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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 2 - Symptoms


Immediate newborn conditions or problems

PROBLEMS

  • The newborn has serious conditions or problems:

- not breathing or is gasping;

- breathing with difficulty (less than 30 or more than 60 breaths per minute, indrawing of the chest or grunting);

- cyanosis (blueness);

- preterm or very low birth weight (less than 32 weeks gestation or less than 1 500 g);

- lethargy;

- hypothermia;

- convulsions.

  • The newborn has other conditions or problems that require attention in the delivery room:

- low birth weight (1 500–2 500 g);

- possible bacterial infection in an apparently normal newborn whose mother had prelabour or prolonged rupture of membranes;

- possible congenital syphilis in newborn whose mother has a positive serologic test for syphilis or is symptomatic.

IMMEDIATE MANAGEMENT

Three situations require immediate management: no breathing (or gasping, below), cyanosis (blueness) or breathing with difficulty.

 

NO BREATHING OR GASPING

GENERAL MANAGEMENT

 

RESUSCITATION

Box S-8    

Resuscitation equipment 

To avoid delays during an emergency situation, it is vital to ensure that equipment is in good condition before resuscitation is needed:

  • Have the appropriate size masks available according to the expected size of the baby (size 1 for a normal weight newborn and size 0 for a small newborn).

  • Block the mask by making a tight seal with the palm of your hand and squeeze the bag:

- If you feel pressure against your hand, the bag is generating adequate pressure;

- If the bag reinflates when you release the grip, the bag is functioning properly.

 

OPENING THE AIRWAY

  • Position the newborn (Fig S-28):

- Place the baby on its back;

- Position the head in a slightly extended position to open the airway; 

- Keep the baby wrapped or covered, except for the face and upper chest.

Figure S-28

 Correct position of the head for ventilation; note that the neck is less extended than in adults

 

 

 

  • Clear the airway by suctioning first the mouth and then the nostrils. If blood or meconium is in the baby’s mouth or nose, suction immediately to prevent aspiration.

Note: Do not suction deep in the throat as this may cause the baby’s heart to slow or the baby may stop breathing.

  • Reassess the baby:

- If the newborn starts crying or breathing, no further immediate action is needed. Proceed with initial care of the newborn;

- If the baby is still not breathing, start ventilating (see below).

VENTILATING THE NEWBORN

 

  • Recheck the newborn’s position. The neck should be slightly extended (Fig S-28).

  • Position the mask and check the seal (Fig S-29):

- Place the mask on the newborn’s face. It should cover the chin, mouth and nose;

- Form a seal between the mask and the face;

- Squeeze the bag with two fingers only or with the whole hand, depending on the size of the bag;

- Check the seal by ventilating twice and observing the rise of the chest.

Figure S-29

 Ventilation with bag and mask 

 

  • Once a seal is ensured and chest movement is present, ventilate the newborn. Maintain the correct rate (approximately 40 breaths per minute) and the correct pressure (observe the chest for an easy rise and fall):

- If the baby’s chest is rising, ventilation pressure is probably adequate;

- If the baby’s chest is not rising:

- Recheck and correct, if necessary, the position of the newborn (Fig S-28);

- Reposition the mask on the baby’s face to improve the seal between mask and face;

- Squeeze the bag harder to increase ventilation pressure;

- Repeat suction of mouth and nose to remove mucus, blood or meconium from the airway.

  • If the mother of the newborn received pethidine or morphine prior to delivery, consider administering naloxone after vital signs have been established (Box S-9).

  • Ventilate for 1 minute and then stop and quickly assess if the newborn is breathing spontaneously:

- If breathing is normal (30–60 breaths per minute) and there is no indrawing of the chest and no grunting for 1 minute, no further resuscitation is needed. Proceed with initial care of the newborn;

- If the newborn is not breathing, or the breathing is weak, continue ventilating until spontaneous breathing begins.

