7.
Neonatal Resuscitation
Study Session 7 Neonatal Resuscitation.......................................................................3
Introduction................................................................................................................3
Learning Outcomes for Study Session 7....................................................................4
7.1 Newborn respiration and resuscitation................................................................4
7.1.1 Breathing in a healthy newborn...................................................................4
Question.................................................................................................................5
Answer...................................................................................................................5
7.1.2 Newborn asphyxia........................................................................................6
7.2 Types of neonatal resuscitation...........................................................................7
7.2.1 Basic equipment needed for newborn resuscitation.....................................8
7.2.2 Before you start resuscitation.......................................................................8
7.3 Assessing the degree of asphyxia........................................................................9
7.4 Neonatal resuscitation procedures.....................................................................11
7.4.1 The first five seconds.................................................................................11
7.4.2 Checking the newborn’s heart rate.............................................................12
Question...............................................................................................................12
Answer.................................................................................................................12
7.4.3 The initial actions.......................................................................................13
7.4.4 Dry the baby quickly and keep it warm.....................................................14
7.4.5 Clearing the mouth and nose......................................................................14
7.4.6 Apply gentle tactile stimulation to initiate or enhance breathing..............16
7.4.7 If you diagnose asphyxia, start resuscitation!............................................18
1
7.4.8 Ventilate at 40 breaths per minute.............................................................21
7.4.9 Evaluate the baby during ventilation..........................................................22
Question...............................................................................................................22
Answer.................................................................................................................22
7.5 Immediate essential newborn care....................................................................23
Box 7.1 Health risks to newborns.......................................................................24
Summary of Study Session 7...................................................................................25
Self-Assessment Questions (SAQs) for Study Session 7.........................................25
Case Study 7.1 Atsede’s baby can’t breathe.......................................................26
SAQ 7.1 (tests Learning Outcomes 7.2 and 7.3)..................................................26
Answer.................................................................................................................26
SAQ 7.2 (tests Learning Outcomes 7.4................................................................26
Answer.................................................................................................................26
SAQ 7.3 (tests Learning Outcomes 7.1, 7.2, 7.4, 7.5 and 7.6).............................27
Answer.................................................................................................................27
SAQ 7.4 (tests Learning Outcome 7.4)................................................................27
Answer.................................................................................................................28
SAQ 7.5................................................................................................................28
Answer.................................................................................................................28
2
Study Session 7 Neonatal Resuscitation
Introduction
The moment when a baby is born is also the time when the birth attendant has to
make a very rapid assessment of the condition of the newborn to decide whether it
needs helping to breathe. Within a few seconds you have to be able to identify the
general danger signs in a newborn that tell you to intervene quickly to protect it from
developing serious complications, or even dying, because it is not able to get enough
oxygen into its body. Of course, most babies breathe spontaneously as soon as they
are born and all you need to do is follow the steps of basic newborn care, which were
briefly outlined in Study Session 5 of this Module. You will learn them in much
greater detail in the Module on Postnatal Care and the steps will be covered again in
the Module on Integrated Management of Newborn and Childhood Illness.
3
However, in this study session our focus is on newborns who are not breathing well,
and what you need to do in order to resuscitate them and get them breathing normally.
You will learn how to distinguish between a healthy baby and one that is moderately
or severely asphyxiated (i.e. short of oxygen due to breathing problems), and the
correct action that you should take. This study session is unusual in that much of it is
taught through diagrams.
Learning Outcomes for Study Session 7
When you have studied this session you should be able to:
7.1 Define and use correctly all of the key words printed in bold. (SAQ 7.2)
7.2 Summarise the most important signs of neonatal asphyxia that mean you should
begin neonatal resuscitation. (SAQ 7.1)
7.3 Explain how newborns can be helped to breathe by applying standard
resuscitation techniques. (SAQs 7.1 and 7.2)
7.4 Identify the equipment you will need to give newborn resuscitation and how it
should be used correctly. (SAQ 7.3)
7.5 Describe the things you should not do when assessing a newborn for possible
breathing difficulties. (SAQ 7.4)
7.6 Summarise the main health risks to newborns and the activities that form the
basis of essential newborn care. (SAQ 7.5)
7.1 Newborn respiration and resuscitation
We begin by briefly summarizing what usually happens when a newborn makes the
transition from life in its mother’s uterus, to life in the outside world, where it must
breathe for itself.
