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Primary Newborn Care: Care of infants at birth

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: the care of infants at birth, the care of normal infants, the care of low-birth-weight infants, emergency management of infants, the management of important problems.

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Primary Newborn Care: Care of infants at birth

  1. 1. IntroductionAIM OF THE PERINATAL rural areas usually have the least continuing education as they are furthest away fromEDUCATION PROGRAMME the training hospitals in urban centres. It is not possible to send teachers to all theseThe aim of the Perinatal Education rural areas for long periods of time whileProgramme (PEP) is to improve the care of staff shortages and domestic reasons makepregnant women and their newborn infants in it impractical to transfer large numbersall communities, especially in poor periurban of doctors and nurses from primary- andand rural districts of southern Africa. secondary-care centres to centralised tertiaryAlthough the Programme was written as a hospitals for training.distance-learning course for both midwives Ideally all medical and nursing staff shouldand doctors in district and regional health have regular training to improve and updatecare facilities, it is also used in the training of their theoretical knowledge and practical skills.medical and nursing students. One way of meeting these needs in continuingThe authors of the Perinatal Education education is with a self-help, outreachProgramme consist of nurses, obstetricians and educational programme. This decentralisedpaediatricians from South Africa. This ensures method allows health care workers to takea balanced, practical and up-to-date approach responsibility for their own learning andto common and important clinical problems. professional growth. They can study at a timeMany colleagues in South African universities and place that suits them. Participants in theand health services were also consulted with a programme can also study at their own pace.view to reaching consensus on the management The education programme should be cheapof most perinatal problems. and, if possible, not require a tutor.PERINATAL EDUCATION PERINATAL EDUCATION PROGRAMME BOOKSIf all three levels of perinatal care are tobe efficiently provided within a perinatal Initially the Perinatal Education Programmehealth care region, continuous education and was presented as two books only. The first PEPtraining of all professional staff is essential. book, Maternal Care, deals with problemsUnfortunately this often is achieved in the experienced by women during and afterlarge, centralised tertiary-care hospitals only pregnancy while the second PEP book,and not in the rural secondary- or primary- Newborn Care, deals with problems in thecare centres. The providers of primary care in newborn infant. Both books should be studied
  2. 2. 8 PRIMAR Y NEWBORN CAREto improve your knowledge of all aspects of blood glucose concentration, insertion ofperinatal care. an umbilical catheter, phototherapy, apnoea monitors and oxygen therapy.Now six additional, supplementary books havebeen prepared to address further common andimportant problems related to both pregnantwomen and their newborn infants. BOOK 3: PERINATAL HIV/ AIDSBOOK 1: MATERNAL CARE The HIV epidemic is spreading at an alarming pace through many developingThis book addresses all the common and countries, increasing the maternal and infantimportant problems that occur during mortality rates, and adding to the financialpregnancy, labour and delivery, and the burden of providing health services to allpuerperium. It includes booking for antenatal communities. Nowhere is the devastatingcare, problems during the antenatal period, effect of this infection more obvious than inmonitoring and managing the mother, fetus the transmission of HIV from mothers toand progress during labour, medical problems their infants. In order to decrease this risk, allduring pregnancy, problems during the health care workers dealing with HIV positivethree stages of labour and the puerperium, mothers and infants will need to receivefamily planning after pregnancy, and additional training. Perinatal HIV/AIDS wasregionalised perinatal care. Skills workshops written to address this challenge.teach the general examination, abdominal This book will enable midwives, nurses andand vaginal examination in pregnancy and doctors to care for pregnant women and theirlabour, screening for syphilis and HIV, infants in communities where HIV infectionuse of an antenatal card and partogram, is present. Special emphasis has been placedmeasuring blood pressure and proteinuria, on the prevention the mother-to-infantand performing and repairing an episiotomy. transmission of HIV.Maternal Care is aimed at professional healthcare workers in level 1 hospitals or clinics. Chapters have been written on HIV infection, antenatal, intrapartum and infant care, and counselling. Colleagues from a number ofBOOK 2: NEWBORN CARE hospitals and universities in South Africa were invited to review and comment on the draftNewborn Care was written for health document in order to achieve a well balancedprofessionals providing special care for infants text. It is hoped that this training opportunityin regional hospitals. It covers resuscitation will help to stem the tide of HIV infection inat birth, assessing infant size and gestational our children.age, routine care and feeding of both normaland high risk infants, the prevention,diagnosis and management of hypothermia, BOOK 4: PRIMARYhypoglycaemia, jaundice, respiratory distress, NEWBORN CAREinfection, trauma, bleeding, and congenitalabnormalities, as well as communication This book was written specifically for nurseswith parents. Skills workshops address and doctors who provide primary careresuscitation, size and gestational age for newborn infants in level 1 clinics andmeasurement, history, examination and hospitals. Primary Newborn Care addresses theclinical notes, nasogastric feeds, intravenous care of infants at birth, care of normal infants,infusions, use of incubators, measuring care of low birth weight infants, neonatal
  3. 3. INTRODUCTION 9emergencies, and important problems in are at increased risk of giving birth to annewborn infants. infant with a birth defect. Special attention is given to modes of inheritance, medical genetic counselling, and birth defects dueBOOK 5: MOTHER AND to chromosomal abnormalities, single gene defects, teratogens and multifactorialBABY FRIENDLY CARE inheritance. This book is being used in the Genetics Education Programme which hasWith the recent technological advances in been developed to train health care workers inmodern medicine, the caring and humane genetic counselling in South Africa.aspects of looking after mothers and infantsare often forgotten. This book describes better,gentler, kinder, more natural, evidence-based BOOK 8: PRIMARYways that care should be given to womenduring pregnancy, labour and delivery. It MATERNAL CAREsimilarly looks at improved methods ofproviding infant care with an emphasis This book addresses the needs of health careon kangaroo mother care and exclusive workers who provide both antenatal andbreastfeeding. A number of medical and postnatal care but do not conduct deliveries.nursing colleagues in South Africa contributed The content of these chapters is largely takento this book. from the relevant chapters in Maternal Care. It contains theory chapters and skills workshops. This book is ideal for staff providing primaryBOOK 6: SAVING MOTHERS maternal care in level 1 district hospitals and clinics.AND BABIESSaving Mothers and Babies was developed in FORMAT OF THE PERINATALresponse to the high maternal and perinatalmortality rates found in most developing EDUCATION PROGRAMMEcountries. Learning material used in thebook is based on the results of the annual Throughout this Programme the participantconfidential enquiries into maternal deaths takes full responsibility for his or her ownand the Saving Mothers and Saving Babies progress. This method teaches participants toreports published in South Africa. It addresses become self-reliant and confident.the basic principles of mortality audit,maternal mortality, perinatal mortality, 1. The objectivesmanaging mortality meetings, and ways ofreducing maternal and perinatal mortality At the start of each chapter the learningrates. This book should be used together objectives are clearly stated. They help thewith the Perinatal Problem Identification participant to identify and understand theProgramme (PPIP). important lessons to be learned. 2. Questions and answersBOOK 7: BIRTH DEFECTS Theoretical knowledge is taught by a problem solving method which encouragesThis book was written for health care the participant to actively participate in theworkers who look after individuals with learning process. An important question isbirth defects, their families, and women who asked, or problem posed, followed by the correct answer or explanation. In this way,
