Neonatal Care Workbook - KZN HEALTH workbo… · This workbook is intended to be a companion and...
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P ARTICIPANTS W ORKBOOK N EONATAL E XPERIENTIAL L EARNING S ITE Pietermaritzburg Metropolitan Hospitals Complex Pietermaritzburg June 2007
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Transcript of Neonatal Care Workbook - KZN HEALTH workbo… · This workbook is intended to be a companion and...
PARTIC IPANTS WORKBOOK
N E O N ATA L E X P E R I E N T I A L L E A R N I N G S I T E Pietermaritzburg Metropolitan Hospitals Complex
Pietermaritzburg June 2007
ii
iii
C O N T E N T S Introduction 1 A. Self Assessment 1. Skills audit 2 2. Your objectives 4 3. Review of your neonatal unit 5 B. Topics 1. Topic 1: Neonatal Resuscitation
• Objectives 8 • Key learning points 8 • Skills assessment 9 • Self assessment questionnaire 9 • Drug doses 11 • Case studies 12 • Report 16 • Quality improvement 16
2. Topic 2: Routine Management of Well Infants
• Objectives 18 • Skills assessment 18 • Self assessment questionnaire 19 • Case study 21 • Quality improvement 23
3. Topic 3: Managing Premature, Low Birth weight and Sick infants
• Objectives 24 • Skills assessment 25 • Self assessment questionnaire 26 • Drug doses 28 • Case studies 29 • Report 34 • Quality improvement 34
4. Topic 4: Prevention of Mother to Child Transmission of HIV
• Objectives 36 • Self assessment questionnaire 36 • Case study 38 • Report 39
C. Quality Improvement Quality improvement project 41
1
N E O N A T A L C A R E W O R K B O O K
Introduction This workbook is intended to be a companion and guide for you during your time at the neonatal learning site. It is not a text book and does not contain information; you will receive other protocols and guidelines which you can use as resources to find information that you do not know. Completing this workbook will ensure that you have covered the key learning points during your time at the learning site and your answers will provide a starting point for discussions with your supervisor. The workbook includes:
• A skills audit which you should complete at the beginning of your time at the learning site. This is a self learning tool to direct your learning and to ensure that gaps in your knowledge and skills are addressed.
• Space for you to write your objectives for the time at the learning site, so that a timetable can be planned in such a way that you can fulfil your objectives.
• A site review looking at equipment available at your neonatal unit and comparing this with the norms and standards set out by the Department of Health. You should complete this before coming to the learning site if possible. If you are lacking important equipment at your site this can be addressed, as it is not possible to provide good quality care without adequate equipment.
• Self assessment quizzes on key topics are included so that you can be sure that you have the correct factual information on key points. There are no answers provided for the self assessment quizzes, you are expected to go and look up any information that you are not sure about. You will have an opportunity to go through each quiz with your supervisor during your time at the learning site and discuss any queries or problem areas.
• A number of key practical skills that you are encouraged to practise under supervision while at the learning site and members of staff will sign these off to show that you completed these tasks.
• Case studies to be completed. These are exercises and are designed to illustrate important clinical problems that arise at district hospital level. You will be expected to look up or ask about any aspects of these cases that you are not sure about, and to discuss the case studies with your supervisor.
• Case reports that you should write up either during your time at the learning site or later at your own site. You should choose cases which illustrate interesting learning points or difficult clinical cases which show problems that may happen in the real situation. You will also discuss these cases with your supervisor.
• At the end of the workbook, there is space for you to write a report on a quality improvement project you have undertaken at your own site. This will comprise a simple analysis of a problem in providing good quality care that you have observed at your site. You will then propose solution(s) to this problem, implement the solution and monitor/evaluate the success of your solution. This quality improvement project will have to be completed before you receive a certificate of having completed a course at the learning site.