7.1.1 Breathing in a healthy newborn
Normally, a healthy baby starts to breath spontaneously immediately after delivery
(Figure 7.1). If the breathing started spontaneously and is sustained by the baby
without assistance, it indicates that:
The fetus was not asphyxiated while in the uterus
The respiratory system is functioning well
The cardiovascular system (heart and blood vessels) is functioning well
There is coordination by the brain of the movements required for sustained
rhythmical breathing (brain is functioning well).
4
Figure 7.1 A full-term normal newborn who is breathing well has pinkish skin colour
and semi-flexed arms and legs; he has made a good transition from the mother’s
uterus to the outside world. (Photo: Dr Mulualem Gessese)
Question
How do you check fetal wellbeing during labour and delivery?
Answer
A healthy fetus has a heart rate between 120–160 beats/minute. When the fetal
membranes rupture, the amniotic fluid that leaks from the mother’s vagina is clear,
not heavily blood-stained or coloured greenish-black by meconium — the baby’s first
stool.
End of answer
If you checked the fetal heart rate at regular intervals all through the mother’s labour,
and recorded the result on the partograph (as you learned in Study Session 4), you
should have referred any mother whose unborn baby showed signs of fetal distress.
Therefore, it should be relatively uncommon for you to deliver an asphyxiated baby.
However, complications in childbirth can develop unpredictably, or you may be
called to a woman who is already far advanced in the second stage of labour when
you reach her. Therefore, you need to know how to provide neonatal resuscitation in
case you deliver an asphyxiated baby.
5
7.1.2 Newborn asphyxia
As you learned in Study Session 4 of this Module, asphyxia (shortage of oxygen) in
the uterus is due to an inadequate supply of oxygen from the mother’s blood or a
problem in the placenta. This may result in:
Asphyxia at birth (mild, moderate or severe)
Learning difficulties or cognitive impairment, which become apparent during
childhood development; they are due to brain cells being destroyed by lack of
oxygen during labour and delivery.
Death of the newborn.
Gas exchange is when oxygen from the inhaled air is absorbed into the blood as it
passes through the lungs, and waste carbon dioxide is released from the blood into the
air that is breathed out
However, neonatal asphyxia is mainly due to failure of the newborn to breathe after
birth, or its heart fails to pump enough blood to the lungs for gas exchange, or it has
low haemoglobin levels (anaemia) so it cannot deliver enough oxygen around the
body. The baby who cannot breathe cannot establish independent life outside the
mother. Therefore, the purpose of neonatal resuscitation is to help the newborn to
establish spontaneous breathing and facilitate oxygen delivery to its organs and
tissues – particularly the brain, which is very quickly damaged by oxygen shortage.
You may also need to resuscitate any baby that is severely anaemic due to blood loss
during labour and delivery, or that continues to be cyanotic despite established
breathing. Cyanosis is a bluish discolouration of the lips and skin, which occurs when
there is insufficient oxygen in the blood (Figure 7.2).
Figure 7.2 A preterm newborn with problems: she looks cyanotic (bluish), her limbs
are floppy because her muscle tone is not strong, and she has breathing problems.
(Photo: Dr Mulualem Gessese)
6
To avoid the immediate and long-term complications of asphyxia, in addition to the
labour and delivery care that you provide to the mother, and the routine newborn care
of the baby (e.g. cutting the cord, keeping the baby warm), you also have to provide
life-saving interventions for any newborn who cannot breathe properly.
7.2 Types of neonatal resuscitation
There are three techniques that you will learn about in this study session and in your
practical skills training. They are:
Ventilation: using a hand-operated pump called an ambu-bag (Figure 7.3),
which pumps air into the baby’s lungs through a mask fitted over its nose and
mouth. (You may hear health professionals referring to ventilation as ‘ambu-
bagging’.)
Figure 7.3 Resuscitation technique practiced with a ventilator (ambu-bag) on a
training doll. (Photo: Dr Yifrew Berhan)
Suctioning: using a device called a bulb syringe to extract mucus and fluid
from the baby’s nose and mouth.
Heart massage: pressing on the baby’s chest in a rhythmic way to stimulate
the heartbeat (Figure 7.4).
7
Figure 7.4 Cardiac massage technique practiced on a training doll. You can see
a ventilator at the top right of the picture. (Photo: Dr Yifrew Berhan)
7.2.1 Basic equipment needed for newborn resuscitation
Two clean linen/cotton cloths: one to dry the newborn and one to wrap him or
her afterwards
Plastic bulb syringe to remove secretions from the mouth and nose, especially
when meconium is present
Ambu-bag and mask to give oxygen directly into the baby’s lungs
A person trained in neonatal resuscitation (like you)
Heat source (lamp) to provide warmth, if possible.