  • If the newborn starts crying, stop ventilating and continue observing breathing for 5 minutes after crying stops:

- If breathing is normal (30–60 breaths per minute) and there is no indrawing of the chest and no grunting for 1 minute, no further resuscitation is needed. Proceed with initial care of the newborn;

- If the frequency of breathing is less than 30 breaths per minute, continue ventilating;

- If there is severe indrawing of the chest, ventilate with oxygen, if available (Box S-10). Arrange to transfer the baby to the most appropriate service for the care of sick newborns.

  • If the newborn is not breathing regularly after 20 minutes of ventilation:

- Transfer the baby to the most appropriate service for the care of sick newborns;

- During the transfer, keep the newborn warm and ventilated, if necessary.

Box S-9 

Counteracting respiratory depression in the newborn caused by narcotic drugs 

If the mother received pethidine or morphine, naloxone is the antidote for counteracting respiratory depression in the newborn caused bythese drugs.

Note: Do not administer naloxone to newborns whose mothers are suspected of having recently abused narcotic drugs.

  • If there are signs of respiratory depression, begin resuscitation immediately:

- After vital signs have been established, give naloxone 0.1 mg/kg body weight IV to the newborn;

- Naloxone may be given IM after successful resuscitation if the infant has adequate peripheral circulation. Repeated doses may be required to prevent recurrent respiratory depression.

  • If there are no signs of respiratory depression, but pethidine or morphine was given within 4 hours of delivery, observe the baby
    expectantly for signs of respiratory depression and treat as above if they occur. 

 

CARE AFTER SUCCESSFUL RESUSCITATION

  • Prevent heat loss:

- Place the baby skin-to-skin on the mother’s chest and cover the baby’s body and head;

- Alternatively, place the baby under a radiant heater.

  • Examine the newborn and count the number of breaths per minute:

- If the baby is cyanotic (bluish) or is having difficulty breathing (less than 30 or more than 60 breaths per minute, indrawing of the chest or grunting), give oxygen by nasal catheter or prongs (below).

  • Measure the baby’s axillary temperature:

- If the temperature is 36�C or more, keep the baby skin-to-skin on the mother’s chest and encourage breastfeeding;

- If the temperature is less than 36�C, rewarm the baby.

  • Encourage the mother to begin breastfeeding. A newborn that required resuscitation is at higher risk of developing hypoglycaemia:

- If suckling is good, the newborn is recovering well;

- If suckling is not good, transfer the baby to the appropriate service for the care of sick newborns.

  • Ensure frequent monitoring of the newborn during the next 24 hours. If signs of breathing difficulties recur, arrange to transfer the baby to the most appropriate service for the
    care of sick newborns.

 

CYANOSIS OR BREATHING DIFFICULTY

  • If the baby is cyanotic (bluish) or is having difficulty breathing (less than 30 or more than 60 breaths per minute, indrawing of the chest or grunting) give oxygen by nasal catheter or prongs:

- Suction the mouth and nose to ensure the airways are clear;

- Give oxygen at 0.5 L per minute by nasal catheter or nasal prongs (Box S-10);

- Transfer the baby to the appropriate service for the care of sick newborns.

  • Ensure that the baby is kept warm. Wrap the baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss.

Box S-10

 Use of oxygen 

When using oxygen, remember:

  • Supplemental oxygen should only be used for difficulty in breathing or cyanosis;

  • If the baby is having severe indrawing of the chest, is gasping for breath or is persistently cyanotic, increase the concentration of oxygen by nasal catheter, nasal prongs or oxygen hood.

Note: Indiscriminate use of supplemental oxygen for premature infants has been associated with the risk of blindness.

 

ASSESSMENT

Many serious conditions in newborns—bacterial infections, malformations, severe asphyxia and hyaline membrane disease due to preterm birth—present in a similar way with difficulty in breathing, lethargy and poor or no feeding.   

It is difficult to distinguish between the conditions without diagnostic methods. Nevertheless, treatment must start immediately even without a clear diagnosis of a specific cause.  Babies with any of these problems should be suspected to have a serious condition and should be transferred without delay to the appropriate service for the care of sick newborns.

