Helping Babies Breathe - Facilitator Flip Chart
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Helping Babies Breathe
Facilitator Flip Chart
© American Academy of Pediatrics, 2010
HBB Flipchart 20-00371 rev C.indd 1 19.03.12 08.47Start with a story Practice with the Action Plan Check yourself (page 7)
Before showing any flip charts, have each Ask learners to practice Review with learners their answers
learner place one hand on the simulator • Identifying a helper and reviewing to the Check yourself questions in
or mannequin. the emergency plan the Learner Workbook.
Say to the learners, “Close your eyes and imagine that a • Preparing the area for delivery
baby is born. The baby is not breathing. There is no one • Hand washing or use of hand rub When should a skilled person be present at a birth?
to help the baby. (Pause) The baby dies.” Pause to allow • Preparing an area for ventilation and If problems occur
the learners to reflect with their eyes closed. With the
learners’ eyes still closed, say, “Imagine that another
checking the ventilation bag and mask x At every birth
baby is born. The baby is not breathing. You are there When should you wash your hands?
to help the baby. You rub him dry, keep him warm, and Follow the Action Plan: When they look dirty
help him breathe with a bag and mask. The baby begins Ask a learner to point out x Before and after caring for a mother or a baby
to cry.” (Imitate a baby crying.) • The action step “Prepare for birth”
“At every birth, there must be a skilled person to assess • The equipment and supplies needed
the baby and help the baby who is not breathing well.” for Helping Babies Breathe®
Present and demonstrate
Background and educational advice Encourage the participants to help everyone learn by sharing their experience and
How to make a difference their questions.
• Be present and prepared to help Identify a helper and review the emergency plan. Emergency planning should
be part of every birth plan and every health system. Mother’s birth companion can
a baby who does not breathe. As a skilled birth attendant, call for help as directed and observe the mother’s condition. A second skilled birth
you make the difference attendant can assist as needed – for example, clamping or tying and cutting the cord,
• Promote cleanliness, warmth, evaluating the umbilical cord pulse or heartbeat, or seeking advice from a higher-
level facility.
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Prepare the area for delivery. The birthing area should always be clean, warm, and
well-lighted. Eliminate drafts from fans, air conditioners, or open windows and doors.
Preparation for a birth Warm the birthing room and/or use a radiant heater to warm the area for ventilation.
• Identify a helper and review the Wash hands. Hand washing prevents infection. Everyone who attends a delivery,
including the mother, father, and birth companion, must wash their hands. Learners
emergency plan. should follow the pictures on page 39 of the Learner Workbook to practice. Clean
gloves also help prevent infection and protect the birth attendant from blood and
• Prepare the area for delivery. body fluids. Review the procedures for personal protection in your region.
• Wash hands. Prepare an area for ventilation and check equipment. The area for ventilation
should always be clean, warm, and well-lighted. It should also be dry, flat, and safe
• Prepare an area for ventilation
2
- without risk for falls or other injury. Learners can follow the steps on page 40 of the
and check equipment. Learner Workbook to check the bag and mask for ventilation.
2b
HBB Flipchart 20-00371 rev C.indd 2 19.03.12 08.47As a skilled birth attendant,
you make the difference
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HBB Flipchart 20-00371 rev C.indd 3 19.03.12 08.47Exercise: Preparation for a birth (pages 8-9)
Checklist Background and educational advice
Identify a helper and review the In a small group of learners (no more than 6 persons with 1 facilitator)
• Demonstrate preparation for a birth.
emergency plan • Emphasize communication with the mother.
• Have learners complete the checklist in pairs.
• Ask learners to change roles and repeat the checklist.
............................................................ • Answer questions and encourage correct actions during the exercise.
• Give feedback after the exercise.
Identify helper Prepare the area Wash hands Prepare an area • Review the group discussion questions.
and review for delivery for ventilation and Prepare the area for delivery
emergency plan check equipment
............................................................ Group discussion (page 9)
The facilitators will demonstrate At the end of the exercise, ask learners to answer these questions in the
Wash hands small group. Encourage them to work together to find solutions. Make
how to prepare for a birth.
note of other questions that learners ask and their solutions.
Learners will work in pairs to
............................................................ 1. What is the emergency plan where you work?
prepare for a birth. One person
takes the role of the skilled birth 2. What could a helper do during a delivery?
attendant. The other person Prepare an area for ventilation How do you prepare the helper?
takes the role of the helper. 3. How will you prepare the area for delivery and the area for ventilation
Learners switch roles and repeat ............................................................ where you work?
the exercise.
4. Is there a source of clean water? If not, how can you prepare
Begin by introducing yourself Assemble all supplies and clean water?
to the mother. Then carry out equipment 5. How will you have clean, working equipment and supplies ready
the steps of the checklist. for use at every birth?
............................................................
Check the bag and mask for
ventilation
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............................................................
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3b
HBB Flipchart 20-00371 rev C.indd 4 19.03.12 08.48Exercise: Preparation for a birth
3
HBB Flipchart 20-00371 rev C.indd 5 19.03.12 08.48Present and demonstrate Practice with the Action Plan Check yourself (page 10)
At birth, dry thoroughly. Ask learners to practice
Remove the wet cloth. • Drying thoroughly A baby is not dried, but she is placed on a cloth beside
the mother. What happens?
Note time of birth. • Clearing the airway first when there x The baby can become cold.
is meconium in the amniotic fluid, The baby will stay warm.
If meconium, first clear the airway. and then drying thoroughly
What can happen when a baby inhales meconium?
Suction mouth, then nose. x The baby can have breathing problems.
Dry thoroughly. Follow the Action Plan: Meconium rarely causes a breathing problem.
