et al (2004) <ul><li>Studied a total of 525 infants in NICU . </li></ul><ul><li>Life-supporting care : 322 liveborn infants, 303 admitted for intensive care. </li></ul><ul><li>Overall survival rate of liveborn infants was 54%. </li></ul><ul><li>Of the infants who were alive at the age of 7 days, 82% survived to discharge </li></ul>
  28. 28. <ul><ul><li>Among the 175 survivors, </li></ul></ul><ul><ul><ul><li>63% had 1 or more of the 3 major adverse outcome </li></ul></ul></ul><ul><ul><ul><ul><li>serious neuromorbidity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>chronic lung disease at 36 weeks' postmenstrual age </li></ul></ul></ul></ul><ul><ul><ul><ul><li>treated retinopathy of prematurity. </li></ul></ul></ul></ul><ul><ul><li>The chance of survival free from serious neonatal morbidity at the time of hospital discharge was <15% (21 of 158) for the admitted infants with a gestation <26 weeks. </li></ul></ul>
  29. 29. Finner et al ( 1999) <ul><li>Studied the feasibility of Cardiopulmonary resuscitation (CPR) on Extremely Preterm Babies. </li></ul><ul><li>Previous report : none of the 20 previously reported infants weighing <750 g at birth who received CPR in the delivery room (DR) survived. </li></ul><ul><li>To clarify whether such resuscitation is futile or not </li></ul><ul><li>Evaluated experience with DR-CPR over a 4-year period. </li></ul><ul><li>Retrospective : Outcome infants with birth weights <1000 g at University of California, San Diego Medical Center from January 1993 to December 1996.  </li></ul>
  30. 30. <ul><li>Surviving infants and matched control infants were followed for 40 months' adjusted age using standardized neurodevelopmental assessments </li></ul><ul><li>Results :  </li></ul><ul><li>Infants with birth weight <1000 g : 29% (51/177) died : </li></ul><ul><ul><li>44% : <750 g </li></ul></ul><ul><ul><li>16% : 750 g. </li></ul></ul><ul><li>Overall, 19 infants received DR-CPR : 12  < 750 g. </li></ul><ul><li>Of the infants received DR-CPR, 79% (15/19) survived, </li></ul><ul><ul><li>10 of 13 infants < 750 g </li></ul></ul><ul><ul><li>5 of 6 infants 750 g. </li></ul></ul>
  31. 31. <ul><li>Of 15 survivors, 10  followed up : </li></ul><ul><ul><li>70% : normal neurologically and developmentally </li></ul></ul><ul><ul><li>2 : CP + mild cognitive and severe motor developmental delay. </li></ul></ul><ul><ul><li>7 infants <750 g, 6 normal neurodevelopmental outcomes. </li></ul></ul><ul><ul><li>Mean composite mental and motor scores of DR-CPR survivors were 93 ± 10 and 89 ± 25, respectively. </li></ul></ul><ul><ul><li>No differences were found in neurologic or developmental outcome between DR-CPR survivors and control infants </li></ul></ul><ul><ul><ul><li>Conclusion : intact survival is possible for infants weighing <750 g at birth after DR-CPR. </li></ul></ul></ul>
  32. 32. Intervention <ul><li>Needed to overcome the problem and improve the survival. </li></ul><ul><li>Should be comprehensive and continuum approach ( Maternal ---- Neonatal ) </li></ul><ul><li>Consist of : </li></ul><ul><ul><ul><li>Hospital based </li></ul></ul></ul><ul><ul><ul><li>Community based </li></ul></ul></ul>
  33. 33. Both mother and newborn can be improved <ul><ul><li>Good antenatal care and antenatal steroid </li></ul></ul><ul><ul><li>Shared between community centers and local hospitals with good lines of communication. </li></ul></ul><ul><ul><li>Management of labor by use of partogram,. </li></ul></ul><ul><ul><li>Detection, prevention, and management of fetal asphyxia : still a prime target </li></ul></ul><ul><ul><li>Best possible liaison between obstetric and pediatric teams should be fostered to ensure the optimal management </li></ul></ul><ul><ul><li>All high-risk deliveries should be attended by someone who is skilled in resuscitation . </li></ul></ul>
  34. 34. Hospital Based Intervention <ul><li>Increased prenatal/antenatal steroid therapy, </li></ul><ul><li>Cesarean section delivery in the right and proper reason </li></ul><ul><li>Assisted ventilation in the delivery room </li></ul><ul><li>Surfactant therapy </li></ul><ul><li>Postnatal steroid use. </li></ul><ul><li>Therapeutic interventions for hypoxic-ischemic encephalopathy Neuroprotective </li></ul>