  4. 4. 10 PRIMAR Y NEWBORN CAREthe participant is led step by step through 4. Multiple-choice questionsthe definitions, causes, diagnosis, prevention, An in-course assessment is made at thedangers and management of a particular beginning and end of each chapter in theproblem. form of a test consisting of 20 multiple-choiceIt is suggested that the participant cover the questions. This helps participants manage theiranswer for a few minutes with a piece of paper own course and monitor their own progressor card while thinking about the correct reply by determining how much they know beforeto the question. This method helps learning. starting a chapter, and how much they haveSimplified flow diagrams are also used, where learned at the end of the chapter. The resultsnecessary, to indicate the correct approach to will help the participant decide whetherdiagnosing or managing a particular problem. they have successfully learned the importantCopies of these flow diagrams may be of value facts in that chapter and will also draw thein the labour ward or nursery. participant’s attention to the areas where their knowledge is inadequate.Different forms of text are used to identifyparticular sections of the Programme: In the multiple-choice tests the participant is asked to choose the single, most correctEach question is written in bold, like this, answer to each question or statement fromand is identified with the number of the four possible answers. A separate loose sheetchapter, followed by the number of the should be used to record the test answersquestion, e.g. 5-23. before (pre-test) and after (post-test) the chapter is studied. The list of correct answers also indicates which section should be Important practical lessons are emphasized by restudied for each incorrect post-test answer. placing them in a box like this. On the website, the multiple-choice questions are only made available to participants who NOTE Additional, non-essential information is provided for interest and given in notes like this. wish to complete a PEP course and have These facts are not used in the case studies or obtained an exam code (more on this below). included in the multiple-choice questions.3. Case problems STUDY GROUPSA number of clinical presentations in story- It is strongly advised that the Programmeform are given at the end of each chapter so courses are studied by a group of participantsthat the participant can apply his/her newly and not by individuals alone. Each group oflearned knowledge to solve some common 5 to 10 participants should be managed by aclinical problems. This exercise also gives the local co-ordinator who is usually a member ofparticipant an opportunity to see the problem the group, if a formal trainer is not available.as it usually presents itself in the clinic or The local co-ordinator arranges the time andhospital. A brief history and/or summary of venue of the group meetings (usually oncethe clinical examination is given, followed by every three weeks). At the meeting the chaptera series of questions. The participant should just studied is discussed and the pre-testsattempt to answer each question before reading and post-tests are done. The skills workshopsthe correct answer. The knowledge presented should also be demonstrated and practiced atin the cases is the same as that covered earlier the meetings. In this way the group managesin the chapter. The cases, therefore, serve to all aspects of their course. The principles ofconsolidate the participant’s knowledge. peer tuition and co-operative learning play a large part in the success of PEP.
  5. 5. INTRODUCTION 11THE IMPORTANCE successfully completed that course. Credit for completing the course will only be given ifOF A CARING AND the final examination is successfully passed. AQUESTIONING ATTITUDE separate examination is available for each book and a certificate will be given to participants who pass each final examination. A mark ofA caring and questioning attitude is 80% is needed to pass the final examinations.encouraged. The welfare of the patient is of Any official recognition for completing a PEPthe greatest importance, while an enquiring course will have to be negotiated with yourmind is essential if participants are to continue local health care authority.improving their knowledge and skills. Theparticipant is also taught to solve practical To write the examination on the website, aproblems and to form a simple, logical participant first has to obtain an exam code,approach to common perinatal problems. which can be obtained through the course website.COPYRIGHT OBTAINING AN EXAM CODETo be most effective, the Perinatal EducationalProgramme course should be used under To obtain an exam code, visit this website:the supervision of a co-ordinator. Using part www.ebwhealthcare.comof the Programme out of context will be oflimited value only, while changing part of the An exam code is a unique number for oneProgramme may even be detrimental to the participant and one course. An exam codeparticipant’s perinatal knowledge. Therefore, enables a participant to test their knowledgecopyright on all PEP materials means that and write the final examination online. The feeno portion of the Programme can be altered. and how to pay for exam codes is explained onHowever, for teaching and management the website.purposes only, parts or all of the Programmemay be photocopied provided that recognitionto the Programme is acknowledged. If the MANAGING YOUR OWNroutine care in your clinic or hospital differsfrom that given in the Programme, you should COURSE STEP-BY-STEPdiscuss it with your staff. 1FINAL ASSESSMENT Before you start each chapter, take the test for that chapter at the back of the book. Do theOn completion of each book, participants test by yourself even if you are studying withmay apply to write a formal multiple-choice a group of colleagues. Choose the best answerexamination on the course website – www. for each multiple-choice question and noteebwhealthcare.com – to assess the amount your answers on a piece of loose paper. This isof knowledge that they have acquired. All called your ‘pre-test’ for that chapter. There isthe questions will be taken from the tests an answer sheet that you should use to markat the end of each chapter. The content of your completed pre-test. Record your pre-testthe skills workshops will not be included in mark out of a possible 20.the examination. Successful examinationcandidates will be able to print their owncertificate which states that they have
  6. 6. 12 PRIMAR Y NEWBORN CARE2 www.ebwhealthcare.com. To write the final examination you will need to have an examNow work through the chapter. Read each code. This is a unique number that entitlesquestion and answer, and make sure you you to write the examination for a course. Ifunderstand it. Pay particular attention to you don’t have one yet, you or your group canthe facts in grey boxes as these are the main buy exam codes. The fee and how to pay ismessages. Read the case studies to check described on the website. This exam code willwhether you have learned and understand the only work once for one examination.important information. You will be able to write the examination,3 consisting of 75 multiple-choice questions, on the website. You will only have a limitedIf you are part of a study group, use this time to answer each question and you willopportunity to discuss with your colleagues not be able to go back and check previousany difficulties you may have experienced. questions. Set aside at least an hour toTalking about what you have read is a very write the examination. When you write theimportant part of the learning process. If examination, do not use the book to look upthe book includes skills workshops, these the correct answers. Remember, you are yourshould be conducted at the time of the group own teacher, so be strict with yourself!meetings. Invite an experienced colleague whocan help you master the particular skill. 74 Your examination answers will automatically be marked as soon as you have completedWhen you have learned all the knowledge in the last question. If you get 80% or better youthat chapter, take the same test again. This have passed and will be able to print yoursecond test is called your ‘post-test’. Now own certificate which states that you havemark the post-test and compare your pre-test successfully completed the course. However,and post-test marks. Your marks should have if you have failed to achieve 80%, you canimproved considerably. In the answers section purchase another exam code to write theof the book, opposite each correct answer, is examination again.the number of the section where the questionwas taken from. Re-read and learn the sections Tipsfor any post-test answers you got incorrect.Now you are ready to move on to the next • Work through the course with a group ofchapter. friends or colleagues. • One person in your group (your co-5 ordinator or ‘convenor’) should take responsibility for organising meetings toRepeat steps 1 to 4 for each chapter as you discuss each chapter before you write thework your way through the book. This enables post-test.you to obtain the knowledge, monitor your • Set yourself targets, such as ‘two units aprogress, and measure how much you are month’.learning. Most people will take about 2 to 4 • Keep your book with you to read wheneverweeks per chapter. you have a chance. • Write the examination only when you feel6 ready.Once you are confident that you havemastered all the main lessons in the book,you can write the final examination online at