Remove the wet cloth. Ask a learner to point out
• The action step “Dry thoroughly”
• The first action step for a baby with
meconium-stained amniotic fluid
Background and educational advice
At birth
Drying helps keep a baby warm and clean. Drying also stimulates breathing. of the nose, mouth, and throat also may be performed before the delivery of the
Dry thoroughly A wet baby can easily become cold. A cold baby can have difficulty breathing. shoulders. Where available, endotracheal intubation may be performed if meconium
Drying removes blood, body fluids and stool of the mother. Drying thoroughly is present in the amniotic fluid and the baby is not breathing well at birth, has a slow
involves gently rubbing the body, arms and legs, and head. Blotting or patting a heart rate, or poor muscle tone.
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baby dry does not stimulate breathing.
Meconium in the amniotic fluid may be a sign that a baby has experienced stress
If meconium-stained
amniotic fluid, before birth. A baby may pass stool, called meconium, before birth. Meconium in-
clear the airway before drying.
haled into the lungs can cause breathing difficulty.
Care of the baby with meconium in the amniotic fluid may differ from one
region to another. The best way to care for the baby with meconium in the am-
niotic fluid is not known. Suctioning of the mouth and nose may be performed
with a bulb suction device or a tube and reservoir device after delivery. Suctioning
4
4b
HBB Flipchart 20-00371 rev C.indd 6 19.03.12 08.48At birth
Dry thoroughly
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If meconium-stained
amniotic fluid,
clear the airway before drying.
4
HBB Flipchart 20-00371 rev C.indd 7 19.03.12 08.48Present and demonstrate Practice with the Action Plan Check yourself (page 11)
Most babies cry at birth. Ask the learners to practice
Crying means a baby is breathing well. • Simulating movement of the chest A baby cries after birth and then breathes quietly
and regularly. What should you do?
Demonstrate chest movements with cry. with crying and not crying x Give routine care.
Provide help to breathe.
A baby who does not cry needs help Follow the Action Plan:
A baby is not crying at birth. He is not breathing or
to breathe. Ask a learner to point out moving and he is limp. What should you do?
About 1 in 10 babies needs help to breathe. • The evaluation question “Crying?” Give routine care.
x Provide help to breathe.
Demonstrate irregular chest movements • The decision “Crying” or “Not crying”
or no chest movement.
Without help, a baby who does not
breathe may suffer serious injury or die.
Background and educational advice
Evaluation after drying
A skilled person should be present at every delivery. Problems during the
Is the baby crying? pregnancy, labor or delivery predict some - but not all - babies who need help
to breathe.
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In rare cases, a newborn baby does not cry but does breathe quietly and
regularly. This baby may be healthy, but clearing the airway and stimulating
breathing will not harm a quietly breathing baby.
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5b
HBB Flipchart 20-00371 rev C.indd 8 19.03.12 08.48Evaluation after drying
Is the baby crying?
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HBB Flipchart 20-00371 rev C.indd 9 19.03.12 08.48Present and demonstrate Practice with the Action Plan Check yourself (page 12)
A baby who has been dried and is Ask the learners to practice
crying can receive routine care. • Positioning the baby skin-to-skin and What can you do to encourage breastfeeding?
x Keep mother and baby together.
• Keep warm - position skin-to-skin and covering head and body Give warm tea to both the mother and baby.
cover head and body. • Checking breathing
• Check breathing. Demonstrate quiet How long should you wait to clamp or tie and cut the
umbilical cord of a crying baby?
and regular breathing. Follow the Action Plan: Ask a learner to Clamp or tie and cut the cord immediately.
• Clamp or tie and cut the cord after 1-3 • Point out each step in routine care x Wait 1 to 3 minutes to clamp or tie and cut the cord.
minutes (as demonstrated on next page). • Explain the meaning of the green area
of the Action Plan
Position skin-to-skin on mother’s chest
to encourage breastfeeding.
Background and educational advice
If the baby is crying
Keep warm. Placing the baby skin-to-skin with mother gives the baby a source
Keep warm, of heat. Skin-to-skin contact can help a baby breathe well. Being close to mother
check breathing, cut cord encourages early breastfeeding.
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Check breathing. Most babies who cry at birth continue to breathe well. Some
babies may have large amounts of fluid in the mouth and nose. Positioning these
babies on their side may help the fluid drain. A baby’s neck should be slightly
extended – not flexed or hyperextended. The nose should not be blocked by
mother’s skin or clothing.
6
6b
HBB Flipchart 20-00371 rev C.indd 10 19.03.12 08.48If the baby is crying
Keep warm,
check breathing, cut cord
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HBB Flipchart 20-00371 rev C.indd 11 19.03.12 08.48Present and demonstrate Practice with the Action Plan Check yourself (page 13)
Use clean technique. Ask learners to practice
(Wash or change gloves if possible.) • Clamping or tying and cutting the You notice bleeding from the umbilical cord even
though a tie is in place. What should you do?
umbilical cord using locally available x Place another tie between the first one and
How to clamp or tie and cut the supplies the baby’s skin.
Wait to see if the bleeding will stop on its own.
umbilical cord
• Place two clamps or ties on the cord. Follow the Action Plan: Ask a learner What actions help prevent infection of the
• Cut between the clamps or ties. to point out umbilical cord?
x Good hand washing, wearing clean gloves,
• Leave the cut end of the cord open to air. • The action step of clamping or tying cutting with sterile scissors
and cutting the cord Covering the cord to keep it moist
Background and educational advice
Timing of clamping or tying and cutting the cord may vary. Timing of clamp- The equipment and technique to clamp or tie and cut the cord differ from one
How to clamp or tie and cut the umbilical cord ing or tying and cutting the cord depends on the condition of the baby and the region to another. Use clamps or ties and scissors or a razor blade in demonstra-
mother during the third stage of labor. Wait about 1 to 3 minutes after birth to tions and practice.
clamp or tie and cut the cord of a healthy baby. The newborn should be kept on
the mother’s abdomen or at the level of the perineum during this time. Maternal
bleeding or moving the baby to the area for ventilation may require earlier clamp-
ing or tying and cutting of the umbilical cord.
