Neonatal Care Workbook by yho59756

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									       PARTICIPANTS WORKBOOK

N E O N ATA L E X P E R I E N T I A L L E A R N I N G S I T E
   Pietermaritzburg Metropolitan Hospitals Complex




                                                 Pietermaritzburg
                                                      June 2007
ii
                                    CONTENTS

     Introduction                                                      1

A.   Self Assessment

1.   Skills audit                                                      2

2.   Your objectives                                                   4

3.   Review of your neonatal unit                                      5

B.   Topics

1.   Topic 1: Neonatal Resuscitation
                       • Objectives                                    8
                       • Key learning points                           8
                       • Skills assessment                             9
                       • Self assessment questionnaire                 9
                       • Drug doses                                   11
                       • Case studies                                 12
                       • Report                                       16
                       • Quality improvement                          16

2.   Topic 2: Routine Management of Well Infants
                      • Objectives                                    18
                      • Skills assessment                             18
                      • Self assessment questionnaire                 19
                      • Case study                                    21
                      • Quality improvement                           23

3.   Topic 3: Managing Premature, Low Birth weight and Sick infants
                      • Objectives                                    24
                      • Skills assessment                             25
                      • Self assessment questionnaire                 26
                      • Drug doses                                    28
                      • Case studies                                  29
                      • Report                                        34
                      • Quality improvement                           34

4.   Topic 4: Prevention of Mother to Child Transmission of HIV
                       • Objectives                                   36
                       • Self assessment questionnaire                36
                       • Case study                                   38
                       • Report                                       39

C.   Quality Improvement

     Quality improvement project                                      41




                                         iii
                    N E O N ATA L C A R E W O R K B O O K

Introduction

This workbook is intended to be a companion and guide for you during your time at the
neonatal learning site. It is not a text book and does not contain information; you will
receive other protocols and guidelines which you can use as resources to find information
that you do not know. Completing this workbook will ensure that you have covered the
key learning points during your time at the learning site and your answers will provide a
starting point for discussions with your supervisor.

The workbook includes:
   • A skills audit which you should complete at the beginning of your time at the
      learning site. This is a self learning tool to direct your learning and to ensure that
      gaps in your knowledge and skills are addressed.
   • Space for you to write your objectives for the time at the learning site, so that a
      timetable can be planned in such a way that you can fulfil your objectives.
   • A site review looking at equipment available at your neonatal unit and comparing
      this with the norms and standards set out by the Department of Health. You
      should complete this before coming to the learning site if possible. If you are
      lacking important equipment at your site this can be addressed, as it is not
      possible to provide good quality care without adequate equipment.
   • Self assessment quizzes on key topics are included so that you can be sure that
      you have the correct factual information on key points. There are no answers
      provided for the self assessment quizzes, you are expected to go and look up any
      information that you are not sure about. You will have an opportunity to go
      through each quiz with your supervisor during your time at the learning site and
      discuss any queries or problem areas.
   • A number of key practical skills that you are encouraged to practise under
      supervision while at the learning site and members of staff will sign these off to
      show that you completed these tasks.
   • Case studies to be completed. These are exercises and are designed to illustrate
      important clinical problems that arise at district hospital level. You will be expected
      to look up or ask about any aspects of these cases that you are not sure about,
      and to discuss the case studies with your supervisor.
   • Case reports that you should write up either during your time at the learning site
      or later at your own site. You should choose cases which illustrate interesting
      learning points or difficult clinical cases which show problems that may happen in
      the real situation. You will also discuss these cases with your supervisor.
   • At the end of the workbook, there is space for you to write a report on a quality
      improvement project you have undertaken at your own site. This will comprise a
      simple analysis of a problem in providing good quality care that you have observed
      at your site. You will then propose solution(s) to this problem, implement the
      solution and monitor/evaluate the success of your solution.                 This quality
      improvement project will have to be completed before you receive a certificate of
      having completed a course at the learning site.




                                              1
A. SELF ASSESSMENT

1. Skills audit


This skills audit is a tool to help you assess your essential skills. It should be seen as a
baseline evaluation and help you to identify areas in which you may want to develop your
skills further. It is based on the McCord DEPAM & Vocational Training & SCEPAM
Programs Competency Assessment tools.