  35. 35. <ul><li>Neuroprotective Strategy </li></ul><ul><li> Decrease Cerebral metabolism totally and supress specific targetted neurotoxine agent </li></ul><ul><li>Within 6-12 hours post asphyxia by giving neuroprotective agent  decrease or prevent brain damage </li></ul><ul><li>Prevent brain damage depend on the initial status of fertal brain </li></ul>
  36. 36. The therapeutic window <ul><li>Interval after resuscitation from hypoxia-ischemia </li></ul><ul><li>Efficacious in reducing the severity of the ultimate brain damage. </li></ul><ul><li>In adult process : slow ( hours -- a day or more) </li></ul><ul><li>Human infants : process  more rapid than adults </li></ul><ul><li>Full-term infant: shortly no longer than 1 to 2 hours. </li></ul><ul><li>In immature animals : No drug efficacious > 2 hrs after termination of the hypoxic-ischemic insult </li></ul>
  37. 37. Community Based Intervention <ul><li>To achieve the (MDG-4), neonatal deaths need to be prevented. </li></ul><ul><li>Issues : addressed and related to improving neonatal survival : </li></ul><ul><ul><li>availability of skilled care during childbirth </li></ul></ul><ul><ul><li>family/community-based care </li></ul></ul><ul><ul><li>Integrated management of neonatal illness into the integrated management of childhood illness initiative (IMCI) </li></ul></ul><ul><ul><li>Engagement of the community and promotion of demand for care. </li></ul></ul><ul><ul><li>Development, implementation, and monitoring of national action plans for neonatal survival is a priority. </li></ul></ul>
  38. 38. <ul><li>Estimation of the running costs at 90% coverage in the 75 countries with the highest mortality rates to be $4·1billion a year : </li></ul><ul><ul><li>30% : improve neonatal survival, </li></ul></ul><ul><ul><li>70% :improving survival of mothers and older children,and at substantially reducing rates of stillbirths. </li></ul></ul><ul><li>The cost per neonatal death averted is estimated at $2100 (range $1700–3100). </li></ul><ul><li>Maternal, neonatal, and child health receive little funding relative to the large numbers of deaths </li></ul><ul><li>International donors and leaders of developing countries should be made to commit to increasing resources. </li></ul>
  39. 39. <ul><li>Skilled care during delivery is universally recognized as a major long-term priority for improving the care of mothers and newborns, and plans for advancing health system capabilities for providing this care are paramount. </li></ul><ul><li>Based on a consideration of the fact that most births and neonatal deaths occur at home during the early neonatal period, </li></ul><ul><ul><li>Birth asphyxia </li></ul></ul><ul><ul><li>Infections, </li></ul></ul><ul><ul><li>LBW infants </li></ul></ul>
  40. 40. Evidence-based packages of interventions at different time points www.thelancet.com March, 2005 Detection and treatment of asymptomatic bacteriuria Intermittent presumptive treatment for malaria <ul><li>Antenatal care package </li></ul><ul><li>Outreach visits, including history and physical examination, with assessment of blood pressure, weight gain, and fundal height; urine screen for rotein; screen for anaemia; two doses of tetanus toxoid immunisation; syphilis screening and treatment; counseling on plan for birth, emergencies, breastfeeding; referral in case of complication </li></ul>Antenatal Folic acid supplementation Periconceptual Additional Situational Interventions Universal
  41. 41. Evidence-based packages of interventions at different time points (Cont’d) www.thelancet.com March, 2005 Antibiotics for preterm premature rupture of membranes <ul><li>Skilled maternal and immediate </li></ul><ul><li>neonatal care package </li></ul><ul><li>Skilled attendant at birth; labour surveillance; encouragement of supportive companion; assistance to birth (including vacuum extraction); early detection, clinical management and referral of maternal or fetal complications (emergency obstetric care at .rst level); resuscitation of the newborn baby </li></ul>Intrapartum Folic acid supplementation Periconceptual Additional Situational Interventions Universal