Cleanliness is important to help prevent infection when clamping or tying and
cutting the cord. Infection of the umbilical cord can lead to serious infection.
Everything used to clamp or tie and cut the cord should be sterile or completely
disinfected. Follow the guidelines for clean delivery used in your region. In some
regions, antiseptic solutions may be applied to the cord.
7
7b
HBB Flipchart 20-00371 rev C.indd 12 19.03.12 08.48
How to clamp or tie and cut the umbilical cord
7
HBB Flipchart 20-00371 rev C.indd 13 19.03.12 08.48Exercise: Routine care (pages 14-15)
Checklist Background and educational advice
The facilitators will
demonstrate routine If meconium, clear airway In a small group of learners (no more than 6 persons with 1 facilitator)
care and the baby’s • Demonstrate routine care.
responses. • Emphasize communication with the mother.
............................................................ • Have learners complete the checklist in pairs.
• Ask learners to change roles and repeat the checklist.
Learners will work • Answer questions and encourage correct actions during the exercise.
in pairs with the Dry thoroughly • Give feedback after the exercise.
• Review the group discussion questions.
mannequin to
practice the steps ............................................................
in routine care.
One person takes
Recognize crying Group discussion (page 15)
the role of the birth
attendant. The other At the end of the exercise, ask learners to answer these questions in
............................................................ the small group. Encourage them to work together to find solutions.
person gives the
Make note of other questions that learners ask and their solutions.
response of the baby
and acts as a helper Keep warm 1. How do you recognize a healthy baby?
when needed.
2. Where will you place a healthy baby immediately after birth?
............................................................ In your experience, do mothers routinely practice skin-to-skin care?
Learners switch
3. How can you protect mother and baby from infection during and
roles and repeat
after delivery?
the exercise. Check breathing
4. What cord care is used locally? Is this care useful or harmful or neither?
............................................................
Clamp or tie and cut the
umbilical cord
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............................................................
Place on mother’s chest to
encourage breast-feeding
............................................................
8b
HBB Flipchart 20-00371 rev C.indd 14 19.03.12 08.48
Exercise: Routine care
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8
HBB Flipchart 20-00371 rev C.indd 15 19.03.12 08.48Present and demonstrate Practice with the Action Plan Check yourself (page 16)
If the baby is not crying, clear the Ask the learners to practice
airway and stimulate breathing. • Keeping the baby warm How long should it take to dry the baby, clear the
airway, stimulate breathing?
• Keep warm – position skin-to-skin • Positioning the head x Less than 1 minute – the Golden Minute
and cover with cloth. • Clearing the airway Two minutes
• Position the head – extend the • Stimulating breathing
Suctioning for a long time or suctioning deeply can
head slightly. Make a baby breathe
• Clear the airway – remove secretions Follow the Action Plan: Ask a learner to x Keep a baby from breathing
from mouth, then nose. • Point out The Golden Minute®
• Stimulate breathing – rub the back • Tell why The Golden Minute is important
once or twice.
Background and educational advice
If the baby is not crying
The device used to clear the airway differs from one place to another. Some forms of stimulation can harm babies and should never be used.
Clear the airway A bulb suction device, tube and reservoir suction device, or a soft wipe may be used Harmful methods include slapping the back, squeezing the ribs, forcing the thighs
and stimulate breathing to clear the airway. Each has advantages and disadvantages. Infection can occur onto the abdomen, dilating the anus, using hot/cold water, and shaking or holding
with any device if it is not absolutely clean. A suction device must be opened, the baby upside down. Help the learners evaluate other methods of stimulation that
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cleaned of any visible material, and boiled (or completely disinfected in another may be in use.
way) before re-use.
If a baby is not breathing well or crying after clearing the airway and brief stimulation,
Clearing the airway can cause harm if not done gently. the baby needs ventilation with bag and mask. More stimulation is unlikely to be
Suctioning too deeply can bruise or tear the back of the throat. Wiping the mouth too effective. Prolonged stimulation only wastes time while the baby is becoming sicker.
hard can injure the lining of the mouth. In both cases, the baby may not breastfeed well.
9
9b
HBB Flipchart 20-00371 rev C.indd 16 19.03.12 08.48If the baby is not crying
Clear the airway
and stimulate breathing
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9
HBB Flipchart 20-00371 rev C.indd 17 19.03.12 08.48Present and demonstrate Practice with the Action Plan Check yourself (page 17)
A baby who is breathing well Ask learners to practice
• Crying • Crying If a baby is not breathing well after drying, clearing the air-
way and rubbing the back once or twice, you should give
OR • Breathing quietly and regularly More stimulation
• Breathing quietly and regularly • Gasping x Ventilation with bag and mask
• Not breathing at all
Which baby is breathing well?
A baby who is not breathing well x A baby who is breathing quietly and regularly
• Gasping Follow the Action Plan: A baby who takes one deep breath followed by a
long pause
OR Ask a learner to point out
• Not breathing at all • The evaluation question “Breathing?”
• The decisions “Breathing well” or
Demonstrate each type of breathing. “Not breathing”
Background and educational advice
After clearing the airway and stimulation
Some babies will require close monitoring to decide if they need more help to
Is the baby breathing well? breathe. Shallow or irregular breathing, chest wall indrawing (retractions), noisy
breathing (grunting) require close monitoring immediately after birth. Some babies
who breathe in these ways will improve and begin to breathe normally. Others will
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need more help to breathe. Discuss with learners the local terms for abnormal
breathing and what they mean.
10
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HBB Flipchart 20-00371 rev C.indd 18 19.03.12 08.48After clearing the airway and stimulation
Is the baby breathing well?
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HBB Flipchart 20-00371 rev C.indd 19 19.03.12 08.48Exercise: The Golden Minute® – clear the airway and stimulate breathing (pages 18-19)
Checklist Background and educational advice
The facilitators
will demonstrate If meconium, clear airway In a small group of learners (no more than 6 persons with 1 facilitator)
clearing the airway • Demonstrate The Golden Minute – clear airway and stimulate breathing.