7.2.2 Before you start resuscitation
Before you apply any form of resuscitation, make sure that:
The baby is alive: If the newborn doesn’t appear to be alive, FIRST listen to its
chest with a stethoscope. If there is no heartbeat, the baby is already dead (see
Table 7.1 below).
You graded the extent of asphyxia: If you can hear a heartbeat, but you
estimate it to be less than 60 beats/minute, apply heart massage first, then
ventilate alternately on and off, till the heartbeat is above 60 beats/minute (see
Table 7.1 below).
8
The baby is not deeply meconium stained: If the baby’s skin is stained with
meconium, or the oral and nasal cavities are filled with meconium-stained fluid
(Figure 7.5), you should not resuscitate before suctioning the oral, nasal and
pharyngeal areas. Ventilation will aggravate the baby’s breathing problem
because it will force the meconium-stained fluid deep into the baby’s lungs,
where it will block the gas exchange.
Figure 7.5 A baby who is not breathing (no signs of chest or nose movement) and
with meconium stained all over its body. (Photo: Dr Mulualem Gessese)
7.3 Assessing the degree of asphyxia
Moderate to severely asphyxiated babies usually require intensive resuscitation, so the
next thing you have to learn is how to grade asphyxia in a newborn. Within no more
than 5 seconds after the birth, you should make a very rapid assessment to find out
whether the baby is alive or dead, and (if it is alive) to assess whether it has any
degree of asphyxia. A severely asphyxiated baby may not breathe at all, there may be
no movement of its limbs (arms and legs), and the skin colour may be deeply blue or
deeply white. A baby who is not breathing at all after birth, or who is only gasping for
breath, or who is breathing less than 30 breaths per minute needs help immediately. If
a baby does not breathe soon after birth, it may get brain damage or die. Most babies
who are not breathing can be saved if resuscitated correctly and quickly.
From Table 7.1, you can learn how to assess a newborn’s degree of asphyxia. Also
look again at the three photos of newborns with different level of asphyxia (Figures
7.1, 7.2 and 7.5).
9
Gasping is when the newborn can take only a few breaths with difficulty and with
wide gaps in between; it is usually a sign that the baby is close to death.
Table 7.1 Assessing the degree of asphyxia.
Moderate
Signs No asphyxia Mild asphyxia Severe asphyxia
asphyxia
Above 100 Above 100 Above 60 Below 60
Heart rate
beats/minute beats/minute beats/minute beats/minute
Skin colour Pink Mild blue Moderately blue Deeply blue
Breathing Breathing but Not breathing, or
Crying Crying
pattern not strong gasping type
Limb
Moving well Weakly moving Floppy Floppy
movement
Meconium-
No No Maybe Usually
stained
Takes a long time
Resuscitation No need Fast response Good response
to respond
10
Asse
ssment of the degree of asphyxia should not take you more than 5 seconds. Do it fast
but don’t panic.
Since neonatal resuscitation is an action that you need to perform rapidly (within one
minute after delivery), it is better to estimate than to count the heart rate, and to
observe the pattern of breathing rather than to count the respiratory rate. Table 7.2
gives you a simplified description of the signs that indicate what is normal and
abnormal immediately after birth.
Table 7.2 Normal and abnormal physical findings in the newborn immediately
after birth.
Signs Normal findings Abnormal findings
Blue or cyanosed (shortage of oxygen)
Colour Should be pink White, pallor (anaemia)
Yellowish (jaundice)
Breathing 40–60 breaths/minute No breathing
11
Signs Normal findings Abnormal findings
Breathing rate less than 30/minute
Gasping (very few breaths with difficulty
breathing)
No heartbeat at all
Heart rate 120–160 beats/minute
Heartbeat less than 100/minute
Full term newborn has semi- Poor flexion of the limbs; arms and legs
Muscle
flexed arms and legs (Figure floppy (Figure 7.2), indicates moderate to
tone
7.1) severe asphyxia affecting the brain
Baby responds to a finger put No response to touching the roof of the
Reflexes
into the roof of its mouth baby’s mouth
‘Less than’ can be replaced by the < symbol, as in <30/min. ‘More than’ can be
replaced by the > symbol, as in >30/min.