PLEASE FILL IN THE LIST AS HONESTLY AS YOU CAN


             0       No knowledge or skill
             1       Vague knowledge
             2       Good knowledge
             3       Experience but need supervision/support
             4       No need for supervision
             5       Can do this and have taught to others


           Name:…………………………………………… Date:………………………

Neonatal health                                                 0    1    2    3    4    5
A1    Diagnose asphyxia
A2    Resuscitation of a neonate
       Selective suctioning e.g. meconium
       Face mask ventilation
       External cardiac massage
       E.T. intubation
       Maintain & use appropriate equipment
       Control & use appropriate medications & fluids
A3    Initial assessment
       Examination
       Gestational age (SPLEN/Ballard)
       Check for congenital abnormalities
A4    Manage nutritional and fluid requirements
       Breastfeeding
       Artificial e.g. formula
       Nasogastric tube feeding
       Cup feeding
       Putting up peripheral IV infusion on neonates
       Umbilical vein catheterisation
       Monitoring of fluid intake and IV site
       Use fluid controller
       Give additives to feeds/fluids
       Monitoring and maintenance of glucose
       Calculation of feeds and fluids for neonates

                                                2
Neonatal health cont.                                 0   1   2   3   4   5
     Promote neonatal bonding in well and sick
A5
     neonates
     Developmental care
     Kangaroo mother care (KMC)
A6   Promote thermo neutral state and homeostasis
     Brown fat metabolism
     Heat loss
A7   Identify and manage neonatal problems
     Premature infant
     Growth retarded neonate
     Respiratory distress, HMD & apnoea
     Hypoxic Ischaemic Encephalopathy (HIE)
     Convulsions
     Jaundice & phototherapy
     Anaemia
     Hypoglycaemia
     Hyperglycaemia
     Hypothermia
     Hypoxaemia
     Acidosis
     Bleeding
     Trauma
     Septicaemia & other severe neonatal infections
     Neonatal tetanus
     Meningitis in the neonate
     GIT abnormalities
     Cardiac abnormalities
     HIV positive infants
     Pneumonia
A8   Transportation of a sick neonate
     Kangaroo mother care
     Transport incubator
     Stabilisation
     Notes and communication




                                          3
2. Your objectives

Write below any skills or knowledge that you feel are gaps in your competence and that
you want to develop while you are learning about neonatal care. You should discuss this
list with your supervisor and make sure that all the gaps in your knowledge or skills are
addressed while you are at the learning site, if possible.

1)   ____________________________________________________________________________________


2)   ____________________________________________________________________________________


3)   ____________________________________________________________________________________


4)   ____________________________________________________________________________________


5)   ____________________________________________________________________________________


6)   ____________________________________________________________________________________


7)   ____________________________________________________________________________________


8)   ____________________________________________________________________________________




                                                 4
3. Review of your neonatal unit

In this section you should review the facilities and equipment that are available in the
neonatal unit at your hospital. You should compare this with the norms and standards
that are set out by the KZN Department of Health to see if you have the correct number of
beds and quantity of equipment available to provide an appropriate quality of care. The
norms and standards set out below are for a district (level one) hospital.



Beds
No. of deliveries in catchment area____________(include clinic deliveries)

                                        Number that
                                                         Actual number        Number
       Item            Norm set out      should be
                                                           available          required
                                          present
                        3 per 1000
Total beds
                         deliveries
                        1 per 1000
High care beds
                         deliveries
                        1 per 1000
General beds
                         deliveries
                        1 per 1000
KMC
                         deliveries

The following general equipment should be available in the neonatal unit:
Check that the equipment is in working order before recording it

                                        Number that                            Number
                                                         Actual number
        Item           Norm set out      should be                           required for
                                                           available
                                          present                              nursery
Double O2 flow
                       1 per O2 point
meter
Suction unit            1 per point
Pulse oxymeter         1 per nursery            1
Bassinette               1 per bed
Cardiac trolley        1 per nursery            1
Electronic infant
                       1 per nursery            1
scale
Stethoscope            2 per nursery            2
Diagnostic set         1 per nursery            1
Patella hammer         1 per nursery            1
Glucometer             2 per nursery            2
Haemoglobinometer      1 per nursery            1
Calculator             1 per nursery            1
Portable O2            2 per nursery            2
Portable suction       1 per nursery            1
Angled
                       1 per 3 beds
phototherapy lights
Head box               1 per O2 point