• Emphasize communication with the mother.
and stimulating ............................................................ • Have learners complete the checklist in pairs.
breathing during Dry thoroughly • Ask learners to change roles and repeat the checklist.
The Golden Minute • Answer questions and encourage correct actions during the exercise.
• Give feedback after the exercise.
and the baby’s ............................................................
• Review the group discussion questions.
responses. Recognize not crying
Learners will work ............................................................
in pairs with the Keep warm Group discussion (page 19)
mannequin to
practice clearing ............................................................ At the end of the exercise, ask learners to answer these questions in the small
group. Encourage them to work together to find solutions. Make note of other
the airway and Position head
questions that learners ask and their solutions.
stimulating
breathing. One ............................................................ 1. How do you clear the baby’s airway when there is meconium in the
amniotic fluid? What are the advantages and disadvantages of this method?
person takes the Clear airway
role of the skilled 2. How do you recognize a baby who is breathing well? Not breathing well?
birth attendant. ............................................................
Stimulate breathing 3. Drying and rubbing the back are methods to stimulate breathing.
The other person
Are there other methods used in your region? Are these useful or
gives the response harmful for babies, or neither?
of the baby and acts ............................................................
as a helper when Recognize breathing well
needed.
............................................................
Learners switch Keep warm
roles and repeat
the exercise. ............................................................
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Check breathing
............................................................
Clamp or tie and cut the
umbilical cord
............................................................
Position skin-to-skin on mother’s
chest to encourage breastfeeding
............................................................
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HBB Flipchart 20-00371 rev C.indd 20 19.03.12 08.48Exercise: The Golden Minute®
– clear the airway and stimulate breathing
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60 sec
11
HBB Flipchart 20-00371 rev C.indd 21 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 20)
Initiate ventilation. Ask the learners to practice
• Move to the area for ventilation • Clamping or tying and cutting the How do you select the correct mask?
x Select the mask that covers the chin, mouth, and
(a separate area if the cord is cut; cord (optional) nose, but not the eyes.
on or beside the mother if the cord • Moving to the area for ventilation Select the mask that covers the chin, mouth, nose,
is not cut). • Standing at the baby’s head and the eyes.
• Stand at the baby’s head. • Selecting the correct mask Which cloth will keep a baby warmer during ventilation?
• Select the correct mask. A cloth soaked in warm water
Follow the Action Plan: x A warm, dry cloth
Ask a learner to point out
• The action step “Cut cord” in
The Golden Minute®
• The action step “Ventilate”
Background and educational advice
If the baby is still not breathing well, cut cord and
The Golden Minute holds the most important steps to help a baby who does Selecting the correct mask is important to form a tight seal on the face and
Ventilate with bag and mask not breathe. Clearing the airway and stimulation help many babies breathe well. keep the airway open during ventilation.
Ventilation is the most effective way to help the baby who has not responded to • If the mask is too large, it will not make a good seal.
clearing the airway and stimulation. Ventilation with bag and mask carries air into • If the mask is too small, it can block the mouth and nose.
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the lungs. It starts the changes in the body that are necessary so the baby can A mask with a round or pointed shape may be used. When using a pointed mask,
begin to breathe. the pointed part fits over the nose and the round part fits over the chin. Masks with
cushioned or flexible rims follow the shape of the face and form a seal more easily.
Within The Golden Minute the baby should be breathing well or receiving
ventilation. Delay in starting ventilation will mean that a baby needs ventilation The best time to clamp or tie and cut the cord of the baby who needs ventila-
longer before beginning to breathe. Delay in ventilation may cause serious injury tion is not known. The cord may be clamped or tied and cut before ventilation.
to the brain. Clamping is often faster than tying. Cutting the cord should not delay ventilation.
In some cases, clamping or tying and cutting the cord will occur after ventilation
Assembling equipment and supplies and checking the bag and mask should has begun. This order avoids delay in starting ventilation when there is no skilled
be part of preparation for every birth. It is too late to look for equipment when helper to assist the birth attendant.
a baby is not breathing.
12 The area for ventilation depends on when the cord is cut. If the baby receives
ventilation before the cord is cut, the baby can remain on the mother’s abdomen or
beside the mother.
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HBB Flipchart 20-00371 rev C.indd 22 19.03.12 08.49If the baby is still not breathing well, cut cord and
Ventilate with bag and mask
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12
HBB Flipchart 20-00371 rev C.indd 23 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 21)
How to ventilate with bag and mask Ask learners to practice
• Position the head. • Positioning the head What allows you to move air into the baby’s lungs
during ventilation?
• Position the mask on the face. (Note the effect of correct and incorrect A flexed position of the head
• Make a firm seal between the mask head position on chest movement.) x A good seal between the mask and the face
and face while squeezing the bag to • Positioning the mask on the face
To help open the baby’s airway, you should
move the chest gently. • Making a firm seal while squeezing the position the baby’s head
• Give 40 ventilation breaths per minute. bag to move the chest gently x Slightly extended
Hyperextended
• Giving 40 ventilation breaths per minute
Develop with the learners a method to
set the correct tempo for ventilation.
Background and educational advice
The amount of air delivered with each ventilation breath from a bag and mask hand position that forms a firm seal between the mask and face.
