Clinical paperEarly initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: A prospective descriptive observational study☆
Introduction
Each year approximately 136 million babies are born globally. It is estimated that about 90% make the transition from intrauterine to extrauterine life without any intervention.1, 2, 3 The remaining ten per cent or 13.6 million newborns are delivered with absent or poor respiratory effort and need some degree of support to achieve cardiopulmonary stability. Between three to six per cent need assisted positive pressure ventilation, and less than one per cent require advanced resuscitation including intubation, chest compressions, and medications.2 However, these estimates are based on five reports,2, 3, 4, 5, 6 none of which reflect Sub-Sahara Africa where the burden of perinatal deaths and morbidity is considered to be highest.7
Current International Guidelines on Newborn Resuscitation suggest about 30–60 s of time following delivery should be allocated to assess spontaneous respiratory and heart activity before initiating intermittent positive-pressure ventilation if indicated.8, 9 Failure to initiate spontaneous respirations at birth in most cases is thought to be secondary to primary apnea, and the infant should respond fairly promptly to early intervention, i.e. drying, stimulation, clearing the airways as indicated, as well as face mask ventilation (FMV) applied within the first minute. Delaying basic resuscitation in apneic infants is thought to result in a progressive decrease in heart rate and blood pressure and eventual death and/or brain injury in those who may eventually start gasping and/or breathing (frequently called “birth asphyxia”), based on the cardio-respiratory responses described in asphyxiated newborn monkeys (Fig. 1).10 However, the definition of “birth asphyxia” is imprecise. In low-income countries it has been defined as a failure to initiate spontaneous regular respirations after birth and/or a 5 min Apgar score < 7. This is distinct from the definition in high-income countries which is more comprehensive and includes biochemical evidence of interruption of placental blood flow with a cord arterial pH < 7.00; a distinctive marker of severe acidemia and the need for resuscitation in the delivery room as well as a low 10 min Apgar score.11 The use of more precise terms to describe “birth asphyxia” is advocated in several recent papers.7, 12 Irrespective of definition, defining transitional changes at birth is critical towards understanding the problem of intrapartum-related hypoxia and the importance of basic interventions in the first minutes after birth.
Global estimates on immediate postpartum neonatal needs and interventions are uncertain due to a paucity of data from low-and middle-income countries and almost a complete lack of data from rural community-based settings. Haydom Lutheran Hospital (HLH) is located in rural Northern Tanzania, 300 km, from the nearest urban centre, with a poor rural population in the catchment area. It is the referral hospital for approximately 500,000 people, while the greater reference area covers over two million people.13 HLH provides comprehensive emergency obstetric and basic emergency newborn care. Midwives are the primary providers at most deliveries as well as the initiators of neonatal resuscitation when indicated, with doctors on 24 h backup call. The midwives are trained in basic resuscitative actions (stimulation, mouth suctioning, and providing face mask ventilation when indicated) during nursing school and sporadically re-trained by doctors at HLH. Following birth, infants requiring more than routine care are triaged to a neonatal area; a ten square meter room located within the labour ward, with the capability of administering oxygen, use of wall suction, and providing intravenous fluids and antibiotics. No mechanical ventilation support device is available, thus if required, respiratory support is provided with a self-inflating bag. The infants who are admitted to this area are cared for by family members and labour staff.
The objectives of this study were to define the normal transitional respiratory adaption at birth, to describe interventions performed by birth attendants in the delivery room with ensuing short-term outcomes of the newborns at 24 h, and to assess the importance of the “Golden MinuteSM”14 after birth as it relates to early neonatal outcome.
Section snippets
Methods
This is an ongoing descriptive observational study initiated in August of 2009 at HLH; a rural referral hospital in Northern Tanzania. Research assistants (observers) are continuously present in the labour ward to observe the routine practice of health care providers in the delivery room as well as in the neonatal area through the initial 24 postnatal hours. The observers work in three shifts over 24 h. Three observers cover each shift; two are always located in the labour ward or in the
Results
During the 14 months of the observational period, 5845 newborns were born and evaluated. Of these 5689 infants (97.3%) were liveborn; 56 infants (0.9%) (9 per 1000 live births) died within 24 h and 20 infants (0.5%) remained in the neonatal area at 24 h. Infants who died were of lesser BW (p ≤ 0.0005) and GA (p ≤ 0.0005) as compared to normal infants (Table 1). There were 156 (2.7%) stillborns of whom 93 (1.6%) were categorized as fresh/intrapartum (16 per 1000 births) and 63 (1.1%) as
Discussion
The data in this report for the first time describe the natural transitional respiratory adaption of newborns delivered in a rural setting in a low-income country, and the population of newborns needing basic stabilization/resuscitation in the delivery room. Thus 84% initiated spontaneous respirations within the “Golden Minute SM”, with an additional 15% responding to stimulation/suctioning alone or with FMV by initiating breathing. This proportion of newborns in need of basic resuscitative
Conclusion
The majority of newborn infants, delivered in a rural institution in Sub-Sahara Africa, spontaneously initiate respirations within one minute and a substantial number of apneic babies begin breathing in response to basic actions (stimulation/suction) and/or FMV with a favourable short term outcome in the majority of infants. Infants who required FMV were more likely to die particularly when the intervention was delayed or prolonged. Understanding the factors contributing to the delay in
Conflicts of interest
All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) HLE has received research grants from The Laerdal Foundation for Acute Medicine for the submitted work, (2) Haydom Lutheran Hospital has received project funds from The Laerdal Foundation for Acute Medicine for the submitted work, and (3) JMP has no conflict of interest. The financial source had no role in study design, data
Acknowledgements
This study was made possible because of the research assistants and health providers working in the Maternity Ward at Haydom Lutheran Hospital. Statistical assistance was provided by Bjørn Auestad, PhD, statistician at University of Stavanger. We thank Professors Johanne Sundby, University of Oslo and Eldar Søreide, Stavanger University Hospital for their support.
References (21)
- et al.
Reducing intrapartum-related neonatal deaths in low- and middle-income countries – what works?
Semin Perinatol
(2010) - et al.
Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial
Lancet
(2005) - et al.
Neonatal resuscitation in low-resource settings: what, who, and how to overcome challenges to scale up?
Int J Gynaecol Obstet
(2009) - et al.
Cardiopulmonary resuscitation in the delivery room: associated clinical events
Arch Pediatr Adolesc Med
(1995) - et al.
Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room
Pediatrics
(2006) Methods of resuscitation in low-Apgar-score newborn infants – a national survey
Acta Paediatr
(1992)- et al.
The impact of the neonatal resuscitation program guidelines (NRPG) on the neonatal mortality in a hospital in Zhuhai
China Singapore Med J
(1997) - et al.
Impact of education and training on neonatal resuscitation practices in 14 teaching hospitals in India
Ann Trop Paediatr
(2001) - et al.
Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done?
Int J Gynaecol Obstet
(2009) - et al.
Part 11: Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
Resuscitation
(2010)
Cited by (0)
- ☆
A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.12.011.
- f
Haydom Lutheran Hospital, POB Private Bag, Manyara, Tanzania. Tel.: +255 755876879.
- g
Steinkjellerbakken 4, 5003 Bergen, Norway. Tel.: +4791584567.
- h
Department of Pediatrics, Weill Cornell Medical College 525 East 68th Street, New York, NY 10065, USA. Tel.: +1 212 746 3530.