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Newborn Care: Introduction


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Introduction

  1. 1. NewbornCareA learning programmefor professionalsDeveloped by thePerinatal Education
  2. 2. VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Newborn Care:A learning programme for professionalsUpdated: 15 June 2010First published by EBW Healthcare in 2009Text © Perinatal Education Programme 2009Cover photograph © Harris SteinmanIllustrations by Mary Hann and Anne WestobyGetup © Electric Book Works 2009ISBN (paperback): 978-1-920218-28-7ISBN (PDF ebook): 978-1-920218-57-7All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand
  3. 3. ContentsAcknowledgements 7 Case study 3 51 Case study 4 52Introduction 9 Case study 5 52 About the EBW Healthcare series 9 Skills workshop: Gestational age and Why decentralised learning? 9 weight 53 Books in the EBW Healthcare series 9 Assessing the gestational age 53 Format of the courses 11 Measuring weight and head circumference Contributors 12 57 Updating the course material 13 Plotting weight and head circumference 57 Contact information 13 References 601 Neonatal asphyxia and resuscitation 15 3 The routine care of normal infants 61 Assessing the infant at birth 15 Managing normal infants 61 Neonatal resuscitation 17 Common minor problems 66 Preventing meconium aspiration 23 Discharging a normal infant 68 Neonatal encephalopathy 24 Case study 1 68 Case study 1 26 Case study 2 69 Case study 2 27 Case study 3 70 Case study 3 28 Case study 4 70 Case study 4 28 Skills workshop: Clinical history andSkills workshop: Neonatal resuscitation 31 examination 72 Assessing the Apgar score 31 Taking a perinatal history 72 Giving mask ventilation 33 The physical examination of a newborn Tracheal intubation 34 infant 73 Chest compressions 40 The road-to-health card 812 Assessing gestational age and size at 4 Feeding normal infants 83 birth 43 Introduction to infant feeding 83 Assessing an infant’s gestational age at The benefits of breastfeeding 84 birth 43 Promoting breastfeeding 85 Assessing an infant’s size at birth 45 Teaching mothers to breastfeed 86 Grouping infants by their weight for Managing breastfeeding problems 89 gestational age 45 Formula-feeding newborn infants 91 Case study 1 50 The baby friendly initiative 93 Case study 2 51 Feeding the HIV-exposed infant 93
  4. 4. 4 NEWBORN CARE Case study 1 94 Case study 1 137 Case study 2 95 Case study 2 138 Case study 3 95 Case study 3 138 Case study 4 96 Skills workshop: Temperature control and5 Care of high-risk and sick infants 97 hypothermia 140 Classification of infants on the basis The telethermometer 140 of risk 97 The closed incubator 141 Managing a sick infant 99 The overhead radiant warmer 144 Monitoring a high-risk or sick infant 100 The management of shock 101 8 Glucose control and hypoglycaemia 147 The management of fits 102 Glucose control 147 The management of acidosis 103 Hypoglycaemia 150 Case study 1 105 Hyperglycaemia 153 Case study 2 105 Case study 1 153 Case study 3 106 Case study 2 154 Case study 4 106 Case study 3 154Skills workshop: Clinical notes and Skills workshop: Glucose control and observations 107 hypoglycaemia 156 Writing good clinical notes 107 Measuring the glucose concentration in Recording routine observations 111 capillary blood with reagent strips 156 Recording fluid intake and output 111 Measuring the glucose concentration in capillary blood with a glucose meter 1586 Feeding sick or high-risk infants 115 Inserting an umbilical vein catheter 159 Fluid requirements 115 Intravenous fluids 117 9 Jaundice, anaemia and Milk feeds for sick or high-risk infants 119 polycythaemia 163 Vomiting 121 Jaundice 163 Case study 1 122 Haemolytic disease 167 Case study 2 122 Phototherapy 170 Case study 3 123 Anaemia 173 Case study 4 123 Polycythaemia 174 Case study 1 175Skills workshop: Feeding sick or high-risk Case study 2 175 infants 125 Case study 3 176 Passing a nasogastric tube 125 Case study 4 176 Nasogastric feeding 126 Case study 5 177 Preparation of formula feeds 126 Starting a peripheral intravenous Skills workshop: Jaundice and infusion 127 phototherapy 178 Using a fluid controller 129 Measuring the packed cell volume 178 Using a phototherapy unit 1807 Temperature control and hypothermia 131 Measuring body temperature 131 10 Respiratory distress and apnoea 183 Heat production and loss 132 Respiratory distress 183 Hypothermia 133 Hyaline membrane disease 185 Pyrexia 137 Wet lung syndrome 187