2
A. SELF ASSESSMENT 1. Skills audit
This skills audit is a tool to help you assess your essential skills. It should be seen as a baseline evaluation and help you to identify areas in which you may want to develop your skills further. It is based on the McCord DEPAM & Vocational Training & SCEPAM Programs Competency Assessment tools. PLEASE FILL IN THE LIST AS HONESTLY AS YOU CAN
0 No knowledge or skill 1 Vague knowledge 2 Good knowledge 3 Experience but need supervision/support 4 No need for supervision 5 Can do this and have taught to others
Name:…………………………………………… Date:……………………… Neonatal health 0 1 2 3 4 5
A1 Diagnose asphyxia
A2 Resuscitation of a neonate
Selective suctioning e.g. meconium
Face mask ventilation
External cardiac massage
E.T. intubation Maintain & use appropriate equipment
Control & use appropriate medications & fluids
A3 Initial assessment
Examination
Gestational age (SPLEN/Ballard)
Check for congenital abnormalities
A4 Manage nutritional and fluid requirements
Breastfeeding
Artificial e.g. formula
Nasogastric tube feeding
Cup feeding
Putting up peripheral IV infusion on neonates
Umbilical vein catheterisation Monitoring of fluid intake and IV site
Use fluid controller
Give additives to feeds/fluids
Monitoring and maintenance of glucose Calculation of feeds and fluids for neonates
3
Neonatal health cont. 0 1 2 3 4 5
A5 Promote neonatal bonding in well and sick neonates
Developmental care
Kangaroo mother care (KMC)
A6 Promote thermo neutral state and homeostasis
Brown fat metabolism
Heat loss
A7 Identify and manage neonatal problems
Premature infant
Growth retarded neonate
Respiratory distress, HMD & apnoea
Hypoxic Ischaemic Encephalopathy (HIE)
Convulsions
Jaundice & phototherapy
Anaemia
Hypoglycaemia
Hyperglycaemia
Hypothermia
Hypoxaemia
Acidosis
Bleeding
Trauma
Septicaemia & other severe neonatal infections
Neonatal tetanus
Meningitis in the neonate
GIT abnormalities
Cardiac abnormalities
HIV positive infants
Pneumonia
A8 Transportation of a sick neonate
Kangaroo mother care
Transport incubator
Stabilisation
Notes and communication
4
2. Your objectives Write below any skills or knowledge that you feel are gaps in your competence and that you want to develop while you are learning about neonatal care. You should discuss this list with your supervisor and make sure that all the gaps in your knowledge or skills are addressed while you are at the learning site, if possible. 1) ____________________________________________________________________________________ 2) ____________________________________________________________________________________ 3) ____________________________________________________________________________________ 4) ____________________________________________________________________________________ 5) ____________________________________________________________________________________ 6) ____________________________________________________________________________________ 7) ____________________________________________________________________________________ 8) ____________________________________________________________________________________
5
3. Review of your neonatal unit In this section you should review the facilities and equipment that are available in the neonatal unit at your hospital. You should compare this with the norms and standards that are set out by the KZN Department of Health to see if you have the correct number of beds and quantity of equipment available to provide an appropriate quality of care. The norms and standards set out below are for a district (level one) hospital.
Beds No. of deliveries in catchment area____________(include clinic deliveries)
Item Norm set out Number that
should be present
Actual number available
Number required
Total beds 3 per 1000 deliveries
High care beds 1 per 1000 deliveries
General beds 1 per 1000 deliveries
KMC 1 per 1000 deliveries
The following general equipment should be available in the neonatal unit: Check that the equipment is in working order before recording it
Item Norm set out Number that
should be present
Actual number available
Number required for
nursery Double O2 flow meter 1 per O2 point
Suction unit 1 per point
Pulse oxymeter 1 per nursery 1
Bassinette 1 per bed
Cardiac trolley 1 per nursery 1 Electronic infant scale 1 per nursery 1
Stethoscope 2 per nursery 2
Diagnostic set 1 per nursery 1
Patella hammer 1 per nursery 1
Glucometer 2 per nursery 2
Haemoglobinometer 1 per nursery 1
Calculator 1 per nursery 1
Portable O2 2 per nursery 2
Portable suction 1 per nursery 1 Angled phototherapy lights 1 per 3 beds
Head box 1 per O2 point
6
Item Norm set out Number that
should be present
Actual number available
Number required for
nursery
Oxycheck 1 per 2 head boxes
Heating pad 2 per nursery 2
Breast pump 2 per nursery 2
Spot light 2 per nursery 2
Resuscitaire 1 per nursery 1
Resuscitation set: Laryngoscope handles – neonatal
2 per nursery 2
Blades – straight size 0 1 per nursery 1
Blades – straight size 1 1 per nursery 1
Small Macgills forceps 1 per nursery 1
Ambubag – infant (neonatal masks)
1 per nursery 1
Bilirubinometer 1 per nursery 1 X-ray viewing box 1 per nursery 1
In addition the following equipment should be available for each high care bed: Check that equipment is in working order
Allocated number per high care bed
Norm (x no of high care beds)
Actual number available
Number required for high care
Double O2 flow meter 1
O2 blender 1
Suction unit 1 Closed incubator 1 per 2 beds
ICU crib 1 per 2 beds
Pulse oxymeter 1
Infusion pumps 1
Drip stand 1
Syringe pump 1
Dinamap 1 per 5 beds
Apnoea alarm 1
Head box 1
Ambubag 1
Stethoscopes 1
Heat shield 1
7
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B. CLINICAL NEONATAL TOPICS
1. Neonatal resuscitation 1) Objectives On completion of this topic you should have the knowledge and skills to complete the following tasks:
Selecting and checking equipment for resuscitation
Assessing condition of the baby at delivery and monitoring progress during the resuscitation
Management of meconium stained liquor during resuscitation
Bag and mask ventilation
Cardiac compressions
Intubation (optional)
Insertion of an umbilical venous line (optional)
Appropriate administration of naloxone
Appropriate administration of adrenaline
Decide when to stop resuscitation
Describe situations when it may be inappropriate to initiate resuscitation
2) Key learning points for neonatal resuscitation
Resuscitation requires a team approach. Do not attempt to resuscitate on your own - call for help. Even a mother can be of assistance.