  7. 7. INTRODUCTION 13UPDATING OF THE funded and managed on a non-profit basis by the Perinatal Education Trust.PROGRAMMEBased on the comments and suggestions FURTHER INFORMATIONmade by participants and other authorities,the chapters and skills workshops of the Further information on the PerinatalProgramme will be regularly edited to make Education Programme can be obtained in thethem more appropriate to the needs of following ways:perinatal care and to keep the Programmeup to date with new ideas and developments. By postEveryone studying the Programme is invitedto write to the editor-in-chief with suggestions The Editor-in-Chief, Perinatal Educationas to how the books could be improved. You Programme, P O Box 34502, Groote Schuur,can also send your comments on parts of the Observatory 7937, South Africabooks on the website www.ebwhealthcare.com. By faxUSING THE BOOK AS A • • 021 671 8030 (from South Africa) +27 21 671 8030 (from outside SouthWORK MANUAL Africa)It is hoped that as many participants as By phonepossible will use these books as work manuals From within South Africa:after they have completed the course. Theflow diagrams should be most useful in • 021 671 8030 (PEP Distribution Manager)managing difficult problems and for planning • 021 786 5369 (Editor-in-Chief)management. A further benefit of the bookswill be to standardise the documentation and By emailmanagement of certain clinical problems. pepcourse@mweb.co.zaThis is particularly useful when patients arereferred within or between health care regions. OnlineIt is further hoped that all those who use thesebooks will enjoy learning about new and better www.ebwhealthcare.commethods of caring for mothers and newborn www.pepcourse.co.zainfants. Every opportunity to share knowledgewith both patients and colleagues should beused. By doing this you will find your careermore fulfilling and you will help to improve COMMENTS ANDthe perinatal care in your region. SUGGESTIONS The Perinatal Education Programme has beenPERINATAL EDUCATION produced by a group of perinatal specialists in South Africa, after wide consultation withTRUST colleagues who practice in both rural and urban settings, in an attempt to reach consensusBooks developed by the Perinatal Education on the care of mothers and newborn infants.Programme are provided as cheaply as possible. The Programme is designed so that it can beWriting and updating the Programme is both improved and altered to keep pace with current developments in health care. Participants using
  8. 8. books developed by the Programme can make to the contents. Details of alternative or betteran important contribution to its continual forms of management would be particularlyimprovement by reporting factual or language appreciated. Please send any comments orerrors, by identifying sections that are difficult suggestions to the Editor-in-Chief at the aboveto understand, and by suggesting improvements address.
  9. 9. 1 Care of infants at birth 5. A quick physical examination should be Objectives done to assess the infant for size, serious congenital abnormalities or other obvious When you have completed this unit you clinical problems. should be able to: 6. When the above have been completed, give • Manage a normal infant at birth. the infant to the mother. • Promote early bonding between mother and infant. 1-2 When is the best time to clamp the • Diagnose neonatal asphyxia at birth. umbilical cord? • Assess an Apgar score. It is best to allow the infant to cry well a few • Prepare for resuscitation. times before clamping the cord. Therefore, dry • Resuscitate an infant. the infant well first and only then clamp the • Prevent meconium aspiration. cord with surgical forceps. Drying the infant usually stimulates crying. Delaying clamping the cord, until the infantMANAGEMENT OF A breathes well, allows the infant to receiveNORMAL INFANT AT BIRTH some extra blood from the placenta. This extra blood may help prevent iron deficiency anaemia later in the first year of life. Before1-1 What care should you give a normal clamping the cord, keep the infant on the bedinfant immediately after delivery? at the same level as the mother.1. Dry the infant, especially the head, with The umbilical cord must be clamped or tied a warm towel. Then wrap the infant in a about 3 to 4 cm from the infant’s abdomen. second warm, dry towel. This will help to Once the infant has been dried and assessed, prevent the infant from getting cold after the surgical forceps can be replaced with a delivery. sterile, disposable cord clamp or a sterile2. It is not necessary to suction the nose and cord tie. mouth of a normal infant who is breathing well. If the infant has a lot of secretions, turn 1-3 When should you give the infant to the the infant onto the side for a few minutes. mother?3. Clamp the umbilical cord. It is important for the mother to see and hold4. Assess the Apgar score at 1 minute. her infant as soon as possible after delivery. If
  10. 10. 16 PRIMAR Y NEWBORN CAREthe infant appears to be normal and healthy, This will keep the infant warm. Skin-to-skinthe infant can be given to the mother after the care (kangaroo mother care) is important1 minute Apgar score has been assessed and to promote bonding and breast feeding. Thethe initial examination made. After delivery, infant must not be left alone in a cot.both the infant and mother are in an alertstate. The infant’s eyes are usually open and 1-6 When do you identify the infant?looking around. Once the parents have had a chance toThe mother will usually hold the infant so meet and inspect their new infant, formalthat she can look at its face. She will talk to identification by the mother and staff musther infant and touch the face and hands. This be done. Labels with the mother’s name andinitial contact between a mother and her folder number, together with the infant’s sex,infant is an important stage in BONDING. date and time of birth are then attached toBonding is the emotional attachment that the infant’s wrist and ankle. Twins must bedevelops between mother and child, and is an labelled ‘A’ and ‘B’. Once correctly identified,important step towards good parenting later. other routine care can then be given.Where possible, it is important that the fatheralso be present at the delivery so that he can 1-7 Should all infants be given vitamin K?be part of this important phase of the bondingprocess. Yes. It is important that all infants be given 1 mg of vitamin K1 (0.1 ml of Konakion) by1-4 When should the normal infant be put intramuscular injection into the anterolateralto the breast? aspect of the mid-thigh after delivery. Never give the Konakion into the buttock as it mayIf possible the mother should put the infant damage nerves or blood vessels that are justto her breast within minutes after delivery under the skin in infants. Konakion willbecause: prevent haemorrhagic disease of the newborn.1. Studies have shown that the sooner the Be very careful not to give the infant the infant is put to the breast, the greater is the mother’s oxytocin (Syntocinon) in error. chance that the mother will successfully To avoid this mistake, some hospitals give breast feed. Konakion in the nursery and not in the labour2. Nipple stimulation, by putting the infant ward. Do not use oral Konakion. to the breast, may speed up the third stage of labour by stimulating the release of All infants must be given vitamin K after delivery. maternal oxytocin.3. It reassures the mother that her infant is healthy and helps to promote bonding. 1-8 Should antibiotic ointment be placed inSome women want to hold and look at the infant’s eyes?their infants but do not want to breast feed Yes, it is advisable to place chloromycetinsoon after delivery. Their wishes should be ointment routinely into both eyes to preventrespected. During a complicated third stage, Gonococcal conjunctivitis as an infant’sor during the repair of an episiotomy, some eyes may become infected when the infantmothers would rather not hold their infants. passes through the cervix and vagina. This is particularly important if gonorrhoea is1-5 How should the mother keep her infant common in that community. Many womenwarm? with Gonococcal infection have no symptoms.When the infant is given to the mother, sheshould hold the infant, skin-to-skin, againsther chest and cover the infant with the towel.
