Neonatal sepsis occurs when pathogenic organisms enter the bloodstream of newborns, potentially causing infections like septicemia, pneumonia, or meningitis. Worldwide it accounts for 15% of neonatal deaths. In Nepal, neonatal sepsis causes 47.7% of neonatal deaths. It can be early onset within 3 days of life due to maternal infections, or late onset after 3 days from hospital-acquired infections. Common causes are E. coli, Staphylococcus aureus, and Klebsiella. Risk factors include prematurity, low birth weight, maternal infections, and lack of breastfeeding. Symptoms include pallor, apnea, bulging fontanel, and poor feeding. Diagnosis involves sepsis
About 10% of all newborn require some assistance to begin breathing after birth, and 1% require extensive resuscitation efforts. Newborn resuscitation cannot always be anticipated in time to transfer the mother before delivery to a facility with specialized neonatal support. Therefore, every hospital with a delivery suite should have an organized, skilled resuscitation team and appropriate equipments available.
The EINC initiative of the Philippine Department of Health- Non Communicable Diseases Prevention and Control-Family Health Office (DOH-NCDPC-FHO) and DOH Center for Health Promotions (NCHP), supported by the Joint Programme on Maternal and Neonatal Health (JPMNH), and being funded by AusAID, was piloted in 11 hospitals in the Philippines, and has yielded favorable results.
The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).
For newborns, four core steps were recommended in a time bound sequence. A social marketing handle, “The First Embrace,” accompanied the initiative for practice change among health workers.
In obstetrics, Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus; they are named after the gynecologist Christian Gerhard Leopold. They are also used to estimate term fetal weight.
The aim of Leopold maneuvers is to determine the fetal presentation and position by systematically palpating the gravid abdomen.
ctto Marie Belen Tamayor - Leopold's Maneuver, Miss Marie's presentation provided the slides that explain Leopold's maneuver.
Hypothermia occurs when the newborn’s temperature drops below 36.3°C.
The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.
Early prevention measures are vital.
About 10% of all newborn require some assistance to begin breathing after birth, and 1% require extensive resuscitation efforts. Newborn resuscitation cannot always be anticipated in time to transfer the mother before delivery to a facility with specialized neonatal support. Therefore, every hospital with a delivery suite should have an organized, skilled resuscitation team and appropriate equipments available.
The EINC initiative of the Philippine Department of Health- Non Communicable Diseases Prevention and Control-Family Health Office (DOH-NCDPC-FHO) and DOH Center for Health Promotions (NCHP), supported by the Joint Programme on Maternal and Neonatal Health (JPMNH), and being funded by AusAID, was piloted in 11 hospitals in the Philippines, and has yielded favorable results.
The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).
For newborns, four core steps were recommended in a time bound sequence. A social marketing handle, “The First Embrace,” accompanied the initiative for practice change among health workers.
In obstetrics, Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus; they are named after the gynecologist Christian Gerhard Leopold. They are also used to estimate term fetal weight.
The aim of Leopold maneuvers is to determine the fetal presentation and position by systematically palpating the gravid abdomen.
ctto Marie Belen Tamayor - Leopold's Maneuver, Miss Marie's presentation provided the slides that explain Leopold's maneuver.
Hypothermia occurs when the newborn’s temperature drops below 36.3°C.
The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.
Early prevention measures are vital.
Hi Guys,
This presentation talks about Tuberculosis diagnosed in mother in the antenatal period, its treatment, implications on mother and fetus, the various protocols available currently regarding the neonatal management . Special focus being in major issues like breastmilk feeding, BCG, AKT prophylaxis, mother-child isolation.
Hope you find it useful.
P.S. - Please checkout my youtube channel - 'NEONATOHUB' & Facebook page 'Neonatohub' for lectures on neonatology.
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What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
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http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
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The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
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Sectors of the Indian Economy - Class 10 Study Notes pdf
Neonatal sepsis
1. CONTENT
UNIT 15.2 MAJOR PROBLEMS OF NEWBORN
NEONATAL SEPSIS
Definition:
When pathogenic organisms gain access into the blood stream, they may cause an overwhelming
infection without much localization (septicemia), or may get predominantly localized to the lung
(pneumonia) or the meninges (meningitis). Systemic bacterial infections are known by the
generic term neonatal sepsis (NNS), which incorporates septicemia, pneumonia and meningitis
in the newborn baby.