It is important that the baby is kept warm on a resuscitaire or incubator during resuscitation.
Dry and stimulate the baby by rubbing his back, chest or feet. This is often all the baby needs in order to start breathing. However if baby is in secondary apnoea he will require active resuscitation.
Routine suctioning is never indicated. It is required where there is exposure to and the risk of aspiration of blood, meconium and faeces. In these instances it is best to suction under direct vision, using a laryngoscope to visualize the vocal cords using a soft catheter (F8 or F10) which should not be inserted more than 5cm beyond the mouth or nose.
The most important thing during resuscitation is to maintain oxygenation and this can be done with a bag and mask in most cases. Intubation should only be done by staff who are well trained and competent
Erect IV therapy as soon as possible in order to administer fluids, glucose and resuscitation meds.
A delivery room should have a variety of face masks for preterm, term and large newborns (i.e. sizes 00, 0, 1 and 2) and appropriate size ET tubes (i.e. 2.5, 3.0, 3.5) and laryngoscope blades (i.e. sizes 00, 0 and 1)
A Laerdal Ambubag is designed to deliver high concentrations of oxygen but should be checked before use to make sure that it is functioning properly
All equipment should be checked before the baby is delivered, it is too late to look for missing equipment once the baby is born and delays in starting resuscitation can result in long term complications for the baby.
9
3) Resuscitations skills assessment You are expected to practise the following skills during the time that you are at the learning site. The first six activities will be done on a manikin, so you will need to make a time with your supervisor when these can be done. Once you have completed these tasks adequately, ask your supervisor to sign. Other activities should be completed if you have the opportunity while you are at the learning site to participate in a resuscitation situation. Ask the senior member of staff present to sign these for you. If he/she decides you completed the task competently you will receive two signatures. Otherwise you should try and practise the task again until the supervisor can sign in the box for competency.
Completed (Signature) Comments for learner
Completed competently(Signature)
Checking equipment Bag and mask practice on manikin Intubation practice on manikin Simulated resuscitation scenario 1 with manikin
Simulated resuscitation scenario 2 with manikin
Synchronised breaths and cardiac compressions
Immediate routine care of a newborn following delivery
Suction of a baby where there is meconium at the delivery
Bag and mask ventilation on baby Assessment of heart rate and respiration
Participated in resuscitation situation
Calculation and administration of resuscitation meds
Intubation of a baby (optional) 4) Self assessment resuscitation questionnaire 1) Give the three important things that you should check at delivery to decide whether
resuscitation is required. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) How can you check the heart rate in a newborn?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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3) When suctioning a newborn should you start with the nose or the mouth? Why? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) In what circumstances might you decide not to start resuscitation of a newborn?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) If a baby is breathing, but you want to administer oxygen, how could you do this?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) When you are ventilating a baby with a bag and mask, what signs will show you that
your ventilation is adequate? If it not adequate, what should you do? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) In what circumstances would you decide to intubate a baby?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) If a baby is not responding to bag and mask ventilation and the heart rate remains
below 60 - describe exactly how much adrenaline you would give and how this should be given. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) How much naloxone (Narcan®) should you give if the mother of a term baby weighing
approximately 3 kg was given pethidine 4 hours before delivery? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) Describe the difference between primary and secondary apnoea? How can you tell the
difference when you assess a newborn at the time of delivery? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11
11) What are the dangers of suctioning a newborn and how can these be avoided? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12) When should a volume expander be given? How much should be given, what fluid
and over how long? How often can they be repeated? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
13) What size ET tube should you choose for a 1.2 kg baby and at what level should it be
strapped? ___________________________________________________________________________________
____________________________________________________________________
____________________________________________________________________
14) When should you commence chest compressions and when should you stop?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
15) At what point should CPR be discontinued?
