Delivery and Immediate Neonatal Care Book

3. Delivery and Immediate Neonatal Care

Anticipation, preparation, recognition, and intervention

A successful resuscitation relies on anticipation based on prenatal and intrapartum risk factors, preparation for all deliveries, and monitoring of the fetus during labor for early detection on fetal distress (fetal heart rate monitoring), recognition of the need for resuscitation, and adequately skilled intervention.

Include estimation of gestational age, fetal heart rate check and screening for bleeding, hypertension, and signs of infection. Monitor labor using a partogram. Basic emergency obstetric care includes the capability to administer antibiotics, uteronics, anticonvulsants (magnesium sulfate); manual removal of the placenta or retained products; assisted vaginal delivery; and basic neonatal resuscitation. Refer to a facility for comprehensive emergency obstetric and newborn care for Caesarean sections, blood transfusion, and care of sick and low birthweight newborns. Prevent mother-to-child transmission of HIV with appropriate administration of antiretroviral medications.

In disaster settings, ensure that all deliveries occur in facilities able to provide the basic essential obstetric care services (BEmOC) described above. Also, for complicated cases, be able to refer to a designated facility that will be ensuring Comprehensive essential obstetric care (CEmOC), which will include in addition to the services mentioned above surgery, anesthesia, and blood transfusion. In regions with a high prevalence of HIV prevent mother to child transmission of HIV (PMTCT) and provide HIV treatment for all mothers who are HIV-positive.

Anticipatory planning

Every disaster situation is likely to involve pregnant women and their newborns. Because up to 30% of newly born infants in disaster settings will require resuscitation, anticipatory planning will be fundamental for these interventions to be successful.

What personnel should be available?

If possible, notify personnel with skills in neonatal resuscitation. At least one person who is capable of initiating resuscitation should be present at each birth and immediately available to the newborn. Others who might function as part of a resuscitation team should be available as the need arises. It is important to prepare the area in which the delivery will occur, check the equipment and review the functions of personnel  immediately prior to the delivery. Personnel should review the emergency plan for communication and transportation if either mother or infant needs an advanced level of care.

What maternal, fetal, and neonatal conditions might indicate a higher risk of neonatal depression?

The need for resuscitation cannot always be predicted; it must be kept in mind that prompt neonatal resuscitation might be necessary after any birth. However, some perinatal conditions associated with a need for resuscitation can be recognized in advance. Some of those conditions are shown in Box 1. Thorough assessment of the risk factors allows for the identification of more than half of the deliveries that will need neonatal resuscitation. Prospective identification of perinatal high-risk factors should prompt the transfer of the pregnant woman or the mother and her newly born infant to to a CEmOC facility with enhanced care resources. Keep the mother and baby together, especially if transfer is necessary. The Integrated Management of Childhood Illness (IMCI) strategy from the Pan American Health Organization (PAHO) and the World Health Organization (WHO) includes the assessment and classification of pregnancies in order to determine the risk level and adequate treatment (Table 1). Identification of high-risk factors can also facilitate communication with the family and timely mobilization of the resuscitation and maternal health care team.

What equipment should be available?

Equipment for immediate care of the newborn at birth is listed in Box 2. Prepare the uterotonic before delivery, as well as other supplies to care for the mother. The resuscitation bag and masks should be appropriately sized for newborns and the bag should not require a pressurized gas source.It is recommended that sterile delivery kits be available. An example of the contents of the MSF recommended delivery kit is provided in Box 2.

What are the appropriate delivery procedures?

The Action Plan (Figure 3 – 2nd edition HBB Action Plan) summarizes the actions in providing routine care and help to breathe. Routine care of a baby who cries spontaneously at birth includes:

• Dry thoroughly by rubbing with a dry cloth.
• Keep warm by positioning the baby skin-to-skin with mother, covering with a dry cloth and a head covering.
• Check breathing by listening for grunting or other abnormal sounds, looking
  for chest indrawing or cyanosis, and feeling chest movement to detect rapid breathing.
• Clamp and cut the cord after 1 to 3 minutes. Apply clamps or cord ties 2 and 5 finger breadths from the abdomen. Use a sterile blade or scissors to cut the cord.
• Encourage initiation of breastfeeding in the first hour after birth. Utilize appropriate personal protection; personnel should use sterile gloves to the extent possible.

Everyone present at the ­delivery should perform hand hygiene. Remember to perform adequate identification procedures for the newborn (take the infant’s footprints in a form together with the mother’s fingerprint and provide the newborn with an identification bracelet, if available). This issue takes on added importance in situations of administrative disorder, as is usually the case in acute humanitarian emergencies.

