Factors affecting effective ventilation during newborn resuscitation: a qualitative study among midwives in rural Tanzania

ABSTRACT

Background: Intrapartum-related hypoxia accounts for 30% of neonatal deaths in Tanzania. This has led to the introduction and scaling-up of the Helping Babies Breathe (HBB) programme, which is a simulation-based learning programme in newborn resuscitation skills. Studies have documented ineffective ventilation of non-breathing newborns and the inability to follow the HBB algorithm among providers.
Objective: This study aimed at exploring barriers and facilitators to effective bag mask
ventilation, an essential component of the HBB algorithm, during actual newborn resuscitation in rural Tanzania.
Methods: Eight midwives, each with more than one year’s working experience in the labour ward, were interviewed individually at Haydom Lutheran Hospital, Tanzania. The audio recordings were transcribed and translated into English and analysed using qualitative content analysis.
Results: Midwives reported the ability to monitor labour properly, preparing resuscitation
equipment before delivery, teamwork and frequent ventilation training as the most effective factors in improving actual ventilation practices and promoting the survival of newborns. They thought that their anxiety and fear due to stress of ventilating a non-breathing baby often led to poor resuscitation performance. Additionally, they experienced difficulties assessing the baby’s condition and providing appropriate clinical responses to initial interventions at birth; hence, further necessary actions and timely initiation of ventilation were delayed.
Conclusions: Efforts should be focused on improving labour monitoring, birth preparedness and accurate assessment immediately after birth, to decrease intrapartum-related hypoxia. Midwives should be well prepared to treat a non-breathing baby through high-quality and frequent simulation training with an emphasis on teamwork training.

Read more here.

Fresh stillborn and severely asphyxiated neonates share a common hypoxic–ischemic pathway

Abstract
Objective: To characterize, among non-breathing flaccid neonates at delivery, immediate heartrate and responses to ventilation in relation to the clinical diagnosis of fresh stillbirth (FSB) or early neonatal death (END) within 24 hours.
Methods: The present cross-sectional study included all deliveries at Haydom Hospital in rural Tanzania between July 1, 2013, and July 31, 2016. Ventilation parameters and heartrate were recorded by monitors with ventilation and dry-electrocardiography
sensors. Perinatal characteristics were recorded on data forms by trained research assistants.
Results: Among 12 789 neonates delivered, 915 were ventilated; among ventilated  neonates, there were 53 (6%) FSBs and 64 (7%) ENDs. Electrocardiography was used in 46 FSBs and 55 ENDs, and these neonates were included in a subanalysis. Initial heartrate was detected in 27 (59%) of 46 FSBs and 52 (95%) of 55 ENDs, and was lower in FSBs (52 ± 19 vs 76 ± 37 bpm; P=0.003). More ENDs responded to ventilation (53% vs 9%; P<0.001), with heartrate increasing above 100 bpm. Heartrate at ventilation discontinuation was higher among ENDs (115 ± 49 vs 52 ± 33 bpm; P<0.001).
Conclusion: Progression to FSB or END after intrapartum hypoxia/anoxia is probably
part of the same circulatory end-process. Distinguishing FSB from severely asphyxiated
newborns is clinically difficult and probably influences estimated global perinatal
mortality rates.

Read the full publication here.

A Study on Educational Intervention Study Published

Helping Babies Breathe (HBB) is a simulation-based educational program developed to help reduce perinatal mortality worldwide. A one-day HBB training course did not improve clinical management of neonates. The objective was to assess the impact of frequent brief (3–5 min weekly) onsite HBB simulation training on newborn resuscitation practices in the delivery room and the potential impact on 24-h neonatal mortality. The results showed that on-site, brief and frequent HBB simulation training appears to facilitate transfer of new
knowledge and skills into clinical practice and to be accompanied by a decrease in neonatal mortality. Read the full publication here.

Dr. Jørgen Linde Presents at Norwegian Research Competition

Dr. Jørgen E. Linde, one of the Safer Births PhD fellows, presented his research project at the “Forsker Grand Prix,” the national championship competition for researchers in Norway.

jorgen-1

Jørgen’s presentation “When life is a breath away” was nominated by the audience and the jury as the winner from the Stavanger Region, leading him to represent his work at the final competition in Bergen this fall.  Linde’s presentation included his findings on how his study showed that giving higher volumes when ventilating than the guidelines recommend produces better outcomes.  He also spoke about the importance of using heart rate as a form of feedback during ventilation and various techniques that can be used to optimize bag and mask ventilation.  The judges gave Jørgen’s presentation the top score, and emphasized how important they felt his research was.

jorgen-2

Haydom Begins RCT on Upright w/ PEEP

Haydom Hospital has recently begun a randomized control trial (RCT) comparing the Upright bag-mask with and without PEEP (positive end-expiratory pressure). PEEP is considered to benefit newborn and small infants by preventing repeated lung alveolar collapse, helping recruit lung volume more efficiently, clearing fluid from the lungs and reducing damage to the lung tissue during ventilation. The international Liaison Committee on Resuscitation (ILCOR) suggests using PEEP for preterm infants during delivery room resuscitation. However, ILCOR is unable to make any recommendation for term infants due to insufficient data. The RCT in Tanzania will be helpful in providing the data needed to support use of PEEP in order to improve newborn ventilation.

upright

Positive Results on Training in Neonatal Ventilation with PEEP

Dr. Monica Thallinger’s work using Upright with Newborn PEEP was recently published in the British Medical Journal. Positive end expiratory pressure (PEEP) is considered to be beneficial when ventilating preterm newborns. The aim of Thallinger’s study was to determine whether inexperienced providers were able to generate PEEP during simulated neonatal ventilation. Her study showed that inexperienced participants were successfully able to generate PEEP with a novel silicone PEEP valve attached to an upright self-inflating bag, without an external gas source. Read the full publication here.