7.4 Neonatal resuscitation procedures
Before you go to attend any delivery, you should make certain that you have prepared
the equipment necessary to apply neonatal resuscitation and give immediate care to
the newborn if required. In this section we move on to the actions that you should take
once you have assessed the degree of asphyxia.
7.4.1 The first five seconds
Table 7.3 summarises what you should do in the first 5 seconds after the baby is born
if the signs of asphyxia are present. After you have seen this overview, we will look at
the specific actions in detail.
Table 7.3 Actions in response to signs of neonatal asphyxia.
What is the newborn doing? Assessment Action
Probably a
Crying and moving limbs Resuscitation not needed
healthy baby
Probably Assist breathing by on and off
Weak breathing, not moving
moderately ventilation (as described in
limbs, moderate cyanosis
asphyxiated Section 7.4.8)
Not crying, breathing or gasping; Probably severely Estimate heart rate
not moving limbs/floppy; may be asphyxiated
cyanosed or meconium stained Call an assistant (family
member or other)
Suction the oral, nasal and
pharyngeal area in less than 5
seconds using a bulb syringe
12
What is the newborn doing? Assessment Action
On and off ventilation
Heart rate above
As above
60 beats/minute
As above, but with the addition
Heart rate below
As above of cardiac massage (see Figure
60 beats/minute
7.4)
7.4.2 Checking the newborn’s heart rate
The apical heartbeat (or AHB) is just another name for the heartbeat heard through a
stethoscope over the area of the heart on the left side of the chest, as shown in Figure
7.6. It is called ‘apical’ because the heartbeat is heard directly from the surface of the
heart.
Question
What is the name given to the number of heartbeats per minute measured away from
the the heart?
Answer
It is called the pulse rate.
End of answer
The newborn’s heartbeats can also be counted by feeling the pulse at the base of the
umbilical cord, as shown in Figure 7.6.
13
Figure 7.7 Checking and counting the apical heartbeat (AHB) and feeling for the
pulse at the base of the umbilical cord.
7.4.3 The initial actions
The list below sets out the actions you should take for all newborns in the sequence
shown, irrespective of the degree of asphyxia:
1. Fast drying as shown in Figure 7.8
2. Keeping the baby warm.
3. Clearing the mouth and nose as shown in Figure 7.9
14
4. Apply gentle tactile stimulation to initiate or enhance breathing as shown in
Figure 7.10
5. Simultaneously assessing the degree of asphyxia as shown earlier in Tables
7.1 to 7.3
6. Positioning the baby for resuscitation if there are signs of asphyxia, as shown
in Figure 7.11
Now study each of these figures in turn. Look at them carefully and make sure that
you read the captions and other notes associated with them.
7.4.4 Dry the baby quickly and keep it warm
Lay the baby on a warm surface away from drafts. Use a heat lamp or other overhead
warmer, if available. Then dry the baby as shown in Figure 7.8.
Figure 7.8 How to dry the baby: (top) lay the baby on its back and dry it thoroughly;
(bottom left) remove the wet cloth; (bottom right) tilt the baby’s chin to reposition the
baby’s head and keep its airway open.
Place the baby in skin-to-skin contact with the mother, covered by a warm blanket.
Place a warm cap or shawl to cover the baby’s head.
7.4.5 Clearing the mouth and nose
If a bulb syringe is available:
15
Suct
ion the mouth first, then the baby’s nose (‘m’ before ‘n’) — see Figure 7.9.
No deep suctioning with a bulb syringe! It can cause slowing of the heart rate
(bradycardia).
If no bulb syringe:
Clear secretions from the mouth and nose with a clean, dry cloth.
16
Figure 7.9 Suctioning the newborn with a bulb syringe to clear mucus from its upper
airway: (top) suction the mouth first; (bottom) then suction the baby’s nose (‘m’
before ‘n’).
7.4.6 Apply gentle tactile stimulation to initiate or enhance breathing
17
Figure 7.10 How to give gentle tactile stimulation: (left) rub the baby’s abdomen up
and down; (centre and right) flick the underside of the baby’s foot with your fingers.
18
DO
NOT stimulate by:
These types of stimulation are dangerous and can damage the newborn.
Slapping the back
Squeezing the rib cage
Forcing the baby’s thighs into its abdomen
Dilating the anal sphincter (the ring of muscle that closes the anus)
Hot or cold compresses or baths
Shaking the umbilical cord.