  5. 5. CONTENTS 5 Meconium aspiration syndrome 188 Syphilis 235 Pneumonia 190 HIV infection 236 Pneumothorax 191 Case study 1 238 Heart failure and patent ductus Case study 2 239 arteriosus 191 Case study 3 239 Apnoea 193 Case study 4 239 Case study 1 194 Case study 5 240 Case study 2 195 Case study 3 196 13 Trauma and bleeding 241 Case study 4 196 Trauma 241 Bleeding 245Skills workshop: Respiratory distress and Case study 1 248 apnoea 198 Case study 2 249 Gastric aspirate shake test 198 Case study 3 249 Using an apnoea monitor 200 Case study 4 250 Transillumination of the chest 201 Emergency needling of a pneumothorax 14 Birth defects 251 201 Introduction to birth defects 251 Inserting a chest drain 202 Common birth defects 252 Serious birth defects 25511 Oxygen therapy 205 Major neurological defects 257 Oxygen therapy 205 Important syndromes 257 Measuring the amount of oxygen 206 Managing parents of infants with a birth The advantages and disadvantages of defect 259 extra oxygen 207 Case study 1 259 Administering oxygen safely 209 Case study 2 260 Providing continuous positive airways Case study 3 260 pressure (CPAP) 212 Case study 1 214 15 Communication 263 Case study 2 215 Communication with parents 263 Case study 3 215 Parental bonding 264 Case study 4 216 Managing the family of a sick or dying infant 265Skills workshop: Oxygen therapy 217 Bereavement 265 Using a flow meter with humidifier 217 Communicating with colleagues at other Using a blender or venturi 218 hospitals and clinics 268 Using an oxygen monitor 218 Transferring newborn infants 270 Using a pulse oximeter (oxygen saturation Assessing the perinatal health-care status monitor) 219 in your region 272 Providing nasal cannula oxygen 220 Case study 1 274 Providing nasal CPAP 220 Case study 2 275 Case study 3 27612 Infection 223 Case study 4 276 Preventing infection 223 Tests 279 Minor infections 226 Major infections 230 Chorioamnionitis 233 Chronic intra-uterine infection 234
  6. 6. AcknowledgementsWe acknowledge all the participants of Editor-in-Chief of the Perinatal EducationNewborn Care courses who have made Programme: Prof D L Woodssuggestions and offered constructive criticism. Editor of Newborn Care: Prof D L WoodsIt is only through constant feedback fromcolleagues and participants that the content of Contributors to Newborn Care:Perinatal Education Programme courses can Dr D H Greenfield, Prof G Theron,be improved. Prof H de Groot, Ms H Louw, Dr N Rhoda, Ms M Petersen, Prof P Henning, Prof C Pieper,The production costs of this book were Dr A Horn, Dr M Hann.generously funded by Eduhealthcare, a non-profit organisation dedicated to improving Cover photograph: Dr Harris Steinmanhealthcare education. Illustrations: Mary Hann and Anne Westoby
  7. 7. IntroductionABOUT THE EBW WHY DECENTRALISEDHEALTHCARE SERIES LEARNING?EBW Healthcare publishes an innovative Continuing education for healthcare workersseries of distance-learning books for traditionally consists of courses and workshopshealthcare professionals, developed by the run by formal trainers at large central hospitals.Perinatal Education Trust, Eduhealthcare, These teaching courses are expensive to attend,the Desmond Tutu HIV Foundation and the often far away from the healthcare workers’Desmond Tutu TB Centre, with contributions families and places of work, and the contentfrom numerous experts. frequently fails to address the real healthcare requirements of the poor, rural communitiesOur aim is to provide appropriate, affordable who face the biggest healthcare challenges.and up-to-date learning material forhealthcare workers in under-resourced areas, To help solve these many problems, a self-so that they can manage their own continuing help decentralised learning method has beeneducation courses which will enable them to developed which addresses the needs oflearn, practise and deliver skillful, efficient professional healthcare workers, especiallypatient care. those in poor, rural communities.The EBW Healthcare series is built onthe experience of the Perinatal EducationProgramme (PEP), which has provided BOOKS IN THE EBWlearning opportunities to over 60 000 nurses HEALTHCARE SERIESand doctors in South Africa since 1992. Manyof the educational methods developed by PEPare now being adopted by the World Health Maternal Care addresses all the commonOrganisation (WHO). and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing
  8. 8. 10 NEWBORN CAREthe progress of labour, specific medical glucose concentration, insertion of an umbilicalproblems during pregnancy, labour and the vein catheter, phototherapy, apnoea monitorspuerperium, family planning and regionalised and oxygen therapy.perinatal care. Skills workshops teach clinicalexamination in pregnancy and labour, routine Primary Newborn Care was writtenscreening tests, the use of an antenatal card specifically for nurses and doctors whoand partogram, measuring blood pressure, provide primary care for newborn infants indetecting proteinuria and performing and level 1 clinics and hospitals. Primary Newbornrepairing an episiotomy. Care addresses the care of infants at birth, care of normal infants, care of low-birth-weightMaternal Care is aimed at healthcare workers infants, neonatal emergencies, and commonin level 1 hospitals or clinics. minor problems in newborn infants.Primary Maternal Care addresses the Mother and Baby Friendly Care describesneeds of healthcare workers who provide gentler, kinder, evidence-based ways of caringantenatal and postnatal care, but do not for women during pregnancy, labour andconduct deliveries. It is adapted from theory delivery. It also presents improved methodschapters and skills workshops from Maternal of providing infant care with an emphasisCare. This book is ideal for midwives and on kangaroo mother care and exclusivedoctors providing primary maternal care level 1 district hospitals and clinics,and complements the national protocol of Saving Mothers and Babies was developed inantenatal care in South Africa. response to the high maternal and perinatal mortality rates found in most developingIntrapartum Care