Worldwide neonatal sepsis accounts for 15% of neonatal death. (UNICEF 2015).
According to the survey conducted by Health Policy and Planning Department of Government of
Nepal in 2014 neonatal sepsis accounts for 47.7% of the neonatal death in Nepal.
Types of Neonatal Sepsis
On the basis of onset of symptoms , neonatal sepsis is divided into:
1. Early onset neonatal sepsis : Symptoms develop within 72 hours of life due to intrauterine
infections, maternal conditions like prolonged rupture of membrane, foul smelling liquor
,maternal genital tract infections,multiple per vaginal examination and maternal fever. It
manifests frequently as pneumonia and less commonly as septicaemia and meningitis.
2. Late onset neonatal sepsis: It develops after 72 hours( may be at the end of first week or in
second week). It is acquired as nosocomial infections from the baby care area or due to in
appropriate neonatal care, low birth weight, lack of breast feeding and superficial infections.
Causes / risk factors
Escherichia coli, Staphylococcus aureus and Klebsiella sp. are the predominant organisms.
Organisms like Acinetobacter, Pseudomonas and coagulase negative staphylococci are also
important pathogens in hospital acquired infections.
The risk factors associated with development of neonatal sepsis are:
1.Maternal risk factors
Maternal history of uterine infection i.e. chorioamnionitis
Premature rupture of membranes and prolonged rupture of membranes for more than 24
hours
Maternal infection or fever including STIs.
Unclean delivery
Prolonged, complicated or difficult labor/birth
2. Newborn risk factors
2. Low birth weight, prematurity
Fetal distress
Birth asphyxia and resusucitation
Congenital anomalies i.e. trachea-esophageal atresia
Lack of breast feeding and immunocompromised baby
Performance of invasive procedure without aseptic technique
Sex : male
Pathophysiology
Micro-organisms invade the body tissue
Patient exhibits immune response and immune response activates the biochemical cytokines
and inflammatory mediators
Increased capillary permeability and vasodilation endothelial damage
Fluid seeps from capillaries activation of
coagulation system which begins to form
clots whether or not bleeding present
filling of fluid into lungs
In meningitis, fluid accumulates
collapsed alveoli inability for O2 and CO2 exchange in subarachnoid space
lung failure tissue becomes less perfused increased intracranial pressure
and acidotic
infarction and necrosis of brain tissue
multiple organ failure
different neurological manifestation
Clinical Features
1. Cardiovascular symptoms: Pallor, hypotension and abnormal heart beat.
2. Respiratory symptoms: Apnea, tachypnea, cyanosis, grunting, retractions.
3. Nervous system: Diminished activity, lethargy, hyporeflexia, poor cry, coma, irritability,
tremors , bulging fontanel.
3. 4. Gastrointestinal symptoms: poor feeding , diarrhoea, vomiting, abdominal distention,
hepatomegaly and poor weight gain.
5. Hematopoeitic system: Jaundice, pallor, purpura, petechiae, ecchymosis, splenomegaly and
bleeding.
Diagnosis
History of maternal condition at antennal,intranatal and postnatal period,feeding to child
,delivery history , newborn condition at birth, practice of newborn care and congenital
anomalies..
Newborn examination for clinical features.
Blood test: total count, differential count, culture, haemoglobin and peripheral smear
Sepsis screen should be performed in equivocal cases. A panel of tests (sepsis screen)
consisting of total leukocyte count (TLC; <5000/mm3), absolute neutrophil count (ANC;
<1800/mm3), immature to total neutrophil ratio (I/T ratio; more than 20%), CRP (more than
1 mg/ dl) and micro ESR (15 mm or more in the first hour) constitutes a useful sepsis screen
for clinically doubtful cases. Sepsis screen is considered positive if two of these parameters
are positive. Value of sepsis screen is more for exclusion of diagnosis of neonatal sepsis.
Chest X-Ray : This is a routine component of neonatal septic screen, and is mandatory in all
infants with respiratory distress, apnoea or continuing oxygen requirement.