a) If successful b) If unsuccessful ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) Calculating drug doses for resuscitation 1) What is the dose of adrenaline for a 2 kg baby? Describe how adrenaline is prepared
and how it may be administered. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) What is the dose of naloxone to be given to a baby who is 2 kg (give dose in mg and
in mls). Describe how this should be administered? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12
3) What would be the dose of naloxone if the baby weighed 3.5 kg? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) How much Ringers Lactate should you give a 3 kg baby with poor perfusion and a low
blood pressure? What other fluid could you give? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) Neonatal resuscitation - Case Studies a. Case Study 1: Thobile Thobile, 24 year-old, presents to the labour ward in the evening, with a history of contractions for the whole day. It is her first baby and she tells you that the baby is not due for another 3 months. When you look at the antenatal card she is 30 weeks gestation by dates, and on examination she is also 30 weeks by palpation. On PV examination the cervix is fully dilated, the foetal heart is 120 and reactive, there is no meconium staining of the liquor. 1) Describe how you would prepare the resuscitation trolley - what equipment is needed?
Is there anything particular that you would need to have available when you are expecting the delivery of a low birth weight baby? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) What type of ambubag should be used for resuscitation? Describe what actions are
needed to appropriately check that the ambubag is in good working order. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) You also see in the antenatal card that she has been tested for HIV, is HIV positive
and enrolled in the PMTCT program. She has not taken her nevirapine. What can you do now to try to reduce transmission of HIV to the baby? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
13
4) You take the baby at delivery and transfer to the resuscitaire. Describe how you would quickly assess the condition of the baby. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________________________________________________
5) On your initial assessment the baby is small, you estimate about 1.5 kg, he is pale and
limp but making some gasping respirations. His hands and feet, as well as the tongue, are blue. The heart rate is below 100. He is not responding to stimulation. What is the Apgar score? ________________________________________________________
6) Describe your initial actions in this situation.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) After drying and initial stimulation the baby starts moving and has a heart rate above
100, but is still not breathing regularly. What will you do next? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) The baby is now 3 minutes old and is breathing regularly, is active and crying. He is
pink and the heart rate is above 120. What is the Apgar score now? _________________________________________________________
9) Give three things that should be monitored in this baby to prevent complications?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) Write this case up as if you were completing the case notes.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
14
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________________________
b. Case Study 2: Busi
Busi is 18 years old and presents to the labour ward at term with a history of regular contractions. This is her first baby and she has had an uneventful pregnancy but only attended the antenatal clinic twice. As you are about to examine her she says that she wants to push and you find that she is fully dilated and the head is on the perineum. There is grade 1 meconium staining of the liquor and listening to the foetal heart you find that the foetal heart rate is below 100. Twenty minutes later she delivers a term baby weighing 2.5 kg who is “flat” at delivery.
1) What will be your initial management?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) What is the management of the meconium stained liquor in this situation?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) The baby is floppy, not responding to stimulation, there is central cyanosis and the
baby is making no respiratory effort. The heart rate is 60. What are the next steps in the resuscitation? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) After 30 seconds of resuscitation the heart rate remains 60 and the baby is still making
no respiratory effort. What will you do now? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) After a further 30 seconds with no improvement you decide to intubate the baby.
What size ET tube would you choose for this baby? ______________________________________________________
15
6) Which ways could you use to check whether the tube is in the correct place? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) What drugs will you give if any? Mention the dose and method of administration of the
drug(s). ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) At 20 minutes of age the baby still has a bradycardia and apart from a few gasps has
made no respiratory effort, he remains limp and unresponsive. How will you manage this situation now? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) Is this baby suitable for transfer to a referral centre? If so describe how you would
prepare him for transfer. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) What are the possible reasons for this baby’s condition?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Write this case up as if you were completing the notes.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________________________
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7) Report on resuscitation
Describe resuscitation that you were involved in, either at the training site or at your own neonatal unit. Describe step-by-step the initial assessment of the baby, the actions that were taken and the progress and outcomes of the resuscitation. Describe problems that were encountered by the resuscitation team during the resuscitation and how these were overcome. Is there anything that could have been done differently that would have made the resuscitation go more smoothly?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) Quality improvement During the completion of the topic on neonatal resuscitation you may have noticed that some points are not being routinely implemented at your site. For example you may not have appropriate bags and masks for ventilating babies effectively or appropriate equipment for resuscitating preterm babies. Note below any actions that should be taken at your site to improve neonatal resuscitation.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
17
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2. Routine care of well infants 1) Objectives On completion of this topic you should have the knowledge and skills to complete the following tasks:
Assessment and examination of the newborn
Identification of common congenital abnormalities
Give routine care to a healthy infant
Promote bonding
Observe for signs of abnormality
Understand and implement the principles of the Baby Friendly Hospital initiative
Establish breast feeding
Advise the mother about care of a normal infant and the importance of the road -to-health chart
2) Skills assessment You are expected to practise the following skills during the time that you are at the learning site. Once you have completed these tasks adequately ask your supervisor to sign. If he/she decides you completed the task competently you will receive two signatures. Otherwise you should try and practise the task again until the supervisor can sign in the box for competency.