was developed for doctors countries. Learning material used in this bookand advanced midwives who care for women is based on the results of the annual confidentialwho deliver in district hospitals. It contains enquiries into maternal deaths and the Savingtheory chapters and skills workshops adapted Mothers and Saving Babies reports published infrom the labour chapters of Maternal Care. South Africa. It addresses the basic principlesParticular attention is given to the care of mortality audit, maternal mortality,of the mother, the management of labour perinatal mortality, managing mortalityand monitoring the wellbeing of the fetus. meetings and ways of reducing maternal andIntrapartum Care was written to support perinatal mortality rates. This book shouldand complement the national protocol of be used together with the Perinatal Problemintrapartum care in South Africa. Identification Programme (PPIP).Newborn Care was written for healthcare Birth Defects was written for healthcareworkers providing special care for newborn workers who look after individuals with birthinfants in regional hospitals. It covers defects, their families, and women who are atresuscitation at birth, assessing infant size and increased risk of giving birth to an infant with agestational age, routine care and feeding of both birth defect. Special attention is given to modesnormal and high-risk infants, the prevention, of inheritance, medical genetic counselling,diagnosis and management of hypothermia, and birth defects due to chromosomalhypoglycaemia, jaundice, respiratory distress, abnormalities, single gene defects, teratogensinfection, trauma, bleeding and congenital and multifactorial inheritance. This bookabnormalities, as well as communication with is being used in the Genetics Educationparents. Skills workshops address resuscitation, Programme which trains healthcare workers insize measurement, history, examination and genetic counselling in South Africa.clinical notes, nasogastric feeds, intravenousinfusions, use of incubators, measuring blood
  9. 9. INTRODUCTION 11Perinatal HIV enables midwives, nurses doctors and nurses with wide experience inand doctors to care for pregnant women and the care of adults with HIV, under the auspicestheir infants in communities where HIV of the Desmond Tutu HIV Foundation at theinfection is common. Special emphasis has University of Cape Town.been placed on the prevention of mother-to-infant transmission of HIV. It covers the basicsof HIV infection and screening, antenatal FORMAT OF THE COURSESand intrapartum care of women with HIVinfection, care of HIV-exposed newborninfants, and parent counselling. 1. Objectives The learning objectives are clearly stated at theChildhood HIV enables nurses and doctors start of each chapter. They help the participantto care for children with HIV infection. It to identify and understand the importantaddresses an introduction to HIV in children, lessons to be learned.the clinical and immunological diagnosisof HIV infection, management of childrenwith and without antiretroviral treatment, 2. Pre- and post-testsantiretroviral drugs, opportunistic infections There is a multiple-choice test of 20 questionsand end-of-life care. for each chapter at the end of the book. Participants are encouraged to take a pre-testChildhood TB was written to enable before starting each chapter, to benchmarkhealthcare workers to learn about the primary their current knowledge, and a post-test aftercare of children with tuberculosis. The book each chapter, to assess what they have learned.covers an introduction to TB infection,and the clinical presentation, diagnosis, Self-assessment allows participants to monitormanagement and prevention of tuberculosis their own progress through the children and HIV/TB co-infection.Childhood TB was developed by paediatricians 3. Question-and-answer formatwith wide experience in the care of children Theoretical knowledge is presented in awith tuberculosis, under the auspices of the question-and-answer format, which encouragesDesmond Tutu Tuberculosis Centre at the the learner to actively participate in theUniversity of Stellenbosch. learning process. In this way, the participant is led step by step through the definitions,Child Healthcare addresses all the common causes, diagnosis, prevention, dangers andand important clinical problems in children, management of a particular problem.including immunisation, history andexamination, growth and nutrition, acute and Participants should cover the answer for a fewchronic infections, parasites, skin conditions, minutes with a piece of paper while thinkingand difficulties in the home and society. Child about the correct reply to each question. ThisHealthcare was developed for use in primary method helps settings. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toAdult HIV covers an introduction to HIV diagnosing or managing a particular problem.infection, management of HIV-infected adultsat primary-care clinics, preparing patients forantiretroviral (ARV) treatment, ARV drugs, Each question is written in bold, like this,starting and maintaining patients on ARV and is identified with the number of thetreatment and an approach to opportunistic chapter, followed by the number of theinfections. Adult HIV was developed by question, e.g. 5-23.