  42. 42. Evidence of efficacy for interventions at different time periods www.thelancet.com March, 2005 33 .58% Incidence of neonatal tetanus:88 .100% Prevalence-dependent Prematurity:34%(-1 to 57%) Low birthweight:31%(-1 to 53%) 32%(-1 to 54%) PMR:27%(1-47%)(first/second births) Incidence of prematurity/low birthweight: 40%(20 .55%) V IV IV IV IV Tetanus toxoid immunisation Syphilis screening and treatment Pre-eclampsia and eclampsia:prevention (calcium supplementation) Intermittent presumptive treatment for malaria Detection and treatment of asymptomatic bacteriuria Antenatal Incidence of neural tube defects:72%(42 .87%) IV Folic acid supplementation Preconception Reduction (%)in all-cause neonatal mortality or morbidity/major risk factor if specified (effect range) Amount of evidence
  43. 43. Evidence of efficacy for interventions at different time periods www.thelancet.com March, 2005 Incidence of infections:32%(13 .47%) 40%(25 .52%) Perinatal/neonatal death:71%(14 .90%) (early neonatal deaths):40% 58 .78% Incidence of neonatal tetanus:55 .99% IV IV IV IV IV Antibiotics for preterm premature rupture of membranes Corticosteroids for preterm labour Detection and management of breech (caesarian section) Labour surveillance (including partograph) for early diagnosis of complications Clean delivery practices Intrapartum Preconception Reduction (%)in all-cause neonatal mortality or morbidity/major risk factor if specified (effect range) Amount of evidence
  44. 44. Evidence of efficacy for interventions at different time periods www.thelancet.com March, 2005 6 .42% 55 .87% 18 .42% 13 Incidence of infections:51%(7 .75%) 27%(18 .35%) IV V IV IV V Resuscitation of newborn baby Breastfeeding Prevention and management of hypothermia Kangaroo mother care (low birthweight infants in health facilities) Community-based pneumonia case management Postnatal Preconception Reduction (%)in all-cause neonatal mortality or morbidity/major risk factor if specified (effect range) Amount of evidence
  45. 45. Indonesian Perspective <ul><li>As a developing country : Neonatal problems </li></ul><ul><ul><li>High rate of neonatal morbidity and mortality especially Birth Asphyxia . </li></ul></ul><ul><li>Main cause of Neonatal Death (Household Survey 2001) </li></ul><ul><ul><li>Birth Asphyxia (27.0%) </li></ul></ul><ul><ul><li>Low Birth weight and Premature Birth (29.2 %), </li></ul></ul><ul><ul><li>Infection including Tetanus, Sepsis, Diarrhea and Pneumonia (14.9 %), </li></ul></ul><ul><ul><li>Feeding Problems (9.5%), </li></ul></ul><ul><ul><li>Hematological problems: Kern Icterus and Neonatal Jaundice (5.6%) </li></ul></ul>
  46. 46. Table 1: Cause of Neonates Mortality in Indonesia in 2001
  47. 47. Newborn baby Survive for a while Does not get optimum care Serious health problem & developmental delayed
  48. 48. Intervention <ul><li>Right intervention to overcome the problems is needed </li></ul><ul><li>Most of deliveries ( 80%) are conducted at home or non health care facilities. </li></ul><ul><li>Many efforts attempted by the Government of Indonesia to overcome these problems,n but not optimum and their coverage are inadequate : </li></ul><ul><ul><li>(1) Difficult access due to geographic reason </li></ul></ul><ul><ul><li>(2) limited facilities </li></ul></ul><ul><ul><li>(3) limited human resources. </li></ul></ul>
  49. 49. <ul><ul><li>Skill in implementing resuscitation,: still remains as a big question </li></ul></ul><ul><ul><li>Competence and absorption power of pre-service education is still not convincing as well as its post service, due to limited budget. </li></ul></ul><ul><ul><li>Government was support by : </li></ul></ul><ul><ul><ul><li>Various professional organization : : Indonesian Midwife Association, Indonesian Pediatrician Society and Indonesian Obstetrician and Gynecologist Association etc.. </li></ul></ul></ul><ul><ul><ul><li>NGOs (Non Government Organizations) and Organization with the same interest such as PERINASIA (Indonesian Perinatology Society) </li></ul></ul></ul><ul><ul><li>One of its programs is Neonatal Resuscitation Program (NRP) conducted since 1997. </li></ul></ul>
