In disaster situations, even the minimum care of pregnant woman and newborn babies will prevent a significant amount of morbidity and mortality. Usually a majority of deliveries can be managed successfully with minimum intervention from healthcare workers. The health workers need to be prepared and trained to conduct deliveries and take care of newborn babies even in the absence of any hospital facilities.

The HCW should be able to identify high-risk pregnancies and at-risk newborns so that

Perinatal conditions associated with High Risk Deliveries Maternal Conditions: Presentation other than vertex Vaginal bleeding Non progressing labour (>12 hours in primigravida) >6 hours in multigravida) Non-descent of head despite good uterine contractions Rupture of membranes without labor pains for >12 hours Maternal exhaustion (pulse >120/mt; dry tongue; systolic BP <90 or >140 mmHg) Cord/Hand prolapse Fetal Conditions: Multiple gestation Multiple congenital anomalies (when prediagnosed) Fetal distress (FHR <120 Hm or >160 bpm, meconium stained liquor Pre Term (<36 weeks or post term (>42 weeks) Anticipated low birth weight (<2.0 kg) or high birth weight (>4.5 kg)

The HCW should be able to identify high-risk pregnancies and at-risk newborns so that referral, if possible could be arranged timely. Preferably both, the mother and newborn baby should be transported and kept together.

Referrals of At-risk Newborns to Hospital Extremely low birth weight (<1500 gram), or gestational age (<34 weeks) No spontaneous breathing or severe respiratory distress (grunting, in-drawing of chest, and cyanosis) Seizures and unconscious baby Hypothermia (rectal temperature <35 degree Celsius) Severe pallor, abdominal distension, bleeding Jaundice in first 24 hours Severe birth injury Severe congenital malformations Baby not passing stool in first 24 hours and urine in first 48 hours of life Baby who remains excessively drowsy or cry incessantly Baby not accepting feeds at all

Training Health Workers for Normal Delivery

1. As the labor pains begin, boil 2 lengths of cotton thread (approx 3 inches each) and a sharp instrument (like scissors/blade) for 20 minutes and keep them in the same water. The person assisting the delivery should wash their hands with water and soap and preferably use gloves, if available.
2. Ask the mother to push down when she feels pain, and to rest when the pain stops.
3. When the head is seen, place hand on the baby's head as it is coming out to reduce its speed. Bend the head gently downwards with one hand and support the perineum to avoid a tear with the palm of the other hand.
4. As the head delivers, support the baby's head with both hands very carefully to help the shoulders come out first. Then raise the head to ease the rest of the body to come out.
5. Cut the cord, at a minimum 3 inches away from baby's body with the sterile scissors/ blade/ knife. (In case of dire emergency when there is no time to boil the instrument for 20 minutes, use any sharp instrument like kitchen knife, razor or blade - sterilize it on a flame for 2 to 3 minutes).
6. Normally, the placenta delivers itself within 5 to 10 minutes. A sudden gush of blood indicates that the placenta has separated. Assist the delivery of the placenta by gentle and downward pull on the cord with one hand and gentle pushing of the uterus upwards per abdomen with the other.
7. Examine the placenta to see if it has come out completely along with its membranes.
8. If available, give inj. Methargin 1 amp IM either at the delivery of anterior shoulder or after the expulsion of placenta.
9. Give a uterine massage in case of excessive bleeding (put your hand on the uterus per abdomen and rotate movements till the uterus feels hard). Normally this rectifies on its own. If not seek help.
10. If suture material is available (and the HW is trained) then the episiotomy/ tear should be stiched, otherwise or help should be sought for this.

Training Health Worker For Care of the New Born Baby

Note the time (and date) of delivery, Receive baby in a clean (and warm) cloth, clean the secretions & blood from head, face and trunk, Tie the cord at two places and cut in between. Put the baby skin-to-skin on mother's chest. Ensure that breast-feeding is started within half an hour. Wrap the baby in a dry warm cloth/ towel/ blanket. If the baby cries immediately after birth and continues crying for some time, and breathing is normal then NO resuscitation is needed; provide normal care, Start resuscitation immediately, if the baby does not cry OR breathing is not normal (gasping, difficulty in breathing, asymmetric rise in chest, breath rate <30/minute), or the baby is listless or blue.

Feeding of Newborn Baby Start breast-feeding within ½ hour of delivery and keep the baby by the side of the mother. Do not give pre lacteal feeds like ghutti, glucose, honey etc. Ensure regular and frequent feeds on demand. Feed the baby alternately on both breasts. Breast milk is adequate for all needs of water and nutrients for first 6 months of life. Adequately breastfed child will pass urine 6-8 times in 24 hours (after 48 hours of age). Ensure adequate food and support to lactating mothers.