How to ventilate with bag and mask depends on 3 factors: • Two-point method: The tips of the thumb and first finger push down on the mask
• The amount of air that leaks between the mask and face • Encircling method: The thumb and the first finger form the letter “c” around the top
• How hard and how long you squeeze the bag of the mask
• The set point of the pop-off (pressure-release) valve As the learner pushes down on the mask with the first two fingers, the other fingers
Deliver enough air to move the chest as if the baby is taking a normal breath. Too little should lift the chin and jaw up towards the mask. Pushing down on the mask without
air means the baby may not improve. Too much air may damage the lungs. lifting up on the chin and jaw can flex the head and block the airway. Learners should
practice until they can move the chest gently each time they give a ventilation. Help
A ventilation device may or may not have a pop-off valve. If a ventilation bag has learners find leaks by feeling where the air escapes against their hand.
a pop-off valve, know the set-point at which air escapes. This valve limits the amount
of air sent to the lungs – even when you squeeze the bag very hard. Closing the valve Help learners ventilate at the correct tempo. There must be time for air to move
makes it possible to give a larger breath. A very large breath can rupture the baby’s out of the lungs between breaths. A rate between 30 and 50 breaths per minute is
lungs. acceptable when trying to give 40 breaths per minute.
• Count aloud “One…two…three…One…two…three” and give a breath on “One”.
13
The 2 most important and difficult steps in ventilation are correct head position • Use a timer or watch to set the tempo.
and making a firm seal. Ask learners to experiment with correct and incorrect posi- • Ask learners to think of a phrase or a rhythm from a well-known song or dance that
tion of the head. Note the change in chest movement. Help each learner find the helps them keep a tempo of 40 breaths per minute.
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HBB Flipchart 20-00371 rev C.indd 24 19.03.12 08.49How to ventilate with bag and mask
13
HBB Flipchart 20-00371 rev C.indd 25 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 22)
A baby who is breathing well Ask learners to practice
• Crying • Crying You are giving a baby ventilation with bag and mask.
The baby is gasping. What should you do?
OR • Breathing quietly and regularly Stop ventilation and observe closely with mother.
• Breathing quietly and regularly • Gasping x Continue ventilation.
• Not breathing at all
A baby who is not breathing well A baby begins to breathe well after 30 seconds of
• Other types of breathing that require ventilation with bag and mask. How will you care for
• Gasping
close monitoring - shallow or irregular, this baby?
OR x Monitor the baby closely with the mother.
grunting, chest wall indrawing
• Not breathing at all Provide routine care.
A baby who requires close monitoring Follow the Action Plan:
• Shallow or irregular breathing Ask a learner to point out
• Grunting • Where breathing is evaluated during
• Chest wall indrawing ventilation
• The decisions “Breathing” or
Demonstrate each type of breathing. “Not breathing”
Background and educational advice
During ventilation
Improvement in a baby’s condition with ventilation may occur rapidly or slowly.
Is the baby breathing well? A baby may begin breathing after only a few ventilations. When the baby improves
more slowly, you will need to look for other signs.
• The earliest sign that the lungs are being expanded with air is a rapid rise in the
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baby’s heart rate. This cannot be seen. It requires feeling the umbilical cord
pulse or listening to the heart rate with a stethoscope.
• Next, a baby will show improvement in color and muscle tone. The color will
become pink. The baby will move and no longer be floppy.
• Finally, a baby’s own breathing will begin.
With experience, birth attendants will learn to recognize these signs of
improvement.
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HBB Flipchart 20-00371 rev C.indd 26 19.03.12 08.49During ventilation
Is the baby breathing well?
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14
HBB Flipchart 20-00371 rev C.indd 27 19.03.12 08.49Exercise: The Golden Minute ® - ventilation (pages 24-25)
Checklist Background and educational advice
The facilitators will
demonstrate The In a small group of learners (no more than 6 persons with 1 facilitator)
If meconium, clear airway • Demonstrate The Golden Minute – clear airway, stimulate breathing,
Golden Minute and
and ventilate.
the baby’s respones. ............................................................ • Emphasize communication with the mother.
Dry thoroughly • Have learners complete the checklist in pairs.
Learners will work • Ask learners to change roles and repeat the checklist.
............................................................ • Answer questions and encourage correct actions during the exercise.
in pairs with the
• Give feedback after the exercise.
mannequin to practice Recognize not crying
• Review the group discussion questions.
The Golden Minute.
............................................................
One person takes the
Keep warm, position head,
role of the skilled birth
clear airway Group discussion (page 25)
attendant. The other
person gives the ............................................................ At the end of the exercise, ask learners to answer these questions in the
small group. Encourage them to work together to find solutions. Make note
response of the baby Stimulate breathing
of other questions that learners ask and their solutions.
and acts as a helper
when needed. ............................................................ 1. Where will you place a baby who needs ventilation with bag and mask?
Recognize not breathing well How will you keep the baby warm?
Learners switch roles 2. When will you clamp or tie and cut the cord of the baby who needs
............................................................
and repeat the ventilation? How will you avoid delay in beginning ventilation?
Clamp or tie and cut the
exercise. umbilical cord*
Learners should be ............................................................
prepared to care for Move to area for ventilation,*
a baby who stand at head, select correct
- has clear OR mask
meconium-stained
amniotic fluid ............................................................
Ventilate (by 1 minute)
- does not breathe
after clearing the ............................................................
airway and Recognize breathing well
stimulating
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rev B rev B
- breathes after ............................................................
brief ventilation Monitor with mother
............................................................
*Alternative: Position baby beside
mother with cord intact
15b
HBB Flipchart 20-00371 rev C.indd 28 19.03.12 08.49Exercise:
The Golden Minute® - ventilation
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rev B rev B
60 sec
15
HBB Flipchart 20-00371 rev C.indd 29 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 26)
Call for help. Ask the learner to practice
(Ask for a skilled helper, if available.) • Calling for help A baby does not breathe after brief ventilation.
What should you do first?
Squeeze the bag harder to give a larger breath.
Improve ventilation if the chest is • Improving ventilation X
Call for help.
not moving. - Head: Reapply mask
A baby’s chest does not move with ventilation.
• Head: Reapply mask Reposition head What should you do?
Reposition head - Mouth: Clear mouth and nose Stimulate the baby.
Reapply the mask to the face and reposition the
X
of secretions
• Mouth: Clear mouth and nose of head with the neck slightly extended.