Lumbar puncture and CSF culture should be performed in all babies suspected with neonatal
sepsis.
CSF indices in meningitis
Condition Physical
Characteristic
Cytology
cell/Cumm
Protein (gm/L) Glucose
(mmol/L)
Normal Clear and
colourless
Lymphocytes 0 to
32
0.1 to 0.4 2.5 to 4.2
Bacterial Yellowish and
turbid
Lymphocytes 5 to
50
0.5 to 2.0 <2.0
Tuberculos Colourless spider
web
Lymphocytes 100
to 300
>0.5 <2.0
Viral Clear Lymphocytes 10
to 100 after 36
hour
0.1 to 0.6 Normal
Fungal Clear Lymphocytes 50
to 500
Increased Decreased
4. Management
A. Management at home or community
Advice the mother to keep the baby warm. Kangaroo mother care is a useful modality to
maintain temperature of small and sick neonates.
Encourage for feeding if possible.
Give first dose of antibiotics
Counsel the mother on baby's condition and refer immediately to higher center.
B. Management at hospital
Institution of prompt treatment is essential for ensuring optimum outcome of neonates with
sepsis. Supportive care and antibiotics are the two equally important components of treatment.
1. Supportive care:
Good supportive care requires meticulous attention to various aspects:
Provide warmth to ensure normal temperature (36.5°-37.5°C). Baby should be nursed in a
warm environment. Heat sources can be used to keep the baby warm. Body temperature
should be monitored frequently.
Start oxygen by hood or mask, if the baby is cyanosed or grunting. Provide bag and mask
ventilation if baby is apneic or breathing is inadequate. Instilling normal saline drops in
nostrils may help clear the nasal block.
Establish IV line and give fluid at maintainance volume according to the baby's age for the
first 12 hours. Infuse 10% of glucose at dose of 2 ml/kg stat. The amount of IV fluid for a 1
day old baby with birth weight less then 1500gm is 60 ml per kg of 10% dextrose. Similarly,
if the baby is 7 days old with birth weight less than 1500gm, then 150 ml per kg of 10%
dextrose is given.
Assess capillary refill time by pressing at sternum (normally <2-3 seconds) and also assess
the skin color. If refill time is delayed then infuse normal saline or Ringer lactate 10 ml/kg
over 5-10 minutes. Repeat the same dose if perfusion continues to be poor. Dopamine and
dobutamine may be required to maintain normal perfusion.
If capillary refill time is normal, start on maintainance fluid.
Enteral feeding is to be avoided if baby is very sick or has abdominal distention.
Maintainance of fluid should be done by IV infusion.
Vitamin K 1 mg IM should be given to prevent bleeding disorders.
Measure haemoglobin every 3 days during hospitalization and again at discharge.Transfuse
blood, if baby has a low hematocrit (less than 35-40%) and haemoglobin less than 10 mg/dl.
Provide gentle physical stimulation if apnea is present.
Correction of hypoglycaemia with glucose infusion: 2 ml/kg of 10% glucose, through an
intravenous line is given over 2–3 minutes. Glucose infusion is continued at a rate of 4-6
5. mg/kg/min or 60 ml/kg/day. Blood glucose should be maintained at 70–100 mg/dl. The
infusion may be stopped after hypoglycaemia is corrected.
For convulsions :
Intravenous administration of phenobarbitone 20 mg/kg body weight slowly over a
period of 10–15 minutes is effective. After 1 hour, if seizures still persist, another
20mg/kg body weight IV of phenobarbitone is given. If seizures still persist, another 10
mg/kg IV of phenobarbitone can be given . A maintenance dose of 2.5–4 mg/kg body
weight per day administered orally or intramuscularly for at least a period of 2 weeks or
even longer.
In resistant cases when convulsion reoccur within 6 hrs then IV phenytoin (Dilantin), 20
mg/kg. Mix phenytoin in 15 ml of normal saline and infuse at the rate of 0.5 ml per
minute over 30 minute. Do not use other fluid to infuse phenytoin as it causes phenytoin
to crystallize.
If baby has any 3 of the following conditions, presume early sepsis and start the treatment :
Prematurity or low birth weight (1800gm).