Completed (Signature) Comments for learner
Completed competently (Signature)
1st examination Bathing a newborn Latching at breast Advise mother on common breast feeding problems
Cord care
Give immunisations and complete road-to-health card
Maintain warmth Discharge advice
19
3) Self assessment newborn care questionnaire 1) What are the normal temperature, respiration, heart beat and glucose ranges for
newborns? ____________________________________________________________________
____________________________________________________________________
2) Describe how you would manage secretions in a well newborn without meconium
staining. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) Describe routine treatments that should be given to the baby in the delivery room.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) What routine observations should be completed in the delivery room?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) Describe how breastfeeding should be initiated. At what age should the baby start to
breastfeed? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) If a baby is not latching well in the first 24 hours, or there is little breast milk in the first
24 hours, what would your management be? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) Which risk factors should you check for in a newborn before transferring to the post
natal ward? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
20
8) Which babies should be transferred to the neonatal unit after delivery? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) Describe routine treatments/care that should be given to the baby before being
discharged home? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) What is the normal weight range for a term baby?
____________________________________________________________________
11) What care should you give a normal infant immediately after delivery?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12) When should an infant receive its first bath?
____________________________________________________________________
____________________________________________________________________
13) Should an infant sleep in its mother’s bed?
____________________________________________________________________
____________________________________________________________________
14) When should a well newborn first be put to the breast and how frequently?
____________________________________________________________________
____________________________________________________________________
15) What are the signs of jaundice and what advice would you give the mother with regard
to jaundice if she is discharged on day 1? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
16) If a baby becomes jaundiced on day 1 what is the most likely cause and what should
your management be? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
21
17) What should you look for in the baby if there is a history of polyhydramnios in the pregnancy? What conditions can be associated with this history? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
18) What are the features of Down’s syndrome?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) Routine care of normal infants - Case Study a. Case Study: A term 3200 g baby is delivered by vertex delivery to an unbooked mother. Apgars: 9/10 and 9/10. The labour ward staff report that the liquor smelt offensive. 1) What would your immediate management be?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) Should the vernix be washed off immediately after delivery?
____________________________________________________________________
____________________________________________________________________
3) Should the infant stay with the mother after delivery (room-in)?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) What cord care should the baby receive?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) The mother breast feeds the infant for three days and the infant now weighs 3000 g
Is the infant’s weight loss normal? ____________________________________________________________________
____________________________________________________________________
22
6) Should the mother be advised to give complimentary feeds? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) How can this mother increase her milk supply?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) By day 3 the infant’s eyes are swollen with a purulent discharge.
What is the probable cause of the conjunctivitis? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) Is the conjunctivitis mild, moderate or severe? Give your reason.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) What treatment would you institute?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11) What advice would you give this mother on discharge and when should she visit the
Well Baby clinic? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
23
5) Quality improvement During the completion of the topic on newborn care you may have noticed that some points are not being routinely implemented at your site. For example you may not practise rooming-in or the babies may be bathed shortly after delivery. Note below any actions that should be taken at your site to improve routine care of the well infant.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
______________________________________________________
24
3. Managing premature, low birth weight and sick babies 1) Objectives On completion of this topic you should have the knowledge and skills to perform the following:
Define prematurity, low birth weight (LBW), very low birth weight (VLBW) and
underweight for gestational age
Manage premature and sick babies including feeding, monitoring, apnoea,
anaemia and prevention of complications
Perform a gestational assessment
Identify and manage respiratory distress
Identification and immediate management of neonatal seizures
Management of neonatal sepsis
Management of neonatal jaundice
Recognise and provide immediate care of common neonatal
conditions/complications
Calculate fluid and feeding regimens for the above babies
Erect IV therapy
Prevention and management of hypothermia
Prevention and management of hypoglycaemia
Initiate and support kangaroo mother care appropriately
Provide developmentally supportive care
Stabilise a baby for and organise inter-hospital transfer
25
2) Skills assessment You are expected to practice the following skills during the time that you are at the learning site. Once you have completed these tasks adequately ask your supervisor to sign.