Open mouth slightly
secretions - Bag: Squeeze the bag harder
Open mouth slightly
• Bag: Squeeze the bag harder Follow the Action Plan:
Ask a learner to point out
• The action step “Call for help”
• The action step “Improve ventilation”
Background and educational advice
If the baby is not breathing
Reapplying the mask and repositioning the head often improve chest movement. Squeezing the bag harder increases the amount of air that enters the lungs.
Call for help • Reapply the mask when you hear or feel air escaping around the mask. Squeeze the bag harder to give a larger ventilation breath. If the ventilation bag
Improve ventilation A common place for a leak to occur is between the cheek and the top of the nose. has a pop-off valve and even more air is needed, close the valve and ventilate
• Pressing down on the mask can flex the head and block the airway. Extend the again with caution. Look carefully at the chest movement. Decrease the amount
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rev B rev B
neck slightly. Keep the head in correct position by lifting the chin and jaw up and of air entering the lungs if the chest moves too much.
forward while pressing down on the mask.
If these steps do not improve chest movement, continue on to the next steps.
Clearing the mouth and nose of secretions and opening the mouth slightly
can easily be combined. Remove secretions and open the mouth slightly before
reapplying the mask. Opening the mouth and lifting the jaw up and forward help
prevent the tongue from blocking the airway. If these steps do not improve chest
movement, continue on to the final step.
16
16b
HBB Flipchart 20-00371 rev C.indd 30 19.03.12 08.49If the baby is not breathing
Call for help
Improve ventilation
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rev B rev B
16
HBB Flipchart 20-00371 rev C.indd 31 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 27)
Evaluate heart rate after 1 minute of Ask the learners to practice
ventilation. • Feeling the umbilical cord pulse You are breathing for a baby with bag and mask.
When should you check the heart rate?
• Feel the umbilical cord pulse. • Listening to the heartbeat with a After every 10 breaths with the ventilation bag
OR stethoscope (finger tapping) X
After 1 minute of ventilation
• Listen to the heartbeat with a stethoscope. • Deciding if the heart rate is normal
You feel the umbilical cord to count the heart rate.
(Simulate the heartbeat by tapping out or slow You cannot feel any pulsations. What should you do next?
the pulse with your fingers.) X
Listen for the heartbeat with a stethoscope.
Do nothing more. The baby is dead.
Follow the Action Plan:
• Decide if the heart rate is normal or slow. Ask a learner to point out
- Normal > 100 beats per minute • The evaluation question “Heart rate?”
- Slow < 100 beats per minute
Background and educational advice
If the baby is not breathing well after improved ventilation
Help learners recognize a normal and slow heart rate.
Is the heart rate normal • A normal heart rate for a baby is faster than an adult heart rate. Learners can
or slow? count their own pulse at rest to feel a slow heart rate.
• Ask learners to think of a well-known song or dance with about 100 beats per
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rev B rev B
minute. Tap out that tempo to show a normal heart rate.
• Have learners suggest their own method to help classify the heart rate as
normal or slow.
17
17b
HBB Flipchart 20-00371 rev C.indd 32 19.03.12 08.49If the baby is not breathing well after improved ventilation
Is the heart rate normal
or slow?
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rev B rev B
17
HBB Flipchart 20-00371 rev C.indd 33 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 29)
Continue ventilation. Ask the learners to practice
• Ventilate at a rate of 40 breaths • Continued ventilation (3-5 minutes) A baby has been ventilated for more than 3 minutes
per minute. - Rate of 40 breaths per minute with bag and mask. The heart rate is 120 beats per
minute. The baby is not breathing. What should you
• Look for chest movement with - Chest movement with each ventilation do next?
each ventilation. • Evaluating breathing X
Slowly decrease the rate of ventilation and watch
- Breathing well for breathing.
Evaluate breathing. - Not breathing well Stop the ventilation and wait at least 1 minute to
see if the baby breathes.
• Breathing well • Monitoring with mother
• Not breathing well - Check breathing, heart rate, color, A baby has been ventilated for 10 minutes with bag and
temperature, breastfeeding mask. The baby is now breathing and has a heart rate
Stop ventilation. of more than 100 beats per minute. What care does this
baby need?
• Breathing well Follow the Action Plan:
Routine care with mother
• Heart rate normal Ask a learner to point out X
Close monitoring with specialty consultation
• The evaluation step “Heart rate or referral
Monitor with mother. normal, breathing”
• Check breathing, heart rate, color,
temperature, breastfeeding.
Background and educational advice
If the heart rate is normal
Sometimes ventilation is so effective that a baby does not feel the need to
Ventilate until the baby breathe. Slowly decrease the ventilation, while keeping the baby pink with a normal
is breathing well, heart rate. If the baby still does not breathe, continue ventilation and seek specialty
consultation or referral.
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rev B rev B
then monitor with mother
Help prepare the learners for more complicated cases. Many babies who require
ventilation will recover well and be healthy. Babies who need 5 minutes or more of
ventilation require careful monitoring. Difficulty breathing or slow heart rate after
ventilation is stopped means that a baby needs continued ventilation and specialty
consultation or referral. The baby may need continued care on a ventilator, supple-
mental oxygen, and/or more advanced care.
18
18b
HBB Flipchart 20-00371 rev C.indd 34 19.03.12 08.49If the heart rate is normal
Ventilate until the baby
is breathing well,
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rev B rev B
then monitor with mother
18
HBB Flipchart 20-00371 rev C.indd 35 19.03.12 08.49Present and demonstrate Practice with the Action Plan Check yourself (page 30)
Continue ventilation if the heart rate Ask learners to practice
is slow or the baby does not breathe. • Continued ventilation with You have provided ventilation with bag and mask for
5 minutes. The baby’s chest is moving, but the heart
• Ventilate at a rate of 40 breaths per improvement as necessary rate is about 70 beats per minute. What should you do?
minute. • Re-evaluation of heart rate and X
Continue ventilation, activate the emergency plan,
• Look for chest movement with each breathing and seek advice from a specialty facility.