7.4.7 If you diagnose asphyxia, start resuscitation!
Position the newborn on his or her back with the neck slightly extended as shown in
the top picture in Figure 7.11. Open the airway by clearing the mouth and nose with
suction using the bulb syringe as you saw previously in Figure 7.9.
19
20
Figure 7.11 How to position the newborn’s head to keep its airway open: (top)
correct, the baby’s chin is tilted the right amount; (middle) the baby’s head is tilted
too far back, placing pressure on the windpipe in its neck; (bottom) the baby’s head is
not tilted enough — its chin is too close to its chest and the airway is compressed.
Position yourself at the head of the baby (see Figure 7.12).
Figure 7.12 The correct position for newborn resuscitation using an ambu-bag.
If the apical heartbeat is > (more than) 60 beats/minute:
Ventilate with the appropriate size of mask and a self-inflating ambu-bag. The
mask should be fitted as shown in Figure 7.13. Make a firm seal between the
mask and the baby’s face, so air cannot escape from under the edges of the
mask. But don’t force the mask down onto the baby’s face, because this could
push its chin down towards its chest (bottom diagram in Figure 7.11) and
compress its airway.
If the apical heart beat is < (less than) 60 beats/minute:
Apply heart massage (look back at Figure 7.4) and ventilate alternately (on
and off ventilation) with the ambu-bag.
21
Figure 7.13 Correct and incorrect size of mask: (top) correct: Covers mouth, nose,
and chin; (bottom left) incorrect: too large — covers eyes and extends over chin;
(bottom right) incorrect: too small — does not cover nose and mouth.
7.4.8 Ventilate at 40 breaths per minute
Count out loud: ‘Breathe — two — three’ as you ventilate the baby (see Figure 7.14).
Squeeze the bag as you say ‘Breathe’ and release the pressure on the bag as you say
‘two — three’. This helps you to ventilate with an even rhythm, at a rate that the
newborn’s lungs are naturally adapted to.
The amount of air you are moving into and out of the lungs is the equivalent of about
40 breaths per minute. Apply enough pressure to create a noticeable, gentle rise and
fall in the baby’s chest. The first few breaths may require higher pressures, but if the
baby appears to be taking a very deep breath, you are using too much pressure.
22
Figure 7.14 Timing the rate of ventilation as you say ‘Breathe — two — three’.
7.4.9 Evaluate the baby during ventilation
The best sign of good ventilation and improvement in the baby’s condition is an
increase in heart rate to more than 100 beats/minute.
Question
What other change would you expect to see in the baby while you are ventilating it, if
the resuscitation is going well?
Answer
You would expect to see the baby’s skin colour change from bluish or very pale, to a
healthier pinkish colour. You may also see the baby begin to move a little bit,
beginning to flex its limbs and look less floppy.
End of answer
When you stop ventilating for a moment, is the baby capable of spontaneous
breathing or crying? These are good signs. Many babies recover very quickly after a
short period of ventilation, but keep closely monitoring the baby until you are sure it
is breathing well on its own.
If the baby remains weak or is having irregular breathing after 30 minutes of
resuscitation, refer the mother and baby urgently to a health centre or hospital where
they have facilities to help babies who are having difficulty breathing. Go with them
23
and keep ventilating the baby all the way. Make sure it is kept warm at all times.
Newborns easily lose heat and this could be fatal in a baby that can’t breathe
adequately on its own.
Figure 7.15 summarises the steps in newborn resuscitation which you have learned in
Section 7.4.
Figure 7.15 A summary of the steps in newborn resuscitation in the form of a flow
chart.
7.5 Immediate essential newborn care
24
We end this study session with a reminder about essential newborn care, which you
should conduct with all babies, regardless of whether they have any signs of
asphyxiation. When the baby’s umbilical cord is cut, there are many physiological
changes inside the baby’s body to allow it to make the necessary adaptation to life
outside its mother. It is generally tougher to survive in the outside world than in the
relative safety of the uterus, so we need to provide basic care to the newborn to help it
resist some potential health risks listed in Box 7.1.