  11. 11. CARE OF INFANTS AT BIR TH 171-9 Should all infants be weighed and 1-12 Should the infant be bathed aftermeasured? delivery?Yes, it is important to measure the infant’s There is no need to bath an infant immediatelyweight and head circumference after birth. after delivery. It is much better if the infantThe parents are usually anxious to know the stays with the mother and only be bathed later.infant’s weight. The infant’s length is usually Vernix protects the infant’s skin and helps tonot recorded, as it is very difficult to measure prevent skin infection.accurately. Weighing all infants helps toidentify low birth weight infants (less than2500g) who may need special care. MANAGEMENT OF THE1-10 What care and management should INFANT WITH NEONATALbe documented? ASPHYXIAAccurate notes should be made after theinfant has been delivered. It is important to 1-13 When does a normal infant startdocument the following observations and breathing after delivery?procedures: The normal, healthy newborn infant usually1. Apgar score starts to breathe immediately after birth.2. Any action taken to resuscitate the infant Sometimes gentle stimulation, such as drying,3. Any abnormality or clinical problem is needed before the infant breathes well. By noticed 1 minute after delivery the infants should be4. Identification of the infant breathing well or crying.5. Whether the infant is male or female6. Administration of Konakion 1-14 What is neonatal asphyxia?7. Whether prophylactic eye ointment was given If an infant does not breathe well by 1 minute8. Birth weight and head circumference after birth, the infant is said to have neonatal asphyxia (asphyxia neonatorum).1-11 Should the infant stay with themother after delivery? Neonatal asphyxia is defined as the failure toYes. If the mother and infant are well, they breathe well within one minute after delivery.should not be separated. The infant should bekept skin-to-skin on the mother’s chest, as thisis the best way to keep an infant warm. The 1-15 What important clinical signs shouldinfant can stay with the mother in the labour be looked for in the infant after delivery?ward and should be transferred with her to There are 5 important clinical signs, whichthe postnatal ward. If the infant is cared for should be present after birth. These are calledby the mother, the staff will be relieved of this vital signs:additional duty. 1. Breathing 2. Heart rate The mother and infant should remain together 3. Colour after delivery, if both are well. 4. Tone 5. Response
  12. 12. 18 PRIMAR Y NEWBORN CARE1-16 What is the Apgar score? heart beat is present but the rate is slower than 100 per minute, while a score of 0 is given if noThe Apgar score uses the 5 vital signs at heart beat can be heard or umbilical pulse felt.birth to give a score, which is very useful inassessing an infant’s condition after delivery.It also helps to decide which infants need 1-20 How should you assess an infant’sresuscitation. The famous Apgar score is colour after birth?named after Virginia Apgar, who described the Look at the infant’s tongue and also at the handsscore in 1953. and feet. The tongue should always be pink. It is not helpful to look at the colour of the lips1-17 How is the Apgar score measured? or mucus membranes. If the tongue is blue the infant has central cyanosis. This shows thatEach of the 5 vital signs is given a score of important organs like the brain are not getting0, 1 or 2. If the sign is normal a score of 2 enough oxygen. Almost all newborn infantsis given. Mildly abnormal signs are given a have peripheral cyanosis with blue hands andscore of 1. If the vital sign is very abnormal a feet immediately after delivery. This is normalscore of 0 is given. and within minutes the hands and feet shouldThe scores for each vital sign are then added become pink. A pink tongue indicates thattogether to give the Apgar score out of 10. enough oxygen is reaching the brain.The best possible Apgar score is 10 and the If the hands and feet are pink a score of 2 isworst is 0. given. If the tongue is pink,but the hands and feet are still blue, a score of 1 is given. When1-18 How should you assess an infant’s the tongue, hands and feet are all blue a scorebreathing after birth? of 0 is given.Look at the infant’s chest movements. Bothsides of the chest should move well when the 1-21 How should you assess an infant’sinfant breathes. A normal infant will cry or tone after birth?take at least 40 breaths a minute. Normal infants should have good muscle toneIf the infant breathes well or cries a score of 2 at birth and move their arms and legs actively.is given. If there is poor or irregular breathing, They should not lie still. Normally the armsor the infant only gives an occasional gasp, a and legs are flexed and held above the body,score of 1 is given. A score of 0 is given if the with the knees held together, in a term infant.infant makes no attempt to breathe. If the infant moves well a score of 2 is given. If there is only some movement, and the arms1-19 How should you count an infant’s and legs are not pulled up against the body orheart rate after birth? lifted off the surface, a score of 1 is given. AFeel the base of the umbilical cord or listen to score of 0 is given if the infant is completelythe infant’s heart with a stethoscope to count limp and does not move at all.the heart (pulse) rate. It often is very difficultto feel peripheral pulses immediately after 1-22 How should you assess an infant’sbirth. The normal infant has a heart rate of 140 response to stimulation after birth?(120 to 160) beats per minute. It saves time to If you handle or gently stimulate the infantcount the heart rate for 30 seconds and then there should be a good response. Usually themultiply the rate by 2 to give the heart rate per infant moves a lot or cries. The best methodminute. A wall clock is useful when counting of stimulation is to dry the infant well with athe heart rate. towel. Smacking the infant or flicking the feetIf the heart rate is above 100 per minute a are not recommended.score of 2 is given. A score of 1 is given if a