Completed (Signature)
Comments for learner
Completed competently (Signature)
Admitting a low birth weight baby to the neonatal unit
Performing an initial examination
Checking TSB and making appropriate management decision
Commencing and managing phototherapy
Implementing appropriate infection control measures
Checking blood glucose and making appropriate management decision
Managing a baby with hypoglycaemia
Initiating IV therapy Calculating and administering antibiotic doses for a baby
Calculating fluid/feed regimen for a LBW baby
Passing a nasogastric tube and administering of feed
Initiating oxygen therapy appropriately
Doing a lumbar puncture on a baby (doctors)
Helping a mother initiate kangaroo mother care
Preventing and managing hypothermia
Giving developmental care Using a saturation monitor Suctioning naso-oropharynx Taking blood for lab tests Assessing neonatal x-rays Terminal disinfection of incubators
Commencement and management of nasal CPAP
Perform a Ballard assessment Identify and manage respiratory distress
Identify and manage neonatal seizures
26
3) Self assessment questionnaire
1) Define what is meant by low birth weight. Which LBW babies should be admitted to the neonatal unit? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) Define what is meant by pre-term. How can you tell the difference between a low birth
weight infant born at term and a pre-term infant, and why is it important? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) What congenital infections are included in the STORCH acronym?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) What are signs of respiratory distress in a neonate?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) Give four complications that are common in LBW babies in the first 24 hours of life.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) Should all low birth weight infants be kept nil by mouth for 24 hours? If not, which
babies should be given IV fluids? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) Define what is meant by hypoglycaemia?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) Describe what is meant by apnoea and how it can be prevented? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
27
9) Describe the different signs that might indicate seizures in a neonate? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) When should a LBW baby be routinely bathed?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11) How can you determine whether a baby on oxygen is getting enough oxygen? Can
you give too much oxygen and if so, how do you determine it? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12) What is the best method of giving oxygen to a low birth weight baby with severe
respiratory distress? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
13) Describe the management of a 2 kg baby who has mild hypoglycaemia (blood sugar
1.8mmol) at 24 hours of age ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
14) Give three features that would lead you to suspect sepsis in a premature baby who is
in the neonatal unit. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
15) What investigations should be done if sepsis is suspected in an infant (septic screen)?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
16) At what level of TSB (total serum bilirubin) would you give phototherapy to a baby with
jaundice born at 35 weeks, who is now 48 hours old? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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17) At what level of TSB would an exchange transfusion be indicated in a baby aged 24 hours who weighed 1.8 kg at birth? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
18) List the three principles of positioning for developmental care.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
19) What is the best position in which to nurse a premature baby in order to decrease
apnoea, increase saturations and decrease the risk of aspiration? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
20) What condition should you suspect in a baby who was very frothy at birth, continues to
have lots of secretions and desaturates (condition deteriorates) after feeds? What would be your immediate management for this baby? What would you look for on a chest x-ray? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) Calculating doses for low birth weight babies 1) Calculate the fluid requirements for the first 24 hours in a baby who weighs 1.4 kg
(give amount over 24 hours, as well as hourly rate). What fluids should be given and how would you control the fluids? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) What are the fluid requirements on day 2 for this baby and how should they be given?
(give amount over 24 hours, as well as hourly rate) ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) How much fluids should be given to a baby on day 3, who weighed 1.1 kg at birth? The baby now weighs 1.0 kg (give amount over 24 hours, as well as hourly rate). ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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4) A newborn baby born at 35 weeks gestation and weighing 1.6 kg requires treatment with antibiotics as there was prolonged rupture of membranes before delivery. Give the dose and regimen for benzyl penicillin and gentamicin. How would you prepare and administer the antibiotics? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) This baby also needs to be given nevirapine as the mother was enrolled on the
PMTCT program. What dose of nevirapine would you give? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) The baby also needs theophylline/neulin/caffeine to prevent apnoea. What dose
would you give and how would you administer it? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) A baby weighing 2.2 kg is having a convulsion. What is the anticonvulsant that you
would give and what dose? How would you administer this? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) Management of LBW and VLBW babies – Case Studies
a. Case Study 1:
A 1.9 kg baby is delivered by NVD at 34 weeks. The baby is well with an Apgar score of 7 at 1 minute and 10 at 5 minutes. Soon after this baby was born there is an emergency in the delivery room and he is left on the resuscitaire. When you come back to take him to the neonatal unit you find that he is wrapped in a wet towel and he seems quite cold.
1) What clinical features could suggest hypothermia?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) His axillary temperature is 35.5°C. What would your management be?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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3) What should the incubator temperature be in this situation? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) He recovers quickly and his temperature returns to normal. He is being nursed in an
incubator and is pink and active. When should feeding start? What will you feed him and how? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) How much feed does the baby need and how often should he be fed?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) When would he be able to go to his mother for kangaroo mother care?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) Should this baby be given BCG and Polio? If so, when?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) When can he be discharged?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
b. Case Study 2:
A 1200 g baby is delivered at 29 weeks gestation. He requires resuscitation with a bag and mask at delivery but has established regular respirations at 10 minutes of age with Apgars of 6 at 1 minute, 8 at 5 minutes and 9 at 10 minutes. He is quickly transferred to the neonatal unit.