  50. 50. Government (M O H ) efforts, strategies and programs: <ul><li>Reducing MMR to 125 per 100,000 living births and Neonatal Mortality Rate to 16 per 1000 living birth </li></ul><ul><li>Essential Neonate Health Care </li></ul><ul><li>Midwife Allocation in Villages </li></ul><ul><li>Integrated Management of Childhood Illness (IMCI) for Under Five proposed for Midwives in the Village and Puskesmas (Community Health Centre), </li></ul>
  51. 51. Government (M O H ) efforts, strategies and programs ( Cont’d) : <ul><li>PONED (Pelayanan Obstetri dan Neonatal Emergensi Dasar/) = Basic Emergency Obstetric and Neonate Health Care, in Puskesmas </li></ul><ul><li>PONEK (Pelayanan Obstetri dan Neonatal Emergensi Komprehensif/) = Comprehensive Emergency Obstetric Neonate Health Care in Hospitals of Regency/ City and Provincial levels </li></ul>
  52. 52. Cooperation - Collaboration MOH <ul><li>PROFESSIONAL </li></ul><ul><li>ORGANIZATION </li></ul><ul><li>IDAI </li></ul><ul><li>POGI </li></ul><ul><li>IBI </li></ul>WHO <ul><li>NGO </li></ul><ul><li>Perinasia </li></ul><ul><li>MNH </li></ul><ul><li>Path </li></ul><ul><li>Save the Children </li></ul>
  53. 53. MOH – IDAI – MNH <ul><li>Developed Manual of Management of Newborn Problems in Referral Hospital,for doctors,nurses and midwives </li></ul><ul><li>Supplement Chapter in Normal Delivery care : Resuscitation </li></ul>
  54. 54. MOH – IDAI – Save The Children- PATH <ul><li>Management Asphyxia for Midwives : </li></ul><ul><ul><li>Reference Book </li></ul></ul><ul><ul><li>Guidance book for Trainee </li></ul></ul><ul><ul><li>Guidance book for Trainer </li></ul></ul><ul><li>Video recorder Resuscitation </li></ul>
  55. 55. MOH – PATH – IDAI <ul><li>Appropriate Resuscitation Device for Village Midwives Study : Comparing 4 devices : </li></ul><ul><ul><li>Tube and Mask ( Techno) </li></ul></ul><ul><ul><li>Tube and Mask ( Lerdal ) </li></ul></ul><ul><ul><li>Bag and Mask ( Ambu ) </li></ul></ul><ul><ul><li>Bag and Mask ( Made in Taiwan) </li></ul></ul><ul><li>Verbal Autopsy Study about Neonatal Death in Cirebon </li></ul>
  56. 56. SUMMARY <ul><li>Intact survival : important things within Human Life’s cycle. </li></ul><ul><li>Intact survival : baby was completely survived and free from neurological deficit and grew up optimally </li></ul><ul><li>Birth period : most critical time that babies were exposed to several risks and complication such as death and disabilities </li></ul><ul><li>Birth asphyxia as a starting disaster </li></ul><ul><li>Birth asphyxia should be early recognized and promptly managed </li></ul><ul><li>If neonates could survived and most of them suffered from </li></ul><ul><ul><li>disabilities which consists of three component : impairment , activity limitation and participation restriction </li></ul></ul>
  57. 57. <ul><li>Categories of impairment will be focused on severe impairment of : </li></ul><ul><ul><li>Motor function ( Cerebral palsy ) </li></ul></ul><ul><ul><li>Visual function ( Blindness) </li></ul></ul><ul><ul><li>Hearing ( deafness) </li></ul></ul><ul><ul><li>Mental ability ( IQ < 70 ) </li></ul></ul><ul><li>Right intervention to overcome the problems and improve the problems is needed </li></ul>SUMMARY ( cont’d)
  58. 58. <ul><li>Intervention : Hospital based and Community based </li></ul><ul><li>Hospital based intervention : </li></ul><ul><ul><li>Therapeutic window </li></ul></ul><ul><ul><li>Identification of high risk infants for permanent brain damage </li></ul></ul><ul><li>Community based intervention : </li></ul><ul><ul><li>antenatal care </li></ul></ul><ul><ul><li>skilled care during delivery ( major long-term priority ) </li></ul></ul><ul><li>High-risk deliveries attended by personnel skilled . </li></ul><ul><li>Many efforts and coverage of Government of Indonesia not optimum and inadequate due to many factors. </li></ul><ul><li>Attention should be given in the term of Enhancing the Human Resource of Indonesian people in the future </li></ul>SUMMARY ( cont’d)
  59. 59. Thank you

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