  13. 13. CARE OF INFANTS AT BIR TH 19If the infant responds well to stimulation 1 MINUTE 5 MINUTESand cries or moves a lot a score of 2 is given. Heart rate None 0 None 0If there is only some response a score of 1 is per minute Less than 100 1 Less than 100 1given while a score of 0 is given if the infant More than 100 2 More than 100 2does not respond to stimulation at all. Respiratory rate Absent 0 Absent 0See the table ‘Calculating anor irregular Weak Apgar score’. 1 Weak or irregular 1 Good or cries 2 Good or cries 2 Colour Centrally cyanosed 0 Centrally cyanosed 0 Peripherally cyanosed 1 Peripherally cyanosed 1 Peripherally pink 2 Peripherally pink 2 Muscle tone Limp 0 Limp 0 Some flexion 1 Some flexion 1 Active and well flexed 2 Active and well flexed 2 Response to None 0 None 0 stimulation Some response 1 Some response 1 Good response 2 Good response 2 TOTAL SCORE: /10 /10Table 1: Calculating an Apgar score1-23 When should the Apgar score be birth, a 1 minute Apgar score of 10 is rare.measured? The Apgar score at 5 minutes, and thereafter, should be 7 or more.All infants should have their Apgar scoremeasured at 1 minute after delivery. The 1 A 1 minute Apgar score of 4 to 6 indicatesminute Apgar score is a good method of moderate asphyxia while a score of 0 to 3measuring the infant’s general condition after indicates severe neonatal asphyxia.birth and is one of the best ways of deciding A low 5 minute Apgar score is worrying as itwhether the infant needs resuscitation. If the suggests that the infant is not responding wellApgar score is normal, the score usually does to resuscitation. The longer the score remainsnot need to be repeated. However, in many low, the greater is the risk of death or brainclinics and hospitals the Apgar score is still damage.repeated routinely at 5 minutes. Unfortunatelymany of these normal infants are needlesslyremoved from their mother’s skin-to-skin care The Apgar score should be 7 or more at 1 minute.to have the 5 minute Apgar score determined.However, if the 1 minute Apgar score is low, 1-25 What are the important causes of athe score must be repeated every 5 minutes low Apgar score?while the infant is being resuscitated. This 1. Fetal hypoxiagives a very good assessment of the success or 2. Maternal general anaesthesiafailure of the attempts at resuscitation. With 3. Maternal sedation or analgesia withsuccessful resuscitation the Apgar score will pethidine or morphine given within theincrease to normal. last 4 hours 4. Excessive suctioning of the infant’s mouth1-24 What is a normal Apgar score? and throatThe Apgar score at 1 minute should be 7 or 5. Delivery of a low birth weight infantmore out of a possible 10. As almost all infants 6. Difficult or traumatic deliveryhave blue hands and feet immediately after 7. Severe respiratory distress
  14. 14. 20 PRIMAR Y NEWBORN CARE1-26 What is hypoxia? 1-30 How is neonatal asphyxia managed?Hypoxia is defined as too little oxygen in the cells Neonatal asphyxia is corrected by resuscitatingof the body. If the infant failures to breathe well the newborn infant. Only about 5% ofafter delivery the infant will develop hypoxia. newborn infants have asphyxia and, therefore,As a result of hypoxia, the infant’s heart need resuscitation.rate falls, breathing is poor, central cyanosisdevelops and the infant becomes hypotonic(floppy) and unresponsive. Neonatal asphyxia, RESUSCITATIONif not correctly managed, will lead to hypoxiaand possible brain damage or death. 1-31 What is resuscitation?1-27 What is fetal hypoxia? Resuscitation is a series of actions taken toIf the placenta fails to provide the fetus with establish normal breathing, heart rate, colour,enough oxygen, fetal hypoxia will result. Fetal tone and response in an infant with abnormalhypoxia presents with meconium stained vital signs, i.e. a low Apgar score.liquor and late fetal heart rate decelerationsor bradycardia. These are the signs of fetal 1-32 Which infants need resuscitation?distress (or more accurately, stress). Therefore, All infants who do not breathe well by 1fetal hypoxia results in fetal distress. As minute after delivery, or have a 1 minutehypoxia may damage or kill the fetus, it is very Apgar score below 7, need resuscitation. Theimportant that each infant is well monitored lower the Apgar score the more resuscitationduring labour so that any signs of fetal distress is usually needed. Any infant who stopscan be detected, as soon as possible, so that the breathing or has abnormal vital signs at anycorrect management can be given. time after delivery or in the nursery alsoFetal hypoxia is an important cause of requires resuscitation.neonatal asphyxia. All infants with neonatal asphyxia, or a 1 minute1-28 Are neonatal asphyxia and fetal Apgar score below 7, require resuscitation.hypoxia the same condition?No. Neonatal asphyxia and fetal hypoxia are notthe same although severe fetal hypoxia usually 1-33 Can you anticipate which infants willresults in neonatal asphyxia after delivery. Some need resuscitation at birth?infants with mild fetal hypoxia breathe well Yes. Any of the conditions which causeafter birth and do not have neonatal asphyxia. neonatal asphyxia may result in the infantThere are also many causes of neonatal asphyxia needing resuscitation. However, neonatalother than fetal hypoxia. Therefore, some asphyxia cannot always be predicted beforeinfants have neonatal asphyxia even though delivery. Remember that any infant can bethey have not had fetal hypoxia. born with neonatal asphyxia without any previous warning. It is essential, therefore, to1-29 Can neonatal asphyxia be prevented? be prepared to resuscitate all newborn infants.Good management during labour and the Everyone who delivers an infant must be ableearly detection of fetal distress are the best to perform resuscitation.methods of preventing neonatal asphyxia.However, some cases of neonatal asphyxia Any infant can have neonatal asphyxia at birthcannot be predicted nor prevented. without warning signs during labour and delivery.
