Globally, about a quarter of all neonatal deaths are caused by birth asphyxia." What are the guidelines and interventions in resource-limited settings for effective resuscitation to reduce neonatal mortality?

Understanding the Challenge & Initial Assessment

Resource-limited settings often lack advanced monitoring equipment and specialized personnel. Therefore, resuscitation protocols must be streamlined and rely on readily available resources. The initial assessment, within the first 30 seconds of life, focuses on three key questions:

• Is the baby breathing? If not, proceed to stimulation.
• Is the heart rate less than 100 bpm? If so, initiate positive-pressure ventilation (PPV).
• Is the baby in shock? Assess for signs of poor perfusion.

Stimulation involves drying the baby, providing warmth, and gently rubbing the back. If the baby doesn’t breathe after stimulation, move to the next step.

Airway Management

Establishing a clear airway is paramount. In resource-limited settings, this is often achieved through simple positioning – placing the baby in a sniffing position – and clearing the airway using a bulb syringe or suction device. Avoid deep suctioning, as it can cause bradycardia. The use of a cloth or towel roll under the shoulders can help maintain the sniffing position.

Breathing Support: Positive Pressure Ventilation (PPV)

PPV is the cornerstone of resuscitation for babies who are not breathing or have a heart rate less than 100 bpm. In resource-limited settings, bag-valve-mask (BVM) ventilation is the preferred method. Key considerations include:

• Appropriate Mask Size: A correctly sized mask is crucial for effective ventilation.
• Effective Seal: Ensuring a tight seal between the mask and the baby’s face is essential.
• Ventilation Rate: 40-60 breaths per minute.
• Monitoring Chest Rise: Visible chest rise indicates effective ventilation.

Alternatives to BVM in extremely resource-constrained settings include mouth-to-mask or mouth-to-nose ventilation, although these are less effective and require careful training.

Circulation Support

If the heart rate remains below 60 bpm after adequate ventilation for 15-30 seconds, circulation support is needed. This primarily involves:

• Chest Compressions: Performed at a rate of 120 compressions per minute, coordinating with ventilation (3:1 compression-to-ventilation ratio).
• Volume Expansion: If signs of shock are present (pale, mottled skin, weak pulse), consider volume expansion with normal saline or ringer’s lactate, if available.
• Epinephrine: Reserved for cases unresponsive to ventilation, chest compressions, and volume expansion.

Challenges and Solutions in Resource-Limited Settings

Several challenges hinder effective neonatal resuscitation in resource-limited settings:

• Lack of Trained Personnel: Investing in training programs for skilled birth attendants, nurses, and community health workers is crucial. The Helping Babies Breathe (HBB) program is a widely used, evidence-based training program.
• Limited Equipment: Prioritizing the availability of essential equipment like BVMs, suction devices, and oxygen sources is vital. Exploring low-cost alternatives and ensuring proper maintenance of existing equipment are also important.
• Poor Infrastructure: Reliable electricity and transportation are essential for timely access to care. Developing strategies to overcome these limitations, such as using solar power and establishing referral networks, is necessary.
• Delayed Recognition of Asphyxia: Improving antenatal care and early identification of risk factors can help prevent birth asphyxia.

Post-Resuscitation Care

Following successful resuscitation, ongoing monitoring of vital signs, temperature control, and blood glucose levels is essential. Early breastfeeding should be encouraged, and the baby should be closely observed for any signs of complications.