Stop ventilation and observe to see if the heart
ventilation breath. • Seeking advanced care rate improves.
• Improve ventilation as necessary.
After 10 minutes of ventilation with good chest move-
• Replace the ventilation bag if necessary. Follow the Action Plan:
ment, the baby is not breathing and there is still no
Ask a learner to point out heart rate (no cord pulse, no heartbeat by stethoscope).
Evaluate heart rate and breathing. • The decision “Heart rate slow” What should you do?
Stop ventilation. The baby is dead.
X
• The decision “Heart rate normal,
Seek advanced care. Continue ventilation for another 10 minutes.
not breathing”
Recognize maceration.
Background and educational advice
If the heart rate is slow or normal
and the baby does not breathe Most babies who do not breathe at birth have a heartbeat. These babies usually Maceration indicates that a baby died long before delivery. If a baby’s heart
respond to clearing the airway and stimulation of breathing or ventilation with bag stops hours or days before birth, there will be changes in the baby’s appearance.
Continue ventilation and mask. These changes (called maceration) include purple discoloration of the skin, peeling
and seek advanced care skin, and stiffness of the arms and legs. Ventilation will not be effective. Ventilation
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A few babies will not begin to breathe on their own or will continue to have a can be stopped when maceration is recognized.
slow heart rate despite good ventilation with bag and mask. Continue ventilation
while activating the emergency plan. Check heart rate at 5 and 10 minutes after birth.
Even with access to advanced care, such babies may not recover.
A stillborn is a baby born without a heartbeat, breathing, or any signs of life.
If a baby does not respond with improved color, tone, and breathing after 1 minute
of ventilation with chest movement, it is important to evaluate the heart rate. If there
is no heart rate after 1 minute of ventilation with chest movement, the baby was
probably stillborn . Even with advanced care (intubation, chest compressions, medi-
19
cation) the baby likely will not recover.
19b
HBB Flipchart 20-00371 rev C.indd 36 19.03.12 08.49If the heart rate is slow or normal
and the baby does not breathe
Continue ventilation
and seek advanced care
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rev B rev B
19
HBB Flipchart 20-00371 rev C.indd 37 19.03.12 08.50Present and demonstrate Practice with the Action Plan Check yourself (page 31)
Transport mother and baby together. Ask learners to practice
• Continue skin-to-skin care. • Arranging consultation and referral A baby needed ventilation with bag and mask.
She is breathing fast and cannot breast feed.
• Advising a mother whose baby is ill What should you do?
Support the family • Talking with a family whose baby died Leave mother and baby alone to rest.
• Help mother express breast milk for a Explain the baby’s condition to the mother
X
and birth companion.
baby who is ill. Follow the Action Plan:
• Provide information in a culturally Ask learners to note phone numbers A premature baby will be taken to the district hospital
with breathing difficulty. How should you advise the
appropriate way. to activate the emergency plan.
mother?
• Respect the faith and cultural practices Advise her not to travel for at least a week.
of the family when a baby dies. Advise her to go with her baby if possible.
X
Background and educational advice
If transfer is necessary
Transfer mother and baby together when either one is ill. Keeping mother
Transport mother and baby together, and baby together supports breastfeeding. Skin-to-skin care facilitates close
and support the family observation and protects the baby from cold stress during transport.
The appropriate response to the death of a baby varies by region and culture.
Birth attendant should be aware of cultural beliefs and practices. Discuss with
learners how families deal with the death of a baby. Consider differences among
cultural groups in the region.
20
20b
HBB Flipchart 20-00371 rev C.indd 38 19.03.12 08.50If transfer is necessary
Transport mother and baby together,
and support the family
20
HBB Flipchart 20-00371 rev C.indd 39 19.03.12 08.50Exercise: Continued ventilation with normal heart rate (pages 32-33)
The facilitators will
Checklist Background and educational advice
demonstrate contin- Recognize not breathing In a small group of learners (no more than 6 persons with 1 facilitator)
ued ventilation with • Demonstrate continued ventilation with normal heart rate.
and poor chest movement • Emphasize communication with the mother.
normal heart rate. • Have learners do the exercise in pairs.
x • Ask learners to change roles and repeat the exercise.
Learners will work ............................................................... • Answer questions and encourage correct actions during the exercise.
• Give feedback after the exercise.
in pairs with the
• Review the group discussion questions.
mannequin to Call for help x
practice continued
ventilation with
normal heart rate.
............................................................... Group discussion (page 33)
One person takes At the end of the exercise, ask learners to answer these questions in the
Continue and improve ventilation small group. Encourage them to work together to find solutions. Make
the role of the skilled
note of other questions that learners ask and their solutions.
birth attendant.
The other person ............................................................... 1. How can you give ventilation and evaluate the baby if there is not
gives the response a second skilled person at a delivery?
of the baby and also Recognize still not breathing well
2. How will you activate your emergency plan if a baby needs advanced
acts as a helper care (specialty consultation or referral)?
when needed. ...............................................................
Learners switch Recognize normal heart rate
roles and repeat
the exercise.
...............................................................
Learners should be
prepared to care for Recognize breathing well now OR
a baby who still not breathing well
- has poor chest
movement 20-0037120-00371
rev B rev B
...............................................................
- has a normal heart
rate and breathes
If breathing well, monitor with
well OR does not
mother OR if not breathing well,
breathe well
continue ventilation and seek
advanced care
...............................................................
21b
HBB Flipchart 20-00371 rev C.indd 40 19.03.12 08.50Exercise:
Continued ventilation with
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rev B rev B
normal heart rate
21
HBB Flipchart 20-00371 rev C.indd 41 19.03.12 08.50Exercise: Continued ventilation with slow heart rate (pages 34-35)
The facilitators will
Checklist Background and educational advice
demonstrate contin- In a small group of learners (no more than 6 persons with 1 facilitator)
ued ventilation with Recognize not breathing • Demonstrate continued ventilation with slow heart rate.