  15. 15. CARE OF INFANTS AT BIR TH 211-34 What is needed to resuscitate a HIV if the secretions get into the mouth ofnewborn infant? the person suctioning the infant. 2. Oxygen: Whenever possible, a cylinder1. A suitable, warm area with good lighting or wall source of 100% oxygen should be2. The correct, clean and functioning available. However, oxygen is not essential equipment for resuscitation.3. The knowledge and skills 3. Self-inflating bag and mask: A simple neonatal self-inflating bag and mask, e.g.1-35 What is a suitable resuscitation area? Samson, Laerdal, Ambu, Penlon or CardiffA warm area with good light and a working resuscitator, must be available to providesurface at a comfortable height is needed. In mask ventilation. Direct mouth-to-moutha clinic or hospital, some source of oxygen resuscitation is dangerous due to the risk ofand suction should be available together with becoming infected with HIV.storage space for the equipment. Make sure 4. Naloxone: Ampoules of naloxone (Narcanthere is no draught. The temperature of the 0.4 mg in 1 ml). Small syringes and needlesresuscitation area should be at least 25 °C. will be needed to administer the drug. Neonatal Narcan is no longer used, as theA warm, well lit corner of the delivery room is concentration of drug is too small.ideal for resuscitation. A heat source, such as 5. Wall clock or watch: To time thean overhead radiant warmer or wall heater, is assessment of the Apgar score.needed to keep the infant warm. A good light,such as an angle-poise lamp, is essential so Although not essential for basic resuscitation,that the infant can be closely observed during it is very useful to have an infant laryngoscoperesuscitation. A firm, flat surface at waist height and endotracheal tubes so that infants withis best for resuscitating an infant. There is no severe neonatal asphyxia can be intubated, ifneed to have the infant lying head down, and bag and mask ventilation is not adequate. Ifthe neck must not be overextended. It is very possible, everyone who regularly resuscitatesuseful to have warm towels to dry the infant. newborn infants should learn how to intubate them.1-36 What equipment do you need forinfant resuscitation? 1-37 How should you stimulate respiration immediately after birth?It is essential that you have all the equipmentneeded for basic infant resuscitation. The After birth, all infants must be quickly driedequipment must be clean, in working order in a warm towel and then placed in a secondand immediately available. The equipment warm, dry towel. This must also be done tomust be checked daily. infants with neonatal asphyxia, before starting resuscitation. Drying the infant prevents rapidThe following essential equipment must be heat loss due to evaporation. Handling andavailable in the delivery room: rubbing the newborn infant with a dry towel1. Suction apparatus: An electric or wall is usually all that is needed to stimulate the vacuum suction apparatus is ideal but the onset of breathing. Stimulation alone will start vacuum pressure should not exceed 200 cm breathing in most infants. water. Soft F 10 end-hole suction catheters are needed. A simple mouth suction 1-38 Should all infants be routinely apparatus (mucus extractor) can also be suctioned after delivery? used. It consists of a 2 soft plastic catheters No. Infants who breathe well at delivery attached to a 20 ml plastic container. should not have their mouth and throat Although it is effective, there is a small risk routinely suctioned, as suctioning sometimes that the staff could become infected with
  16. 16. 22 PRIMAR Y NEWBORN CAREcauses apnoea. Infants born by caesarean It is very helpful to have an assistant duringsection also need not be routinely suctioned. resuscitation. It is not necessary to routinely suction the mouth 1-43 How do you resuscitate an infant? and nose of infants after delivery. There are 4 main steps in the basic resuscitation of a newborn infant. They can be easily remembered by thinking of the first 41-39 Which infants should be suctioned letters of the alphabet, ‘ABCD’:after delivery? 1. Airway1. Infants who do not breathe well after 2. Breathing stimulation 3. Circulation2. Meconium-stained infants 4. Drugs Step 1: Clear the airway1-40 When should you start to resuscitatean infant? Gently clear the throat. The infant may be unable to breathe because the airway isIf the infant does not breathe well and fails blocked by mucus or blood. Therefore, if theto respond to stimulation after drying and infant fails to breathe after stimulation, gentlyclamping the umbilical cord, then the infant suction the back of the mouth and throat withmust be actively resuscitated. Drying and a soft F 10 catheter. Too much suctioning,clamping the cord usually takes about 1 especially if too deep in the region of the vocalminute. These infants will have a low 1 minute cords, may result in apnoea and bradycardia.Apgar score. Although resuscitation usually This can be prevented by holding the catheterstarts after 1 minute, if the infant obviously has 5 cm from the tip when suctioning the infant’ssevere neonatal asphyxia, resuscitation should throat. There is no need to suction the nose.be started sooner. Simply turning the infant onto the side will often clear the airway.1-41 Can resuscitation of an infant withsevere neonatal asphyxia result in survival If wall suction or a suction machine are notwith brain damage? available, a mucus extractor can be used to suction the infant’s mouth and throat. BecauseSome people are worried that resuscitation of the small risk of HIV infection, wall suctionmay result in a live, but brain damaged infant, or a suction machine is best.who would have died without resuscitation.This is very uncommon. Not all infants with Correctly position the head. The uppersevere neonatal asphyxia die. Therefore, it is airway (pharynx) can be opened by placingbetter to give good resuscitation early to all the infant’s head in the correct position.infants with neonatal asphyxia and reduce With the infant lying on its back on a flatthe risk of brain damage that may occur if no surface, slightly extend the neck so that theresuscitation is given. The only infants who face is pointing towards the ceiling. Do notmay not be offered resuscitation are those overextend the neck.with a lethal congenital abnormality, such as If the infant is not breathing well after theanencephaly. airway have been suctioned and the head correctly positioned, stop suctioning and1-42 Who should resuscitate the infant? move to step 2.The most experienced person, irrespective of Step 2: Start the infant breathingrank, should resuscitate the infant. However,everyone who conducts deliveries must have If stimulation and suctioning and correctthe skills and equipment to resuscitate infants. position of the head fail to start breathing,
  17. 17. CARE OF INFANTS AT BIR TH 23mask and bag ventilation must be started. 1-44 How do you give oxygen to an infant?Giving mask oxygen alone often does not help. Oxygen is given if the infant is centrallyKeep the infant’s neck slightly extended and cyanosed. Usually wall oxygen is used.hold the mask firmly over the infant’s face. Otherwise an oxygen cylinder or an oxygenMost infants can be adequately ventilated concentrator is needed. Oxygen is best givenwith a neonatal bag and mask, such as a by mask and bag ventilation. It is safer to onlySamson, Laerdal, Ambu, Penlon or Cardiff use room air for resuscitation and only giveresuscitator. Ventilation is the most important oxygen if the central cyanosis is not correctedpart of resuscitation. Usually mask and bag by mask ventilation.ventilation is given with room air. Room air is safer than oxygen for most Ventilation is more important than oxygen. resuscitations.Respiratory stimulants, such as Vandid, mustnot be used, as they are dangerous and do not 1-45 How should you use a self-inflatinghelp. bag and mask to ventilate an infant?Step 3: Obtain a good circulation 1. The position of the infant: The infant must lie face up on a flat surface. TheIf the heart rate remains below 80 beats per infant’s neck should be slightly extended.minute after effective ventilation has been Do not over extend the neck. The infant’sstarted, apply external cardiac massage at face should look towards the ceiling.about 120 times a minute. Infants should be kept in a warm towel during resuscitation.Step 4: Drugs to reverse pethidine and 2. The apparatus: A number of bag andmorphine mask sets are suitable, such as the Samson,If the mother has received either pethidine Laerdal, or Ambu resuscitators. Makeor morphine during the 4 hour period before sure that both the bag and mask aredelivery, the infant’s poor breathing may be designed for newborn infants. If required,due to drug depression. If so, the respiratory the bag should be attached to an oxygendepression caused by the analgesic can be source providing 5 litres per minute. Itrapidly reversed with Narcan (a 1 ml ampoule is important that the correct size mask iscontains 0.4 mg naloxone). Narcan 0.1 mg/kg used to cover the nose and mouth.