Box 7.1 Health risks to newborns
Newborns need additional care to prevent:
Spontaneous bleeding, usually from the gastrointestinal tract, due to Vitamin
K deficiency
Bleeding due to birth trauma (usually manifested late after delivery with
swelling over scalp that requires immediate referral)
Eye infections due to Chlamydia trachomatis and Neisseria gonorrhea
(bacteria which are common causes of sexually transmitted infections; the baby
can acquire these infections as it passes through the birth canal)
Some vaccine preventable diseases such as poliomyelitis and tuberculosis
Hypothermia (becoming too cold)
Hypoglycaemia (low blood glucose level)
Mother-to-child transmission of HIV, if the mother is HIV-positive.
Vaccine preventable diseases are discussed in detail in the Communicable Diseases
Module, Study Sessions 3 and 4.
Prevention of mother-to-child transmission (PMTCT) of HIV is covered in the
Antenatal Care Module, Study Session 17; the drugs and procedures for PMTCT are
given in the Communicable Diseases Module, Study Session 27.
With the health risks in Box 7.1 in mind, make sure that you give all newborn babies
the following essential care:
Tie the umbilical cord two finger-widths from the baby’s abdomen and place a
second tie two finger-widths away from the first one. Cut the cord between the
first and second ties. Check that the umbilical cord stump is not bleeding and is
not cut too short
Apply tetracycline eye ointment once only, to prevent eye infections.
Inject vitamin K (1 mg, intramuscularly) into the front of the baby’s mid-thigh
to prevent spontaneous bleeding.
25
Give the first dose of oral polio vaccine and BCG vaccine (against
tuberculosis) according to the guidelines in the Ethiopian Expanded Programme
of Immunization (EPI).
The body temperature of the newborn must remain above 36oC. Place the baby
on the mother’s abdomen in skin-to-skin contact with her, where it can
breastfeed. Cover them both with a blanket and put a warm hat or shawl over
the baby’s head.
Ensure that the baby is suckling well and the mother’s breast is producing
adequate milk. If breastmilk is not preferred, make sure that adequate
replacement feeding is ready. Initiate early and exclusive breastfeeding unless
there are good reasons to avoid it, e.g. in an HIV-positive mother.
The baby should get preventive treatment to protect it from HIV if its mother
is HIV-positive.
The vaccination schedule for all the vaccines in the EPI are described in full in the
Immunization Module.
You will learn all about breastfeeding in the Postnatal Care Module. Breastfeeding
and HIV are covered in the Communicable Diseases Module, Study Session 27.
Summary of Study Session 7
In Study Session 7, you have learned that:
1. The most important signs of asphyxiation in newborns at delivery are:
difficulty breathing, gasping or no breathing; abnormal heart beat; poor muscle
tone (floppy limbs); lack of movement; bluish skin colour (cyanosis), and being
stained with meconium.
2. Assessment of the degree of asphyxia should be done in the first 5 seconds
after the birth, at the same time as commencing basic newborn care (e.g. drying
the baby, keeping it warm, tying and cutting the cord, etc).
3. Swift action is necessary to begin resuscitating a baby who is not breathing
well, after you have suctioned its mouth and then its nose.
4. Check that the baby is alive (listen for an apical heartbeat); that the heart rate
is above 60 beats/minute (begin heart massage before resuscitation if the heart
rate is less than 60 beats/minute); and that the baby is not stained with
meconium, which must be suctioned out before resuscitation can begin.
5. Position the baby with its neck extended to open the airways; place a correctly
fitting ventilation mask over the baby’s mouth and nose, and begin ventilating
at a rate of about 40 breaths per minute.
26
6. Watch for signs of improvement: e.g. pinkish colour, movement, ability to
breathe unaided, etc. Refer urgently if this has not been achieved after 30
minutes of ventilation.
7. Remember to conduct all the activities of essential newborn care, including
cord care, giving a vitamin K injection and tetracycline eye ointment,
establishing early and exclusive breastfeeding, and ensuring that anti-HIV
medication is given to prevent mother-to-child-transmission.
Self-Assessment Questions (SAQs) for Study Session 7
Now that you have completed this study session, you can assess how well you have
achieved its Learning Outcomes by answering the following questions. Write your
answers in your Study Diary and discuss them with your Tutor at the next Study
Support Meeting. You can check your answers with the Notes on the Self-Assessment
Questions at the end of this Module.
First read Case Study 7.1 and then answer the questions that follow it.
Case Study 7.1 Atsede’s baby can’t breathe
A 25 year-old woman called Atsede was brought to your Health Post after being in
labour for 38 hours at home. Soon after she reached you, she gave birth to a full term
baby boy. You assessed the baby and found he was not making any breathing effort,
he had no movement of his limbs and his whole body was covered with meconium-
stained amniotic fluid. When you dried him and applied tactile stimulation, the baby
still didn’t show any effort to breathe.
