Helping Babies Breathe - Facilitator Flip Chart

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CONTINUE READING
Helping Babies Breathe
                                            Facilitator Flip Chart

                                                                     © American Academy of Pediatrics, 2010

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Start 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.
                       breastfeeding for all babies.                                20-0037120-00371
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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

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As a skilled birth attendant,
                                              you make the difference

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                                                                               2

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Exercise: 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

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Exercise: Preparation for a birth

                                                                             3

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Present 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

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At birth

                                           Dry thoroughly

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           If meconium-stained
               amniotic fluid,
        clear the airway before drying.

                                                               4

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Present 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.

                                                                               5

                                                                                                                                                                                                                              5b

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Evaluation after drying

                                           Is the baby crying?

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                                                                           5

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Present 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

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If the baby is crying

                                                  Keep warm,
                                            check breathing, cut cord
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                                                                              6

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Present 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

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                                            How to clamp or tie and cut the umbilical cord

                                                                                                7

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Exercise: 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

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                                                Exercise: Routine care

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                                                                            8

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Present 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

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If the baby is not crying

                                              Clear the airway
                                           and stimulate breathing
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                                                                               9

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Present 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

                                                                                                                                                                                                                                                               10b

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After clearing the airway and stimulation

                                           Is the baby breathing well?

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                                                                                           10

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Exercise: 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

                                                                                      ............................................................
                                                                                                                                                                                                                                   11 b

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Exercise: The Golden Minute®
                                               – clear the airway and stimulate breathing

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                                                                                            60 sec

                                                                                                      11

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Present 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.

                                                                                                                                                                                                                                                                                                 12b

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If the baby is still not breathing well, cut cord and

                                           Ventilate with bag and mask

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                             rev B rev B

                                                                                                      12

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Present 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.

                                                                                                                                                                                                                                                                        13b

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How to ventilate with bag and mask

                                                                             13

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Present 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.

                                                                                14

                                                                                                                                                                                                                                      14b

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During ventilation

                                            Is the baby breathing well?

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                              rev B rev B

                                                                           14

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Exercise: 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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                         - breathes after 		                                     ............................................................
                            brief ventilation                                    Monitor with mother

                                                                               ............................................................
                                                                            *Alternative: Position baby beside
                                                                             mother with cord intact

                                                                                                                                                                                                                              15b

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Exercise:
                                           The Golden Minute® - ventilation
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                             rev B rev B

                                                                              60 sec

                                                                                        15

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Present 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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                                                                                              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

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If the baby is not breathing

                                              Call for help
                                           Improve ventilation
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                             rev B rev B

                                                                              16

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Present 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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                                                                                                                        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 08.49
If 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 08.49
Present 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 08.49
If 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 08.49
Present 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
                           20-0037120-00371
                                    rev B rev B

                                                                                                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

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If 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

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Present 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

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If transfer is necessary

                                       Transport mother and baby together,
                                             and support the family

                                                                               20

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Exercise: 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 08.50
Exercise:
                                           Continued ventilation with
                    20-0037120-00371
                             rev B rev B
                                               normal heart rate

                                                                         21

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Exercise: 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 08.50
Exercise:
                                           Continued ventilation with
                    20-0037120-00371
                             rev B rev B
                                                slow heart rate

                                                                         22

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or 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

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