                                            5
                                     Number that                          Number
                                                     Actual number
      Item           Norm set out     should be                         required for
                                                       available
                                       present                            nursery
                     1 per 2 head
Oxycheck
                        boxes
Heating pad          2 per nursery        2
Breast pump          2 per nursery        2
Spot light           2 per nursery        2
Resuscitaire         1 per nursery        1
Resuscitation set:
Laryngoscope
handles –            2 per nursery        2
neonatal
Blades – straight
                     1 per nursery        1
size 0
Blades – straight
                     1 per nursery        1
size 1
Small Macgills
                     1 per nursery        1
forceps
Ambubag –
infant (neonatal     1 per nursery        1
masks)
Bilirubinometer      1 per nursery        1
X-ray viewing
                     1 per nursery        1
box

In addition the following equipment should be available for each high care bed:
Check that equipment is in working order
                  Allocated                                          Number
                                    Norm (x no of   Actual number
                  number per                                         required for
                                    high care beds) available
                  high care bed                                      high care
Double O2 flow
                          1
meter
O2 blender                1
Suction unit              1
Closed
                     1 per 2 beds
incubator
ICU crib             1 per 2 beds
Pulse oxymeter            1
Infusion pumps            1
Drip stand                1
Syringe pump              1
Dinamap              1 per 5 beds
Apnoea alarm              1
Head box                  1
Ambubag                   1
Stethoscopes              1
Heat shield               1




                                          6
7
B. CLINICAL NEONATAL TOPICS

1. Neonatal resuscitation

1) Objectives

On completion of this topic you should have the knowledge and skills to complete
the following tasks:
       Selecting and checking equipment for resuscitation
       Assessing condition of the baby at delivery and monitoring progress during the
       resuscitation
       Management of meconium stained liquor during resuscitation
       Bag and mask ventilation
       Cardiac compressions
       Intubation (optional)
       Insertion of an umbilical venous line (optional)
       Appropriate administration of naloxone
       Appropriate administration of adrenaline
       Decide when to stop resuscitation
       Describe situations when it may be inappropriate to initiate resuscitation


2) Key learning points for neonatal resuscitation
       Resuscitation requires a team approach. Do not attempt to resuscitate on your
       own - call for help. Even a mother can be of assistance.
       It is important that the baby is kept warm on a resuscitaire or incubator during
       resuscitation.
       Dry and stimulate the baby by rubbing his back, chest or feet. This is often all the
       baby needs in order to start breathing. However if baby is in secondary apnoea he
       will require active resuscitation.
       Routine suctioning is never indicated. It is required where there is exposure to and
       the risk of aspiration of blood, meconium and faeces. In these instances it is best
       to suction under direct vision, using a laryngoscope to visualize the vocal cords
       using a soft catheter (F8 or F10) which should not be inserted more than 5cm
       beyond the mouth or nose.
       The most important thing during resuscitation is to maintain oxygenation and this
       can be done with a bag and mask in most cases. Intubation should only be done
       by staff who are well trained and competent
       Erect IV therapy as soon as possible in order to administer fluids, glucose and
       resuscitation meds.
       A delivery room should have a variety of face masks for preterm, term and large
       newborns (i.e. sizes 00, 0, 1 and 2) and appropriate size ET tubes (i.e. 2.5, 3.0,
       3.5) and laryngoscope blades (i.e. sizes 00, 0 and 1)
       A Laerdal Ambubag is designed to deliver high concentrations of oxygen but
       should be checked before use to make sure that it is functioning properly
       All equipment should be checked before the baby is delivered, it is too late to look
       for missing equipment once the baby is born and delays in starting resuscitation
       can result in long term complications for the baby.


                                              8
3) Resuscitations skills assessment

You are expected to practise the following skills during the time that you are at the
learning site. The first six activities will be done on a manikin, so you will need to make a
time with your supervisor when these can be done. Once you have completed these
tasks adequately, ask your supervisor to sign.