(i.e. 0.25 ml/kg) can be given by intramuscular 3. The position of the mask: The mask mustinjection into the anterolateral aspect of the be placed over the infant’s mouth, nose andthigh. Intramuscular Narcan takes a few chin. Hold the mask tightly against the faceminutes before it starts to act. Do not use so that there are no air leaks.Neonatal Narcan, as this preparation requires 4. Using the self-inflation bag: The masktoo big a volume. should be held in place with the left hand while the bag is squeezed at about 40Narcan will not help resuscitate an infant breaths per minute with the right hand. Ifif the mother has not received a narcotic the little and ring finger of the left hand areanalgesic during labour, or has received a placed under the angle of the jaw, the jawnon-opioid general anaesthetic, barbiturates can be gently pulled upwards to keep theor other sedatives. tongue from falling back. The position of the mask is the same with all types of bag. Mask and bag ventilation is the most important When giving mask and bag ventilation, step in resuscitating an infant. watch the movement of the chest. Squeeze the bag hard enough to move the chest
  18. 18. 24 PRIMAR Y NEWBORN CARE with each inspiration. Continue giving that the infant did not suffer severe hypoxia mask and bag ventilation at about 40 before delivery. breaths per minute until the infant starts to cry or breathes well. A small percentage of 1-48 When is further resuscitation infants with severe neonatal asphyxia will hopeless? not respond to mask ventilation and need intubation and ventilation. Every effort should be made to resuscitate all infants that show any sign of life at delivery. The Apgar scores at 1 and 5 minutes are1-46 How do you give cardiac massage? not good indicators of the likelihood ofPlace the infant on its back with the head hypoxic brain damage or death. If the Apgartowards you. Place both hands under the score remains low after 5 minutes, efforts atinfant’s back and press on the lower half of resuscitation should be continued. However,the sternum with both your thumbs. This if the infant has not started to breathe, orwill depress the sternum by about 2 cm. only gives occasional gasps, by 10 minutesPush down on the sternum about 100 times the chance of death or brain damage is high.a minute. Pressing on the sternum squeezes Resuscitation is usually stopped if the Apgarblood out of the heart and causes blood to score at 20 minutes is still low with no regularcirculate to the lungs and body. breathing. It is best if an experienced person decides when to abandon further attempts atIt takes 2 people to both mask ventilate and resuscitation.give cardiac massage. An assistant shouldventilate the infant while you give cardiac Resuscitation will not save all infants withmassage. After every third push on the neonatal asphyxia, but it will help most.sternum the assistant should squeeze thebag to give 1 breath after every 3 heart beats. 1-49 What post resuscitation care isContinue cardiac massage until the infant’s needed?heart rate increases to 100 or more beats perminute. If you are resuscitating an infant on All infants that require resuscitation withyour own, good mask ventilation is more bag and mask ventilation must be carefullyimportant that cardiac massage. observed for at least 12 hours. Their temperature, pulse and respiratory rate, colour and activity should be recorded and1-47 How can you assess whether the their blood glucose concentration measured.resuscitation has been successful? Keep these infants warm and provide fluidThe 4 steps in resuscitation are followed step and energy, either intravenously or orally.by step until the 3 most important vital signs Usually these infants are observed in a closedof the Apgar score have returned to normal: incubator. Do not bath the infant until the infant has fully recovered.1. A pulse rate above 100 beats per minute. Easily assessed by palpating the base of Careful notes must be made describing the the umbilical cord or listening to the chest infant’s condition at birth, the resuscitation with a stethoscope. needed and the probable cause of the neonatal2. A good cry or good breathing efforts. asphyxia. This assures adequate breathing.3. A pink tongue. This indicates a good 1-50 What about the mother during oxygen supply to the brain. Do not rely on resuscitation? the colour of the lips. It is very frightening for a mother to know thatWith good resuscitation the Apgar score at 5 her infant needs resuscitation. Therefore, it isminutes should be 7 or more. This suggests important to tell the mother that her infant needs some help and to explain to her what is
  19. 19. CARE OF INFANTS AT BIR TH 25being done to the infant. Remember that the Meconium aspiration results in respiratorymother may start bleeding while the staff are distress after delivery.busy resuscitating the infant. Meconium often burns the infant’s skin and digests away the infant’s eye lashes! Therefore,1-51 How is the resuscitation equipment imagine the damage meconium can cause tocleaned? the delicate lining of the lungs.It is imporant that all the resuscitationequipment is kept clean and in good working 1-54 How can you prevent meconiumorder. After a resuscitation all the equipment aspiration at delivery?must be cleaned to prevent the spread of Before delivery of all meconium stainedinfection. The masks and mucus extractors infants, a suction apparatus and an F 10 endmust be washed with water and soap or hole catheter must be ready at the bedside. Ifdetergent and rinsed. The self-inflating bags, possible, the person conducting the deliverye.g. Laerdal, Ambu and Penlon must be should have an assistant to suction the infant’ssterilised. mouth when the head delivers. After delivery of the head, the shouldersMANAGEMENT OF THE should be held back and the mother asked to breathe fast and not to push. This shouldMECONIUM-STAINED prevent delivery of the trunk. The infant’s faceINFANT is then turned to the side so that the mouth and throat can be well suctioned. The nose can be suctioned after the mouth and throat. The1-52 Does the meconium stained infant infant should be completely delivered onlyneed special care? when no more meconium can be cleared from the mouth and throat.Yes. All infants that are meconium stainedat birth need special care to reduce the risk If the infant cries well after delivery, noof severe meconium aspiration. Whenever further resuscitation or suctioning is needed.possible, all these at-risk infants should be However, some infants develop apnoea andidentified before delivery by noting that the bradycardia as a result fetal hypoxia of theliquor is meconium stained. suctioning and, therefore, need ventilation after delivery. If a meconium stained infant1-53 Why does the meconium stained needs ventilation, the throat should again beinfant need special care? suctioned before ventilation is started.As a result of fetal hypoxia, the fetus may make This aggressive method of suctioning is verygasping movements and pass meconium. Before successful in preventing severe meconiumdelivery, meconium in the amniotic fluid can aspiration in meconium stained infants.be sucked into the upper airways. Fortunatelymost of the meconium is unable to reach the The mouth and throat of all meconium stainedfluid filled lungs of the fetus. Only after delivery, infants must be suctioned before the shoulderswhen the infant inhales air, does meconium are delivered.usually enter the lungs.Meconium contains enzymes from the fetal When a meconium stained infant is deliveredpancreas that can cause severe lung damage by caesarean section, the mouth and throatand even death if inhaled into the lungs at must similarly be suctioned with a F10delivery. Meconium also obstructs the airways. end-hole catheter, before the shoulders are delivered from the uterus. After complete