Maternal fever or UTI prior to delivery for greater than 2 weeks.
Foul smelling liquor
Prolonged rupture of membrane
APGAR score 3 or less than 3 at 5 minutes after birth.
History of repeated vaginal examination before delivery.
2. Antibiotic therapy:
Antibiotic therapy should cover common causative organisms like E.coli, Staphylococcus
aureus and Klebsella pneumonia. A combination of Ampicillin and Gentamycin is
recommended for treatment of sepsis and pneumonia. In case of suspected meningitis,
Cefotaxime should be used along with aminoglycosides .The antibiotic choice depends upon
the causative organisms detected on the culture.
Antibiotic Each dose Frequency
Less
than 7
days of
age
More
than 7 7
days of
age
Route Duration Remarks
1. Septicemia or pneumonia
a. Injection
Ampicill
in
50
mg/kg/dose
12hourly 8hourly IV, IM 7-10 days May switch over to
oral Amoxicillin (15
mg/kg/dose,
8hourly) after 3-4
days of parenteral
ampicillin provided
if infant is
6. improving.
AND
b. Injection
Gentami
cin
2.5
mg/kg/dose
12hourly 12hourl
y
IV,IM 7-10 days May give
5mg/kg/dose as a
single IM dose every
24hrs for neonates
of all ages
2. Meningitis
a. Injection
Ampicill
in
100mg/kg/
dose
12hourly 8hourly IV/IM 3 weeks
AND
b. Injection
Gentami
cin
2.5
mg/kg/dose
12
hourly
8
hourly
IV/IM 3 weeks
AND
c. Injection
Cefotaxi
me
25
mg/kg/dose
12hourly 8hourly IV/IM 3 weeks
Source : Antibiotic Use for Sepsis in Neonates and Children : 2016 Evidence Update, Division of
Clinical Pharmacology, Children's National Health System, Washington.DC.USA.
If the condition is improved after 3 days of treatment with antibiotics , continue treatment
until the dose gets completed.
Observe the baby for 24 hours after discontinuing the antibiotics. If baby is well and no other
problems then discharge the baby.
If signs of sepsis reoccur then repeat the culture and treat with additional antibiotics.
C. Nursing management
1. Assessment
-Assess the child condition ,vital signs, capillary refill.
-Asses for signs and symptoms of sepsis and shock.
-Review of lab investigations.
-Assess for presumed sepsis conditions that may require treatment.
2. Nursing diagnosis
-Increased body tempeature related to infectious procress.
-Impaired gas exchange related to decreased ventilation secondary to inflammation and
infection of air spaces
-Ineffective breastfeeding related to respiratory distress secondary to disease condition.
-Inadequate nutrition: less than body requirement related to ill status of child.
- Risk for injury related to convulsion.
-Anxiety related to disease condition
7. 3. Nursing Interventions
Maintain body temperature
Monitor body temperature regularly and administer the prescribed antipyretics.
Provide tepid sponging, cross ventilation, remove extra clothes, administer IV fluid as
prescribed.
Facilitate respiratory efforts:
Maintenance of warm, humid and well- ventilated environment.
Position of child should be changed frequently to prevent pooling of secretions in lungs.
Oxygen administration as per need and suction secretions.
Provide adequate nutrition:
Provide feeding through NG tube until tolerated according to the demand of the baby.
Enteral feeding has to be discontinued if abdominal distention is present and nutrition of
the baby can be maintained through IV fluids.
Breastfeeding can be encouraged when the baby's condition begins to improve.
Prevention of possible injury.
Keep close observation of the child.
Maintain safe environment by keeping the side rails up.
Administer anticonvulsants drugs as prescribed.
Avoid restraining the baby and interfering during convulsions.
Parent education:
Enforce to complete entire course of antibiotics.
Assess improving status of child.
Teach about danger signs of newborn and to have prompt visit to health facility if present
any.
Advice to keep child warm.
Teach about infection prevention measures , hand hygiene, wearing masks and gown
while handling baby.
Encourage vaccination of the baby according to EPI schedule.
Prevention of Neonatal Sepsis:
Treatment of mother's infection during pregnancy.