Other activities should be completed if you have the opportunity while you are at the
learning site to participate in a resuscitation situation. Ask the senior member of staff
present to sign these for you. If he/she decides you completed the task competently you
will receive two signatures. Otherwise you should try and practise the task again until the
supervisor can sign in the box for competency.


                                                                                Completed
                                      Completed
                                                  Comments for learner          competently
                                      (Signature)
                                                                                (Signature)
Checking equipment
Bag and mask practice on manikin
Intubation practice on manikin
Simulated resuscitation scenario 1
with manikin
Simulated resuscitation scenario 2
with manikin
Synchronised breaths and cardiac
compressions
Immediate routine care of a
newborn following delivery
Suction of a baby where there is
meconium at the delivery
Bag and mask ventilation on baby
Assessment of heart rate and
respiration
Participated in resuscitation
situation
Calculation and administration of
resuscitation meds
Intubation of a baby (optional)


4) Self assessment resuscitation questionnaire

1) Give the three important things that you should check at delivery to decide whether
   resuscitation is required.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) How can you check the heart rate in a newborn?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



                                             9
3) When suctioning a newborn should you start with the nose or the mouth? Why?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) In what circumstances might you decide not to start resuscitation of a newborn?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) If a baby is breathing, but you want to administer oxygen, how could you do this?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) When you are ventilating a baby with a bag and mask, what signs will show you that
   your ventilation is adequate? If it not adequate, what should you do?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) In what circumstances would you decide to intubate a baby?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) If a baby is not responding to bag and mask ventilation and the heart rate remains
   below 60 - describe exactly how much adrenaline you would give and how this should
   be given.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) How much naloxone (Narcan®) should you give if the mother of a term baby weighing
   approximately 3 kg was given pethidine 4 hours before delivery?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) Describe the difference between primary and secondary apnoea? How can you tell the
    difference when you assess a newborn at the time of delivery?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


                                          10
11) What are the dangers of suctioning a newborn and how can these be avoided?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


12) When should a volume expander be given? How much should be given, what fluid
    and over how long? How often can they be repeated?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


13) What size ET tube should you choose for a 1.2 kg baby and at what level should it be
    strapped?
   ___________________________________________________________________________________

   ____________________________________________________________________
   ____________________________________________________________________


14) When should you commence chest compressions and when should you stop?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


15) At what point should CPR be discontinued?
    a) If successful
    b) If unsuccessful
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



5) Calculating drug doses for resuscitation

1) What is the dose of adrenaline for a 2 kg baby? Describe how adrenaline is prepared
   and how it may be administered.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) What is the dose of naloxone to be given to a baby who is 2 kg (give dose in mg and
   in mls). Describe how this should be administered?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



                                              11
3) What would be the dose of naloxone if the baby weighed 3.5 kg?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) How much Ringers Lactate should you give a 3 kg baby with poor perfusion and a low
   blood pressure? What other fluid could you give?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



6) Neonatal resuscitation - Case Studies

a. Case Study 1: Thobile

Thobile, 24 year-old, presents to the labour ward in the evening, with a history of
contractions for the whole day. It is her first baby and she tells you that the baby is not
due for another 3 months. When you look at the antenatal card she is 30 weeks gestation
by dates, and on examination she is also 30 weeks by palpation. On PV examination the
cervix is fully dilated, the foetal heart is 120 and reactive, there is no meconium staining of
the liquor.

1) Describe how you would prepare the resuscitation trolley - what equipment is needed?
   Is there anything particular that you would need to have available when you are
   expecting the delivery of a low birth weight baby?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) What type of ambubag should be used for resuscitation? Describe what actions are
   needed to appropriately check that the ambubag is in good working order.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


3) You also see in the antenatal card that she has been tested for HIV, is HIV positive
   and enrolled in the PMTCT program. She has not taken her nevirapine. What can
   you do now to try to reduce transmission of HIV to the baby?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                              12
4) You take the baby at delivery and transfer to the resuscitaire.
   Describe how you would quickly assess the condition of the baby.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ________________________________________________