Training the Health Worker For New Born Resuscitation

• Position the baby on its back on a dry, clean, and, if possible, warm surface next to mother. Keep the head slightly extended by keeping a folded piece of cloth under the shoulder.
• To clear the airways, suction first the mouth and then nose. A mucus trap, bulb suction or infusion set (cut on both sides of reservoir) may be used. When proper suction machine is available use suction catheter Fr. Gauge 10 and pressure 100 cm of water. Be thorough if there is blood or meconium in baby's mouth.
• Most babies will start breathing by now.
• If still not breathing start ventilating the baby with the help of Ambu Bag and facemask of appropriate size (size 0 for small babies and size 1 for bigger babies).
• Place the mask (fitted to Ambu Bag) on face of the baby covering chin, mouth, and nose. Ensure a seal between the mask and baby's face and squeeze the bag 30-40 times a minute. The chest should rise with each squeeze. If it does not, then check the seal between the bag and face, reposition the head and baby, clear the secretions from mouth, or increase the pressure by squeezing the bag with the whole hand. The first few ventilations require higher inflation pressure.
• When Ambu Bag is not available mouth and mask ventilation may be given. In an emergency even mouth-to-mouth ventilation may have to be given, however the latter should be avoided as far as possible.
• After ventilating for 30 seconds stop and look for spontaneous breathing. If the baby starts crying or breathing then stop ventilating. If not, continue ventilating till either the baby responds or transported. If there are none or weak breathing efforts then continue ventilation and see heart rate (HR) or umbilical cord pulsation at it's base. If HR is below 60 per minute or absent continue the ventilation while an attendant or helper provides chest compression. Encircle the chest by both hands, place thumbs on lower third of the sternum and compress the chest to one third of the anterio-posterior diameter of the chest to generate a palpable impulse. One ventilation should follow every third chest compression. In one minute 90 chest compressions and 30 ventilations should be carried out to a total of 120 events.

Role of Medications in Resuscitation Medicines have very little role in neonatal necessitation and negligible role (in resuscitation) during disaster situations. Adrenaline is indicated when HR is zero or below 60 after 30 seconds of ventilation and chest compression. Dissolve 0.5 ml of Adrenaline 1:1000 in 5 ml of saline and give 0.1 ml/kg IV rapidly. Naloxone is given when baby has respiratory depression with history of narcotics administration to the mother 4 hours before delivery. Give 0.25 mg / kg (0.1 mg/kg) of 0.5 mg/kg solution. IV/ IM/SC/IT In case of acute bleeding or signs of hypovolemia give 10 ml/kg of Normal saline/Ringer's Lactate Intravenously over 5-10 minutes.

Ventilate and compress chest continuously and monitor every 30 seconds for HR. Once the HR is 60 beats per minute or more chest compression should be discontinued. Continue the ventilation and assess the baby every 30 seconds till spontaneous breathing starts. If the baby requires continued ventilation and/or chest compression then arrange for referral, if possible. Transfer for mother should also be arranged along with the baby If there is no gasping or breathing at all after 20 minutes of ventilation, stop ventilating. If there is gasping but no spontaneous breathing after 30 minutes of ventilation, stop ventilating.

Care After Successful Resuscitation

Signs of Well being in Newborn Pink Skin Body Temperature >37°Celsius Normal breathing (40-60 breaths per minute) Occasional cry Good suckling, accepting breast feeding Passes stool first time within 24 hours of life Passes urine first time within 48 hours of life

Check the mother's condition. Ensure that she has delivered placenta, is not bleeding or convulsing. Examine the baby in detail and observe for malformations, birth injury or other signs Talk to her about the well being of the baby and what you did. Advice her about exclusive breast-feeding. Certain practices are not useful in resuscitation and may even be harmful

During this phase, childbirth may have to be conducted by untrained persons. Help of an elderly lady is useful till a Health care worker arrives. Delivery should be conducted as per the guidelines given above.

The childbirth can be better managed in this phase by ensuring the presence of trained persons during the delivery. Basic equipment, better support by referral center, and some medicines can be available now. There is a very little role of medications in resuscitation. However, the medicines may be used whenever indicated.

Ten Harmful (Or Not So Useful) Practices In Early Newborn Care Routine suction of mouth and nose as soon as the head is delivered. Routine suction of mouth (after delivery of baby) when baby is crying and active. Routine stomach wash of the baby. Flicking the soles or rubbing or slapping the back when baby is crying and active. Putting the baby upside down for postural drainage. Squeezing the chest to remove secretions from the airway. Routinely giving soda bicarb in babies who are not breathing. Putting endotracheal tube by an unskilled person. Apply cow dung, ash, or anything on umbilical cord stump. Giving pre-lacteal feeds like honey, glucose water, ghutti, etc

By this time it is expected to have near normal health care services. The delivery should preferably occur in a maternity center or hospital. Although the procedure described above can be used during this phase also it is advised that standard protocols and procedures (respecting the customs and traditions of the community) should be practiced during delivery and for resuscitation of the newborn baby.