  10. 10. 12 NEWBORN CARE4. Important lessons Participants need to achieve at least 80% in the examination in order to successfully complete the course. Successful candidates Important practical lessons are emphasised by will be emailed a certificate which states placing them in a box like this. that they have successfully completed that course. EBW Healthcare courses are5. Notes not yet accredited for nurses, but South African doctors can earn CPD points on the NOTE Additional, non-essential information is provided for interest and given in notes like this. successful completion of an examination. These facts are not used in the case studies or Please contact or included in the multiple-choice questions. +27 021 44 88 336 when you are ready to take the exam.6. Case studiesEach chapter closes with a few casestudies which encourage the participant CONTRIBUTORSto consolidate and apply what was learnedearlier in the chapter. These studies give the The developers of our learning materials are aparticipant an opportunity to see the problem multi-disciplinary team of nurses, midwives,as it usually presents itself in the clinic or obstetricians, neonatologists, and generalhospital. The participant should attempt to paediatricians. The development and review ofanswer each question in the case study before all course material is overseen by the Editor-reading the correct answer. in-Chief, emeritus Professor Dave Woods, a previous head of neonatal medicine at the7. Practical training University of Cape Town who now consults to UNICEF and the WHO.Certain chapters contain skills workshops,which need to be practised by the participants Perinatal Education Trust(preferably in groups). The skills workshops,which are often illustrated with line drawings, Books developed by the Perinatal Educationlist essential equipment and present step-by- Programme are provided as cheaply as possible.step instructions on how to perform each Writing and updating the programme is bothtask. If participants aren’t familiar with a funded and managed on a non-profit basis bypractical skill, they are encouraged to ask an the Perinatal Education Trust.appropriate medical or nursing colleague todemonstrate the clinical skill to them. In this Eduhealthcareway, senior personnel are encouraged to sharetheir skills with their colleagues. Eduhealthcare is a non-profit organisation based in South Africa. It aims to improve health and wellbeing, especially in poor communities,8. Final examination through affordable education for healthcareOn completion of each course, participants workers. To this end it provides financialcan take a 75-question multiple-choice support for the development and publishing ofexamination on the EBW Healthcare website, the EBW Healthcare series.when they are ready to.All the exam questions will be taken from The Desmond Tutu HIV Foundationthe multiple-choice tests from the book. The The Desmond Tutu HIV Foundation at thecontent of the skills workshops will not be University of Cape Town, South Africa,included in the examination. is a centre of excellence in HIV medicine,
  11. 11. INTRODUCTION 13building capacity through training and CONTACT INFORMATIONenhancing knowledge through research.The Desmond Tutu Tuberculosis Centre EBW HealthcareThe Desmond Tutu Tuberculosis Centre at Website: www.ebwhealthcare.comStellenbosch University, South Africa, strives Email: info@ebwhealthcare.comto improve the health of vulnerable groupsthrough the education of healthcare workers Telephone: +27 021 44 88 336and community members, and by influencing Fax: +27 088 021 44 88 336policy based on research into the epidemiologyof childhood tuberculosis, multi-drug- Post: 87 Station Road, Observatory, 7925,resistant tuberculosis, HIV/TB co-infection Cape Town, South Africaand preventing the spread of TB and HIV insouthern Africa. Editor-in-Chief: Professor Dave Woods Website: THE COURSE Email: Telephone: +27 021 786 5369 Fax: +27 021 671 8030EBW Healthcare learning materials Post: Perinatal Education Programme,are regularly updated to keep up with PO Box 34502, Groote Schuur, Observatory,developments and changes in healthcare 7937, South Africaprotocols. Course participants can makeimportant contributions to the continualimprovement of EBW Healthcare booksby reporting factual or language errors,by identifying sections that are difficult tounderstand, and by suggesting additions orimprovements to the contents. Details ofalternative or better forms of managementwould be particularly appreciated. Please sendany comments or suggestions to the Editor-in-Chief, Professor Dave Woods.