5) On your initial assessment the baby is small, you estimate about 1.5 kg, he is pale and
   limp but making some gasping respirations. His hands and feet, as well as the
   tongue, are blue. The heart rate is below 100. He is not responding to stimulation.
   What is the Apgar score?
   ________________________________________________________


6) Describe your initial actions in this situation.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) After drying and initial stimulation the baby starts moving and has a heart rate above
   100, but is still not breathing regularly.
   What will you do next?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) The baby is now 3 minutes old and is breathing regularly, is active and crying. He is
   pink and the heart rate is above 120.
   What is the Apgar score now?
   _________________________________________________________


9) Give three things that should be monitored in this baby to prevent complications?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) Write this case up as if you were completing the case notes.
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


                                            13
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ________________________



b. Case Study 2: Busi

Busi is 18 years old and presents to the labour ward at term with a history of regular
contractions. This is her first baby and she has had an uneventful pregnancy but only
attended the antenatal clinic twice. As you are about to examine her she says that she
wants to push and you find that she is fully dilated and the head is on the perineum.
There is grade 1 meconium staining of the liquor and listening to the foetal heart you find
that the foetal heart rate is below 100. Twenty minutes later she delivers a term baby
weighing 2.5 kg who is “flat” at delivery.

1) What will be your initial management?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) What is the management of the meconium stained liquor in this situation?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


3) The baby is floppy, not responding to stimulation, there is central cyanosis and the
   baby is making no respiratory effort. The heart rate is 60. What are the next steps in
   the resuscitation?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) After 30 seconds of resuscitation the heart rate remains 60 and the baby is still making
   no respiratory effort.
   What will you do now?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) After a further 30 seconds with no improvement you decide to intubate the baby.
   What size ET tube would you choose for this baby?
   ______________________________________________________




                                            14
6) Which ways could you use to check whether the tube is in the correct place?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) What drugs will you give if any? Mention the dose and method of administration of the
   drug(s).
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) At 20 minutes of age the baby still has a bradycardia and apart from a few gasps has
   made no respiratory effort, he remains limp and unresponsive.
   How will you manage this situation now?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) Is this baby suitable for transfer to a referral centre? If so describe how you would
   prepare him for transfer.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) What are the possible reasons for this baby’s condition?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


   Write this case up as if you were completing the notes.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ________________________

                                           15
7) Report on resuscitation

Describe resuscitation that you were involved in, either at the training site or at your own
neonatal unit. Describe step-by-step the initial assessment of the baby, the actions that
were taken and the progress and outcomes of the resuscitation.

Describe problems that were encountered by the resuscitation team during the
resuscitation and how these were overcome. Is there anything that could have been done
differently that would have made the resuscitation go more smoothly?
     ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



8) Quality improvement

During the completion of the topic on neonatal resuscitation you may have noticed that
some points are not being routinely implemented at your site. For example you may not
have appropriate bags and masks for ventilating babies effectively or appropriate
equipment for resuscitating preterm babies.

Note below any actions that should be taken at your site to improve neonatal
resuscitation.

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                            16
17
2. Routine care of well infants

1) Objectives

On completion of this topic you should have the knowledge and skills to complete
the following tasks:

        Assessment and examination of the newborn
        Identification of common congenital abnormalities
        Give routine care to a healthy infant
        Promote bonding
        Observe for signs of abnormality
        Understand and implement the principles of the Baby Friendly Hospital initiative
        Establish breast feeding
        Advise the mother about care of a normal infant and the importance of the road -
        to-health chart


2) Skills assessment

You are expected to practise the following skills during the time that you are at the
learning site. Once you have completed these tasks adequately ask your supervisor to
sign. If he/she decides you completed the task competently you will receive two
signatures. Otherwise you should try and practise the task again until the supervisor can
sign in the box for competency.