SAQ 7.1 (tests Learning Outcomes 7.2 and 7.3)
1. Is this baby asphyxiated? If yes, what is the degree of asphyxia?
2. What are your immediate next steps? Then what do you do?
3. Could the birth complication in this newborn have been prevented, and if so,
how?
Answer
1. Atsede’s baby is severely asphyxiated. The danger signs are that he was not
making any breathing effort, or moving his limbs, he was covered with
meconium and tactile stimulation had no effect.
2. Your next step is to dry him quickly, wrap him warmly, and remove
meconium from his mouth and nose with the bulb syringe and a clean cloth.
Listen for an apical heartbeat and if it is below 60 beats/minute, begin heart
massage, alternating with ventilating the baby at about 40 breaths per minute.
3. The birth complication in this newborn could have been prevented by Atsede
receiving skilled birth attendance much earlier in her labour from someone who
27
could monitor the signs of fetal distress and refer her for emergency care; 38
hours is too long to wait.
End of answer
SAQ 7.2 (tests Learning Outcomes 7.4
List the basic equipment you will need in order to resuscitate a newborn with
breathing difficulties.
Answer
The basic equipment you will need in order to resuscitate a newborn with breathing
difficulties are:
Two clean linen/cotton cloths: one to dry the newborn and one to wrap him or
her afterwards
Plastic bulb syringe to remove secretions from the mouth and nose, especially
when meconium is present
Ambu-bag and mask to give oxygen directly into the baby’s lungs
A person trained in neonatal resuscitation (like you)
Heat source (lamp) to provide warmth, if possible.
End of answer
SAQ 7.3 (tests Learning Outcomes 7.1, 7.2, 7.4, 7.5 and 7.6)
Which of the following statements is false? In each case say what is incorrect.
A If a newborn cries soon after birth, it is a sign of asphyxia occurring before
delivery.
B Cyanosis means being covered with meconium all over the body.
C The apical heartbeat can be detected by listening to the baby’s chest with a
stethoscope.
D Gas exchange in the lungs happens when carbon dioxide is breathed in and oxygen
is breathed out.
E Giving the newborn a Vitamin K injection is to prevent eye infections.
F The recommended ventilation rate for newborns is 40 breaths/minute.
Answer
28
A is false. If a newborn cries soon after birth, it is a sign of asphyxia occurring before
delivery.
B is false. Cyanosis means having a bluish colour to the skin because of oxygen
shortage (asphyxia).
C is true. The apical heartbeat can be detected by listening to the baby’s chest with a
stethoscope.
D is false. Gas exchange in the lungs happens when carbon dioxide is breathed out
and oxygen is breathed in.
E is false. Giving the newborn a vitamin K injection is to prevent spontaneous
bleeding; tetracycline ointment is given to prevent eye infections.
F is true. The recommended ventilation rate for newborns is 40 breaths/minute.
End of answer
SAQ 7.4 (tests Learning Outcome 7.4)
Which of the following ways of stimulating the newborn are recommended, and
which are dangerous and not allowed?
Slapping the back
Rubbing the abdomen gently up and down
Squeezing the rib cage
Forcing thighs into the abdomen
Flicking the underside of the baby’s foot with your fingers
Dilating the anal sphincter
Hot or cold compresses or baths
Shaking the umbilical cord.
Answer
Only two of the ways in the list are recommended for gentle tactile stimulation of the
baby:
Rubbing the abdomen gently up and down
Flicking the underside of the baby’s foot with your fingers.
All the other ways listed are dangerous and should not happen.
29
End of answer
SAQ 7.5
Table 7.1 summarises some common health risks to newborns and the immediate
essential care to prevent those complications. Some of the boxes have been left blank
for you to complete.
Table 7.1 for use with SAQ 7.5
Newborn health risk Essential newborn care
Eye infection
Spontaneous bleeding
Hypothermia
Hypoglycaemia
Answer
The completed Table 7.1 is below.
Table 7.1 Completed
Newborn health risk Essential newborn care
Eye infection Apply tetracycline eye ointment
Inject 1 mg vitamin K
Spontaneous bleeding
intramuscularly
Skin-to-skin contact with mother, blankets and
Hypothermia
cap
Early breastfeeding or adequate replacement
Hypoglycaemia
feeding
End of answer
30