Exclusive breastfeeding and no prelacteal feeding.
Six clean practice for the delivery: clean hand, clean perineum, clean delivery surface, clean
cord cutting, clean cord tie and clean cord care.
8. Hand washing before handling the babies.
Hygiene of the baby (Sponging, clean clothing).
Avoid unnecessary invasive procedure. Aseptic technique in invasive procedure.
Clean environment of neonatal unit and use of sterile gowns before entering the unit and
while handling the baby. Cots and incubators should be washed with soap and water and
sterilized with cetrimide solution.
Isolation of infected babies.
Prophylactic antibiotics for high risk babies. i.e. preterm babies or birth weight less than 2
kg, maternal fever in preceding 2 weeks, foul smelling liquor, prolonged rupture of
membrane for more than 24 hrs,
Limitation of visitors and handling of the baby.
Immunization
Parental education about danger signs of newborn and importance of hospital visit.
Prognosis: The outcome depends upon weight and maturity of the infant, type of etiologic agent,
its antibiotic sensitivity pattern and adequacy of specific and supportive therapy. The early-onset
septicemia carries risk of adverse outcomes. The institution of sepsis screen for early detection of
infection, judicious and early antimicrobial therapy, close monitoring of vital signs and intensive
supportive care are the most crucial factors responsible for a better outcome.
Summary
When pathogenic organisms gain access into the blood stream, they may cause an overwhelming
infection without much localization (septicemia), or may get predominantly localized to the lung
(pneumonia) or the meninges (meningitis) is called neonatal sepsis. Escherichia coli,
Staphylococcus aureus and Klebsiella sp. are the predominant organisms for causing neonatal
sepsis. It is characterised by pallor, apnea, tachypnea, bulging fontanel, poor feeding and
multiple organ failure. it can be diagnosed through sepsis screen and CSF analysis. Appropriate
antibiotics according to etiological factors can be given and necessary supportive care are to be
provided for its management. Prognosis depends upon weight , maturity of the infant and the
etiological agent.
9. References
Subedi, D.,& Gautam ,S.(2017) .Midwifery nursing part III ( 3rd ed.). Medhavi Publication
,Baneshwor, Kathmandu,Nepal (pp:194-198).
Shrestha,T.(2016). Essential child health nursing(2nd
ed.).MedhaviPublication, Jamal,
Kathmandu, Nepal (pp: 89-92).
Datta,P.(2014).Pediatric nursing(3rd
ed.). Jaypee Brothers MedicalPublishers,New
Delhi,India(pp: 101-102).
Koner,H.(Eds.).(2013).DC Dutta's textbook of obstetrics(7th
ed.).Jaypee Brothers Medical
Publishers,New Delhi,India(pp: 487-488).
Paul,V.K & Bagga.A.(2013).Ghai essential paediatrics(8th
ed.).CBS Publishers and Distributors,
New Delhi, India(pp: 552-554).
Sharma,R. (2013). Essential Paediatrics for Nurses( 2nd ed.). Jyapee Brothers Medical Publisher
, New Delhi,India( pp:223-230).
Thakur, L .(2012).Advanced child health nursing (3rd ed.).Ultimate Marketing ,Lazimpat
,Kathmandu,Nepal (pp: 66-69).
Managing newborn problems.(2003).Geneva:Department of reproductive health and
research,WHO.
10. SAMPLE QUESTION
Subject : Midwifery II Total Hour :30 min
Course no : BSN19 Total Mark :10
Pass Mark : 4
Candidates are required to give answers in their own words as far as practicable.
The figures in the margin indicates full marks.
Attempt all questions.
Objective Type of Question
1.Write 'T' for true and 'F' for false for the following statements in the box. 1X2=2
a. The most common causative agent for neonatal sepsis is E.coli.
b. ANC greater than 5000/mm3
indicates positive sepsis screen.
2.Fill in the blanks with suitable answer. 1X2=2
a. Capillary refill in newborn is assessed by pressing…………….
b. Late onset neonatal sepsis appears………………..
Subjective Type of Question
Long Answer Type Question
Answer the following question.
a. What isneonatal sepsis?Discussthe preventive measuresof neonatalsepsis? 2+4=6