                                                                             Completed
                              Completed
                                                 Comments for learner       competently
                              (Signature)
                                                                            (Signature)
1st examination
Bathing a newborn
Latching at breast
Advise mother on
common breast feeding
problems
Cord care

Give immunisations and
complete road-to-health
card
Maintain warmth
Discharge advice




                                            18
3) Self assessment newborn care questionnaire

1) What are the normal temperature, respiration, heart beat and glucose ranges for
   newborns?
   ____________________________________________________________________
    ____________________________________________________________________


2) Describe how you would manage secretions in a well newborn without meconium
   staining.
   ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________


3) Describe routine treatments that should be given to the baby in the delivery room.
   ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________


4) What routine observations should be completed in the delivery room?
   ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________


5) Describe how breastfeeding should be initiated. At what age should the baby start to
   breastfeed?
   ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________


6) If a baby is not latching well in the first 24 hours, or there is little breast milk in the first
   24 hours, what would your management be?
   ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________


7) Which risk factors should you check for in a newborn before transferring to the post
   natal ward?
   ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________




                                                 19
8) Which babies should be transferred to the neonatal unit after delivery?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) Describe routine treatments/care that should be given to the baby before being
   discharged home?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) What is the normal weight range for a term baby?
    ____________________________________________________________________


11) What care should you give a normal infant immediately after delivery?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


12) When should an infant receive its first bath?
    ____________________________________________________________________
   ____________________________________________________________________


13) Should an infant sleep in its mother’s bed?
    ____________________________________________________________________
   ____________________________________________________________________


14) When should a well newborn first be put to the breast and how frequently?
    ____________________________________________________________________
   ____________________________________________________________________


15) What are the signs of jaundice and what advice would you give the mother with regard
    to jaundice if she is discharged on day 1?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


16) If a baby becomes jaundiced on day 1 what is the most likely cause and what should
    your management be?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                           20
17) What should you look for in the baby if there is a history of polyhydramnios in the
    pregnancy? What conditions can be associated with this history?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


18) What are the features of Down’s syndrome?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



4) Routine care of normal infants - Case Study

a. Case Study:

A term 3200 g baby is delivered by vertex delivery to an unbooked mother. Apgars: 9/10
and 9/10. The labour ward staff report that the liquor smelt offensive.

1) What would your immediate management be?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) Should the vernix be washed off immediately after delivery?
   ____________________________________________________________________
   ____________________________________________________________________


3) Should the infant stay with the mother after delivery (room-in)?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) What cord care should the baby receive?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) The mother breast feeds the infant for three days and the infant now weighs 3000 g
   Is the infant’s weight loss normal?
   ____________________________________________________________________
   ____________________________________________________________________




                                           21
6) Should the mother be advised to give complimentary feeds?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) How can this mother increase her milk supply?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) By day 3 the infant’s eyes are swollen with a purulent discharge.
   What is the probable cause of the conjunctivitis?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) Is the conjunctivitis mild, moderate or severe? Give your reason.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) What treatment would you institute?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


11) What advice would you give this mother on discharge and when should she visit the
    Well Baby clinic?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                         22
5) Quality improvement

During the completion of the topic on newborn care you may have noticed that some
points are not being routinely implemented at your site. For example you may not practise
rooming-in or the babies may be bathed shortly after delivery.
Note below any actions that should be taken at your site to improve routine care of the
well infant.
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ______________________________________________________




                                           23
3. Managing premature, low birth weight and sick babies

1) Objectives

On completion of this topic you should have the knowledge and skills to perform
the following:

          Define prematurity, low birth weight (LBW), very low birth weight (VLBW) and
          underweight for gestational age
          Manage premature and sick babies including feeding, monitoring, apnoea,
          anaemia and prevention of complications
          Perform a gestational assessment
          Identify and manage respiratory distress
          Identification and immediate management of neonatal seizures
          Management of neonatal sepsis
          Management of neonatal jaundice
          Recognise and provide immediate care of common neonatal
          conditions/complications
          Calculate fluid and feeding regimens for the above babies
          Erect IV therapy
          Prevention and management of hypothermia
          Prevention and management of hypoglycaemia
          Initiate and support kangaroo mother care appropriately
          Provide developmentally supportive care
          Stabilise a baby for and organise inter-hospital transfer




                                            24
2) Skills assessment

You are expected to practice the following skills during the time that you are at the
learning site. Once you have completed these tasks adequately ask your supervisor to
sign.