• Emphasize communication with the mother.
slow heart rate. and poor chest movement
• Have learners do the exercise in pairs.
x • Ask learners to change roles and repeat the exercise.
Learners will work ............................................................... • Answer questions and encourage correct actions during the exercise.
• Give feedback after the exercise.
in pairs with the • Review the group discussion questions.
mannequin to Call for help x
practice continued
ventilation with slow ...............................................................
heart rate. Group discussion (page 35)
One person takes Continue and improve ventilation At the end of the exercise, ask learners to answer these questions in the
the role of the skilled small group. Encourage them to work together to find solutions. Make
note of other questions that learners ask and their solutions.
birth attendant. The
...............................................................
other person gives the 1. If a baby needs continued ventilation for longer than several
response of the baby minutes, where will that baby receive care?
Recognize still not breathing well
and acts as a helper
2. What conditions can be cared for where you work and what are the
when needed. reasons you would transfer a baby?
...............................................................
Learners switch 3. In your community, how can you best support the family of a baby
Recognize slow heart rate who is ill or who died?
roles and repeat
the exercise.
...............................................................
Continue ventilation and seek
advanced care
...............................................................
20-0037120-00371
rev B rev B
22b
HBB Flipchart 20-00371 rev C.indd 42 19.03.12 08.50Exercise:
Continued ventilation with
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rev B rev B
slow heart rate
22
HBB Flipchart 20-00371 rev C.indd 43 19.03.12 08.50or pulse after 10 minutes of ventilation?
Use the Action Plan as a guide to think about the care you provide to babies in your work.
- What did you do to help the baby breathe?
- What happened to the baby?
- What went well?
- What could have gone better?
- What did you learn from the case?
Share your experiences with other birth attendants so that they can learn from them.
Present and demonstrate Practice with the Action Plan Mastering bag and mask ventilation
The Action Plan serves as a framework Ask learners to practice Ventilation with bag and mask can be lifesaving when a baby does not breathe after clearing
the airway and stimulation. Mastering and maintaining this skill require ongoing practice.
for your approach to actual cases. • Tracing the appropriate path through Use the following steps to practice so that you can perform all of the steps perfectly.
Done Not done
• Evaluation — decision — action steps the Action Plan for each of the 6 cases 1. Check equipment and select the correct mask................................................................................
Test function of bag and mask
• Three zones — increasing amounts of • Describing cases in their experience Make sure mask fits the baby’s face
help to breathe and tracing the corresponding path 2. Apply the mask to make a firm seal...............................................................................................................
Extend the head, place mask on the chin, then over the mouth and nose
• The baby who does not cry at through the Action Plan A firm seal permits chest movement when the bag is squeezed
3. Ventilate at 40 breaths per minute...............................................................................................................
birth — not breathing or stillborn The rate should not be less than 30 or more than 50 breaths per minute
4. Look for chest movement........................................................................................................................................
Check that every ventilation breath produces chest movement
5. Improve ventilation if the chest does not move:
a) Head – reapply mask and reposition head................................................................................
b) Mouth – clear secretions and open the mouth.......................................................................
c) Bag – squeeze the bag harder..................................................................................................................
38
Background and educational advice
Mastering the Action Plan
Trace six cases (page 37) Prepare learners for evaluation of what they have learned. Prepare learners to continue practice and learning in their work place.
1 2 3 4 5 6 Give learners time to ask questions, practice the skills of bag and mask ventila- Once learners leave the classroom, their knowledge and skills quickly decrease
If meconium, clear airway
Dry thoroughly Dry thoroughly Dry thoroughly Dry thoroughly Dry thoroughly Dry thoroughly tion, and work through case scenarios using the Action Plan before beginning unless they are used. Show learners how they can continue to practice the skills
Crying Not crying Not crying Not crying Not crying Not crying
their evaluation. Explain the three types of evaluation - written/verbal knowledge of bag and mask ventilation once they return to their workplace. Help newly
SM
check, bag and mask skills evaluation, and case scenarios (Objective Structured trained birth attendants use their skills in a supervised setting as soon as possible
The Golden Minute
Keep warm Keep warm Keep warm Keep warm Keep warm Keep warm
Check breathing Position head Position head Position head Position head Position head
Clear airway
Stimulate
Clear airway
Stimulate
Clear airway
Stimulate
Clear airway
Stimulate
Clear airway
Stimulate
Clinical Evaluations). The checklist for mastering bag and mask ventilation (above after completing Helping Babies Breathe® . Encourage birth attendants who have
breathing breathing breathing breathing breathing
Breathing well Breathing well Not breathing Not breathing Not breathing Not breathing
and on page 38 of the Learner Workbook) is the same as the bag and mask skills been trained to work together and analyze cases in which babies needed help
Cut cord Cut cord Cut cord Cut cord Cut cord Cut cord
evaluation. Checklists from the 6 exercises can be used to prepare for the case to breathe. With practice and self-reflection, learning will continue beyond the
Routine care Routine care Ventilate
Breathing well
Ventilate
Not breathing
Ventilate
Not breathing
Ventilate
Not breathing
60 sec
scenarios presented in the Objective Structured Clinical Evaluations. classroom.
Monitor with Call for help Call for help Call for help
mother
Continue/improve Continue/improve Continue/improve
ventilation ventilation ventilation
Breathing Not breathing Not breathing
Monitor with Continue Continue
mother ventilation ventilation
20-0037120-00371
rev B rev B
Normal Slow heart rate
heart rate OR
Normal heart rate
Breathing Not breathing
Monitor with Continue
mother ventilation
Advanced care
23
23b
HBB Flipchart 20-00371 rev C.indd 44 19.03.12 08.50You can also read