1) If you are receiving this baby, what will you do initially?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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2) What should be the temperature in the incubator? ____________________________________________________________________
____________________________________________________________________
3) What should this baby wear in the incubator?
____________________________________________________________________
____________________________________________________________________
4) When you check the oxygen saturation you find that the saturation varies between 80-
85% although the baby appears well, active and pink. Would you give this baby oxygen? If so, how? How much oxygen should you give and how will you monitor this? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) How would you feed this baby for the first 24 hours? What are the fluid requirements?
(give mls/kg and total mls required for this baby). ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) What medications should be started routinely for this baby?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) At six hours of age the baby seems jittery and the blood sugar is 1.4 mmol. What
would be your management? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) Should this baby’s condition continue to deteriorate, how would you prepare for
transfer and what documentation would you include? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) The baby is now 2 weeks old and the weight is 1.5 kg. He no longer requires oxygen
and is being fed with expressed breast milk via NGT. How much feed does he require? How frequently should he be fed? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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10) When can transfer to continuous kangaroo mother care be considered? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11) Describe how you would start kangaroo mother care?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12) Once on kangaroo mother care, what monitoring is required?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Case Study 3:
A low birth weight infant is born at term and weighs 1.8 kg. The baby does well over the first 24 hours and is maintaining oxygen saturations of over 90% in air. On the second day of life the baby seems less vigorous and now needs head box oxygen to maintain saturations over 80%. There is nasal flaring and mild recession.
1) What could be the cause of this change in the baby’s condition?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) What investigations would you do?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) What would be your initial management?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) The mother is admitted on the ward with high fevers and is on intravenous antibiotics.
The membranes ruptured at home more than 24 hours before delivery so you suspect sepsis in this baby. What antibiotics would you start? Give the doses per kg for this baby. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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5) The CSF result shows a white cell count of 21. What does this mean and how will it affect your management? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) How much fluid should be given to this baby on day 2? (give mls/kg and total amount
for this baby) ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) The next day the baby is doing well (day 3) but is noticeably jaundiced.
What would your initial management be? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8) The TSB is 200. What would be your management now and what further
investigations should be done? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) Describe how a baby should be safely nursed under phototherapy.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) When should the TSB be repeated?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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6) Report on low birth weight baby Write a report on a low birth weight baby where you have been involved in the care. This could be at the learning site or at your own neonatal unit. Try to choose a case that shows some of the common problems that you deal with at your site and how these were managed. Describe the history from the time of delivery, the initial management of the baby and ongoing care. Describe any complications that arose and how these were managed.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
7) Quality improvement for management of premature babies During the completion of the topic on management of premature babies you may have noticed that some points are not being routinely implemented at your site. Note below any actions that should be taken at your site to improve management of low birth weight babies
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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36
4. Prevention of Mother to Child Transmission of HIV (PMTCT) 1) Objectives On completion of this topic you should have the following knowledge and skills to undertake the following:
Identify an infant on the PMTCT program
Arrange late enrolment in the PMTCT program
Reduce the risk of mother to child transmission during routine delivery by
using safe delivery practices
Reduce the risk of mother to child transmission by appropriate administration
of anti-retroviral drugs
Aadvise the mother about her feeding choice
Support the mother in her feeding choice
Arrange appropriate follow-up for the infant of an HIV-infected mother
2) Self assessment questionnaire
1) If an HIV-infected mother does not know her status and so does nothing to prevent HIV transmission to her baby, but she does not breastfeed - what is the chance that the baby will become infected? ____________________________________________________________________
____________________________________________________________________
2) If she breastfeeds for 2 years, what is the chance that the baby will be infected?
____________________________________________________________________
____________________________________________________________________
3) An HIV-infected mother gets tested during her pregnancy and finds that she is HIV
positive. She takes nevirapine and does not breastfeed her baby - what is the chance that this baby will become infected? ____________________________________________________________________
____________________________________________________________________
4) What can you do during the delivery of the baby of an HIV-infected mother, or a
mother who does not know her status, to reduce the chance of transmission? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) When should the mother take nevirapine? ____________________________________________________________________
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6) A 1.8 kg baby is admitted to the neonatal unit, the mother is HIV positive and has taken nevirapine 3 hours before delivery. What dose of nevirapine should be given to the baby and when should it be given? ____________________________________________________________________
____________________________________________________________________
7) A baby of an HIV-infected mother is admitted to the neonatal unit. The baby was born
at term and weighs 3.2 kg. The mother did take her nevirapine when she started having contractions but the contractions stopped and the baby was only born 4 days later. What dose of nevirapine should be given to the baby and when should it be given? ____________________________________________________________________
____________________________________________________________________
8) Define what is meant by exclusive breastfeeding.