  20. 20. 26 PRIMAR Y NEWBORN CAREdelivery, move the infant immediately to brief examination indicates that the infant isthe resuscitation table. If the infant does not a normal, healthy term infant. The mothersbreathe well, further suctioning is needed should give skin-to-skin care of her infant afterbefore stimulating respiration or starting birth. The infant should not be left in a cot.ventilation. The father should also be present to share this exciting moment.1-55 What care should you give tomeconium stained infants after birth? 2. When should the mother be encouraged to put the infant to her breast?All meconium stained infants should beobserved for a few hours after delivery as they As soon as she wants to. This is usually aftermay show signs of meconium aspiration. Most she has had a chance to have a good look atmeconium stained infants have also swallowed her infant. There are advantages to putting themeconium before delivery. Meconium is a infant to the breast soon after delivery.very irritant substance and causes meconiumgastritis. This results in repeated vomits of 3. Should the vernix be washed offmeconium stained mucus. immediately after delivery?Meconium gastritis may be prevented by Infants should not be bathed straight afterwashing out the stomach with 2% sodium delivery, as they often get cold, while vernixbicarbonate (mix 4% sodium bicarbonate should not be removed as it helps protect thewith an equal volume of sterile water). Five infant’s skin from infection. It would be betterml of 2% sodium bicarbonate is repeatedly to bath the infant later, in the mother’s presence,injected into the stomach via a nasogastric when most of the vernix will have cleared.tube and then aspirated until the gastricaspirate is clear. This should be followed by 4. Do you agree that this well infant doesa feed of colostrum. Only heavily meconium not need chloromycetin eye ointment?stained infants should have a stomach washouton arrival in the nursery. Routine stomach No. All infants should be given chloromycetinwashouts in infants with mildly meconium eye ointment, especially if gonorrhoea isstained liquor are not needed. common in the community. Gonococcal infection may be asymptomatic in the mother.CASE STUDY 1 5. Should the infant stay with the mother after delivery?An infant is delivered by spontaneous vertex Yes, if possible the mother and her infantdelivery at term. Immediately after birth the should not be separated after delivery.infant cries well and appears normal. The cordis clamped and cut and the infant is dried.The infant has a lot of vernix. As the infant CASE STUDY 2appears healthy and the mother has no vaginaldischarge, chloromycetin ointment is not put After a normal pregnancy, an infant is bornin the infant’s eyes. The infant is placed in a cot by spontaneous vertex delivery. There arebeside the mother. no signs of fetal distress during labour. The mother received pethidine 2 hours before1. When should the infant be given to the delivery. Immediately after delivery the infantmother? is dried and placed under an overhead radiantAs soon as the infant is dried, the cord cut, warmer. At 1 minute after birth the infantthe 1 minute Apgar score determined and a has a heart rate of 80 beats per minute, gives irregular gasps, has blue hands and feet but a
  21. 21. CARE OF INFANTS AT BIR TH 27pink tongue, has some muscle tone but does 6. What is this infant’s Apgar score at 5not respond to stimulation. At 5 minutes the minutes?infant has a heart rate of 120 beats per minute The Apgar score at 5 minutes is 9: heart rate=2,and is breathing well. The tongue is pink but breathing=2, colour=1, tone=2, response=2.the hands and feet are still blue. The infant This indicates that the infant has respondedmoves actively and cries well. well to resuscitation.1. What is the infant’s Apgar score at 1 7. Why is this infant very unlikely to haveminute? suffered brain damage due to hypoxia?The Apgar score at 1 minute is 4: heart rate=1, Because there is no history of fetal distressrespiration=1, colour=1, tone=1, response=0. to indicate that this infant had been hypoxic before delivery.2. Does this infant have neonatal asphyxia?Give your reasons. 8. What should be the management of thisYes, the infant has neonatal asphyxia because infant after resuscitation?the infant failed to establish adequate, The infant should be kept warm and besustained respiration by 1 minute. The transferred to the nursery for observation. Asdiagnosis of neonatal asphyxia is supported by soon as the infant is active and sucking well itthe low Apgar score at 1 minute. should given to the mother to breast feed.3. What is the probable cause of theneonatal asphyxia? CASE STUDY 3Sedation due to the maternal pethidine given2 hours before delivery. These sedated infants A woman with an abruptio placentae deliversusually respond rapidly to resuscitation. If not, at 32 weeks in a clinic. Before delivery theNarcan can be given to reverse the sedative fetal heart rate was only 80 beats per minute.effect of the pethidine. The infant has a 1 minute Apgar score of 1 and is ventilated with bag and mask. Cardiac4. What should be the first 2 steps in massage is also given. With further efforts atresuscitating this infant? resuscitation, the Apgar score at 5 minutes is 5 and at 10 minutes is 9.If respiration cannot be stimulated by dryingthe infant then the following 2 steps must betaken: 1. What is the probable cause of neonatal asphyxia in this infant?1. Clear the airway by gently suctioning the throat. Fetal distress caused by hypoxia. Abruptio2. Breathing must be started with mask and placentae (placental separation before bag ventilation. delivery) is a common cause of fetal distress.5. Should oxygen be given? 2. What is the significance of the Apgar scores at 5 and 10 minutes?Room air is usually adequate for resuscitationunless the infant remains centrally cyanosed. The good responds indicates that the resuscitation is successful. If the Apgar score is still low at 5 minutes it is important to repeat the score every 5 minutes. The normal score at 10 minutes indicates the infant’s response to the resuscitation.
  22. 22. 28 PRIMAR Y NEWBORN CARE3. Is this child at high risk of brain damage 2. What mistake was made with thedue to hypoxia? management of this infant?The good response to resuscitation suggests The infant’s mouth and throat should havethat this infant will not have brain damage due been well suctioned before the shoulders wereto fetal hypoxia. delivered. This should reduce the risk of severe meconium aspiration as the airway is cleared of4. When should all attempts at meconium before the infant starts to breathe.resuscitation be abandoned? 3. What size catheter would you have usedIf the Apgar score remains low at 20 minutes, to suction this infant’s mouth and throat?attempts at resuscitation may be stopped. A large catheter (F 10) must be used as a small catheter will block with meconium.CASE STUDY 4 4. Should this infant be given a bath andAfter fetal distress has been diagnosed, an stomach washout in labour ward after itinfant is delivered vaginally after a long starts to breathe spontaneously?second stage of labour. At delivery the infant No. These should not be done until the infantis covered with thick meconium. The infant has been stable for a number of hours in thestarts to gasp before 1 minute. Only then are nursery.the mouth and throat suctioned for the firsttime. The Apgar score at 1 minute is 3. By 5 5. What 2 complications is this infant atminutes the Apgar score is 6. high risk of?1. What are the probable causes of the low This infant may develop meconium aspiration1 minute Apgar score? syndrome as it probably inhaled meconium into its lungs after birth. It may also sufferFetal distress, as indicated by the passage of brain damage due to hypoxia causing fetalmeconium before delivery. The prolonged distress during labour. The poor response tosecond stage may have caused fetal hypoxia. resuscitation suggests that some brain damageInhaled meconium may have blocked the may be present. It would be important toairway and prevented the infant from breathing. repeat the Apgar score every 5 minutes until 20 minutes after delivery.

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