Provide the child with an environment as warm as possible. It is essential to dry the infant immediately. Leaving the baby wet may result in cold stress. Early skin-to-skin contact with the mother has been shown to be effective and desirable. Immediate breastfeeding following delivery is advisable for healthy infants. Even if the newborn requires resuscitation and ongoing care, the parents should have at least brief contact and be fully informed of care.

Three major questions should be asked about every newborn child to define the need for resuscitation:

• Is this a full-term gestation?
• Is the baby breathing or crying?
• Is there good muscle tone?

Recognition

The evaluation question “is the baby crying?” identifies the baby who needs help to breathe. An infant who is gasping, breathing shallowly, or not breathing at all requires help to breathe. Quick action increases the chance of a good response. The Golden Minute emphasizes that a baby who is not crying after thorough drying should be breathing or
receiving positive-pressure ventilation by one minute after birth.

• Is the baby breathing or crying? Absent respiratory effort (apnea) or inadequate respiratory effort (gasping; breathing with superficial and ineffective inspiratory movements) is the first reason to initiate resuscitation.
• Is there good muscle tone? Poor muscle tone might indicate hypoxemia. Preterm newborns normally have a lower muscle tone than term babies.

Term infants with good respiratory effort and muscle tone can be dried and placed over the mother’s body for better thermal protection and suckling under continued observation.

Resuscitation treatment

The sequence of neonatal resuscitation for the baby who is not crying begins with thermal protection, proper positioning of the newborn, and brief stimulation.

• Thermal protection. Dry the baby rapidly to reduce evaporation. Place the baby skin-to-skin with the mother after drying. A radiant heater can be used if resuscitation interventions are required. If a warming device is used, hyperthermia must be avoided. Wrapping a very preterm infant in clear food-grade plastic film is effective in reducing cold stress while allowing access to the infant. Cover the baby’s head with a cap. A sick baby who needs to be transported can be protected from cold by placing an exothermic chemical mattress under a blanket, skin-to-skin contact with an adult, or swaddling in warm blankets covered by a windproof, reflective outer layer. Heating pads, hot water bottles, and surgical gloves filled with hot water should be avoided because they can cause extensive burns.
• Position. The airway of the hypotonic baby is vulnerable to obstruction with flexion or extension of the neck. Position the infant on the back or side, with the head slightly extended in the “sniffing” position (Figure 1).

• Airway clearing. Remove secretions that obstruct the airway by wiping the nose and mouth with a cloth or by using a suction device. When there are copious secretions, suction the mouth before the nose (Figure 2). Suction must be brief, gentle and not very deep. Suctioning that is too vigorous, too deep, or too prolonged can cause damage, apnea, and bradycardia through vagal stimulation. The presence of meconium in the amniotic fluid can be a sign of fetal distress. Pharyngeal suctioning during birth has not been demonstrated to reduce the incidence of meconium aspiration syndrome. If meconium is present in the amniotic fluid, clear the airway before providing positivepressure ventilation.

• Stimulation. Drying an infant thoroughly generally provides sufficient stimulation of breathing in a healthy newborn. Additional stimulation— flicking the soles of the feet or rubbing the back, for example— may encourage the initial respiratory effort and continued breathing during the early transitional period if needed. Vigorous or prolonged stimulation may harm to the baby and is not part of skillful ­resuscitation.

If supplemental oxygen is available, when is it indicated?

A number of studies have demonstrated that for most neonatal resuscitations requiring positive-pressure ventilation, room air is as effective as 100% oxygen. Data also indicate that in the first several minutes after birth cyanosis is common in babies who have normal outcomes.

Poor respiratory effort, as manifested by apnea or gasping (deep, intermittent, slow, spasmodic inspiratory efforts) is the major indication to initiate neonatal resuscitation.

The 2016 AAP Neonatal Resuscitation Program update includes the following recommendations for oxygen supply during resuscitation:

Room air to initiate positive-pressure ventilation in term infants and blended oxygen concentrations (21–30%) for initiation of PPV in very preterm infants.

Oximetry when

• Resuscitation can be anticipated
• Positive pressure is administered for more than a few breaths
• Cyanosis is persistent
• Supplemental oxygen is administered

Targets for oxygen saturation correspond to preductal saturations of healthy term babies in the first minutes after vaginal birth at sea level.

These initial steps and possible subsequent actions are outlined in the flow diagram shown in Figure 3. Further steps in resuscitation are discussed in the following paragraphs.