 

MANAGEMENT

VERY LOW BIRTH WEIGHT OR VERY PRETERM BABY

If the baby is very small (less than 1 500 g or less than 32 weeks), severe health problems are likely and include difficulty in breathing, inability to feed, severe jaundice and infection.  The baby is susceptible to hypothermia without special thermal protection (e.g. incubator).

Very small newborns require special care. They should be transferred to the appropriate service for caring for sick and small babies as early as possible. Before and during transfer:

  • Ensure that the baby is kept warm. Wrap the baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss.

  • If maternal history indicates possible bacterial infection, give first dose of antibiotics:

- gentamicin 4 mg/kg body weight IM (or give kanamycin);

- PLUS ampicillin 100 mg/kg body weight IM (or give benzyl penicillin).

LETHARGY

  • If the baby is lethargic (low muscular tone, does not move), it is very likely that the baby has a severe illness and should be transferred to the appropriate service for the care of sick
    of newborns.

HYPOTHERMIA

Hypothermia can occur quickly in a very small baby or a baby who was resuscitated or separated from the mother. In these cases, temperature may quickly drop below 35�C. Rewarm the baby as soon as possible:

  • If the baby is very sick or is very hypothermic (axillary temperature less than 35�C):

- Use available methods to begin warming the baby (incubator, radiant heater, warm room, heated bed);

- Transfer the baby as quickly as possible to the appropriate service for the care of preterm or sick newborns;

- If the baby is cyanotic (bluish) or is having difficulty breathing (less than 30 or more than 60 breaths per minute, indrawing of the chest or grunting), give oxygen by nasal catheter or prongs (page S-146).

  • If the baby is not very sick and axillary temperature is 35�C or more:

- Ensure that the baby is kept warm. Wrap the baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss;

- Encourage the mother to begin breastfeeding as soon as the baby is ready;

- Monitor axillary temperature hourly until normal;

- Alternatively, the baby can be placed in an incubator or under a radiant heater.

CONVULSIONS

Convulsions in the first hour of life are rare. They could be caused by meningitis, encephalopathy or severe hypoglycaemia.

  • Ensure that the baby is kept warm. Wrap the baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss.

  • Transfer the baby to the appropriate service for the care of sick newborns as quickly as possible.

 

MODERATELY PRETERM OR LOW BIRTH WEIGHT BABY

Moderately preterm (33–38 weeks) or low birth weight (1 500–2 500 g) babies may start to develop problems soon after birth.

  • If the baby has no breathing difficulty and remains adequately warm while in skin-to-skin contact with the mother:

- Keep the baby with the mother;

- Encourage the mother to initiate breastfeeding within the first hour if possible.

 

PRETERM AND/OR PROLONGED RUPTURE OF MEMBRANES AND AN ASYMPTOMATIC NEWBORN

The following are suggested guidelines which may be modified according to local situations:

  • If the mother has clinical signs of bacterial infection or if membranes were ruptured for more than 18 hours before delivery even if the mother has no clinical signs of infection:

- Keep the baby with the mother and encourage her to continue breastfeeding;

- Make arrangements with the appropriate service that cares for sick newborns to take a blood culture and start the newborn on antibiotics.

  • If these conditions are not met, do not treat with antibiotics. Observe the baby for signs of infection for three days:

- Keep the baby with the mother and encourage her to continue breastfeeding;

- If signs of infection occur within 3 days, make arrangements with the appropriate service that cares for sick newborns to take a blood culture and start the newborn on antibiotics.

CONGENITAL SYPHILIS

  • If the newborn shows signs of syphilis, transfer the baby to the appropriate service for the care of sick newborns. Signs of syphilis include:

- generalized oedema;

- skin rash;

- blisters on palms or soles;

- rhinitis;

- anal condylomata;

- enlarged liver/spleen;

- paralysis of one limb;

- jaundice;

- pallor;

- spirochetes seen on darkfield examination of lesion, body fluid or cerebrospinal fluid.

  • If the mother has a positive serologic test for syphilis or is symptomatic but the newborn shows no signs of syphilis, whether or not the mother was treated, give benzathine penicillin 50 000 units/kg body weight IM as a single dose.

Top of page

 

Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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