____________________________________________________________________
____________________________________________________________________
9) Describe the different types of HIV tests that could be used to determine whether a
baby born to an HIV-infected mother is infected. When should these tests be done? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) An HIV-infected mother has chosen to breastfeed her baby. The baby is tested at 6
weeks with a PCR test and the test is negative. What does this mean? Does the baby need another test and if so, when should this be done? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
11) An HIV-infected mother does not breastfeed. The baby is tested at 3 months with a
rapid test. What does this mean? Does the baby need another test and if so when should this be done? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12) Give reasons why it is important for the infant of an HIV-infected mother to attend
regular follow-up. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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3) Prevention of Mother to Child Transmission – Case study a. Case 1: Ntombi 1) Ntombi is 18 years old. She comes into the labour ward at term and in early labour.
How can you find out whether she is on the PMTCT program? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) She says that she did have an HIV test but she was too frightened to go back for the
result. Now she is worried because her boyfriend has been very sick and if she is HIV positive she wants her baby to get nevirapine. Can you test her for HIV during her labour? Explain your answer. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) The baby is delivered and is admitted to the neonatal unit with low Apgars. The
counsellor comes to see Ntombi the next morning and the HIV test is positive. The baby is now 24 hours old. Describe what can be done to reduce transmission to this baby. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) Ntombi is distressed after her post-test counselling and still very unsure about how to
feed her baby. Give three questions that you could ask in order to decide what might be the best feeding choice for Ntombi and her baby. ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
5) The baby is doing well and Ntombi has decided to breastfeed. What advice can you
give her to help her to breastfeed safely? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6) When should she stop breastfeeding?
____________________________________________________________________
____________________________________________________________________
7) When should Ntombi bring her baby back for follow-up?
____________________________________________________________________
____________________________________________________________________
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8) Just as the baby was about to be discharged, he developed respiratory distress. What could the cause of this be? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9) When should routine cotrimoxazole prophylaxis be started?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
10) The baby has a PCR test at 6 weeks and the test is positive. What does this mean?
The baby is still being breastfed. Should the test be repeated if so, when? ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
4) Report on PMTCT Write up the case for a baby that was admitted to the neonatal unit, either at the learning site or at your own facility, where the mother was enrolled in the PMTCT program. Describe whether all safe obstetric practices were observed during the delivery and how and when the nevirapine was given. Mention the plan for ongoing management of this infant.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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C. QUALITY IMPROVEMENT PROJECT
Identify and analyse problems
Define aims Measure outcomes
Plan solutions The aim of using a quality improvement approach is to provide a framework for you to look critically at the service you are providing in your unit. The quality improvement cycle guides you through a process of deciding if good standards of care are being achieved and if not what the reason is for this. Having determined where the failings are, you can then analyse the reasons for these gaps in the provision of good quality care, decide what you are aiming for and make a plan for improvements. You first need to identify a problem with your service. This may be something that you have observed while at the learning site that you realise is not being done optimally at your site. Look carefully at the current situation and decide the reason for this poor quality. You need then to set out an adequate standard of care that you would aim for and plan a solution that would allow you to achieve this in a given time frame. At the end of the time frame you should look at the situation again in order to evaluate whether your plan was successful. This should be an ongoing process in your service whereby you look critically at the care being rendered and look for ways to improve this. You are expected to undertake a simple quality improvement project in your neonatal unit and describe this on the following pages. An example might be that you observe that hypothermia is a common problem among infants being admitted to the neonatal unit. The first step is to define the problem and record how many infants were admitted with hypothermia over a particular time period. Then analyse the possible reasons for this, which may involve talking to labour ward staff or staff in the neonatal unit to find out the circumstances that lead to the infants developing hypothermia. You may find that infants of mothers having a caesarean section are being kept on the resuscitaire in the air conditioned theatre for long periods of time. The solution may be to agree with management that infants should be taken immediately to the nursery after delivery, where it is warm, and be given to the mother when she returns to the postnatal ward. Some training of staff in this new policy will be required and nursery staff should also agree. In order to evaluate the plan and to see if the solution has been effective you should review the number of admissions with hypothermia for a period some time after the policy has been implemented to see if there is an improvement. If not, then look for the reasons why the problem remains.
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The following headings might assist you in formulating your program: Define aims
1) Plan your program 2) Establish a standard 3) Communicate the standard to all involved parties
Identify and analyse problems 1) Assess or evaluate current practice (using a checklist / tool) 2) Define and prioritise problems (using gap between desired and actual performance) 3) Identify team (teamwork is vital - involve all key role-players e.g. infection control or
management) 4) Analyze the problem (using a cause and effect chart/ flowchart) Plan solutions 1) Choose a solution 2) Implement this solution (using an action plan with time frames) Measure outcomes
1) Re-evaluate