                                                                        Completed
                                   Completed        Comments for
                                                                       competently
                                   (Signature)        learner
                                                                       (Signature)
Admitting a low birth weight
baby to the neonatal unit
Performing an initial
examination
Checking TSB and making
appropriate management
decision
Commencing and managing
phototherapy
Implementing appropriate
infection control measures
Checking blood glucose and
making appropriate
management decision
Managing a baby with
hypoglycaemia
Initiating IV therapy
Calculating and administering
antibiotic doses for a baby
Calculating fluid/feed regimen
for a LBW baby
Passing a nasogastric tube and
administering of feed
Initiating oxygen therapy
appropriately
Doing a lumbar puncture on a
baby (doctors)
Helping a mother initiate
kangaroo mother care
Preventing and managing
hypothermia
Giving developmental care
Using a saturation monitor
Suctioning naso-oropharynx
Taking blood for lab tests
Assessing neonatal x-rays
Terminal disinfection of
incubators
Commencement and
management of nasal CPAP
Perform a Ballard assessment
Identify and manage respiratory
distress
Identify and manage neonatal
seizures


                                         25
3) Self assessment questionnaire
1) Define what is meant by low birth weight. Which LBW babies should be admitted to
   the neonatal unit?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) Define what is meant by pre-term. How can you tell the difference between a low birth
   weight infant born at term and a pre-term infant, and why is it important?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


3) What congenital infections are included in the STORCH acronym?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) What are signs of respiratory distress in a neonate?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) Give four complications that are common in LBW babies in the first 24 hours of life.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) Should all low birth weight infants be kept nil by mouth for 24 hours? If not, which
   babies should be given IV fluids?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) Define what is meant by hypoglycaemia?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________

8) Describe what is meant by apnoea and how it can be prevented?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


                                           26
9) Describe the different signs that might indicate seizures in a neonate?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) When should a LBW baby be routinely bathed?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


11) How can you determine whether a baby on oxygen is getting enough oxygen? Can
    you give too much oxygen and if so, how do you determine it?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


12) What is the best method of giving oxygen to a low birth weight baby with severe
    respiratory distress?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


13) Describe the management of a 2 kg baby who has mild hypoglycaemia (blood sugar
    1.8mmol) at 24 hours of age
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


14) Give three features that would lead you to suspect sepsis in a premature baby who is
    in the neonatal unit.
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


15) What investigations should be done if sepsis is suspected in an infant (septic screen)?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


16) At what level of TSB (total serum bilirubin) would you give phototherapy to a baby with
    jaundice born at 35 weeks, who is now 48 hours old?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


                                            27
17) At what level of TSB would an exchange transfusion be indicated in a baby aged 24
    hours who weighed 1.8 kg at birth?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


18) List the three principles of positioning for developmental care.
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


19) What is the best position in which to nurse a premature baby in order to decrease
    apnoea, increase saturations and decrease the risk of aspiration?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


20) What condition should you suspect in a baby who was very frothy at birth, continues to
    have lots of secretions and desaturates (condition deteriorates) after feeds? What
    would be your immediate management for this baby? What would you look for on a
    chest x-ray?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



4) Calculating doses for low birth weight babies

1) Calculate the fluid requirements for the first 24 hours in a baby who weighs 1.4 kg
   (give amount over 24 hours, as well as hourly rate). What fluids should be given and
   how would you control the fluids?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) What are the fluid requirements on day 2 for this baby and how should they be given?
   (give amount over 24 hours, as well as hourly rate)
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
3) How much fluids should be given to a baby on day 3, who weighed 1.1 kg at birth?
   The baby now weighs 1.0 kg (give amount over 24 hours, as well as hourly rate).
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



                                            28
4) A newborn baby born at 35 weeks gestation and weighing 1.6 kg requires treatment
   with antibiotics as there was prolonged rupture of membranes before delivery.
   Give the dose and regimen for benzyl penicillin and gentamicin. How would you
   prepare and administer the antibiotics?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) This baby also needs to be given nevirapine as the mother was enrolled on the
   PMTCT program. What dose of nevirapine would you give?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) The baby also needs theophylline/neulin/caffeine to prevent apnoea. What dose
   would you give and how would you administer it?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) A baby weighing 2.2 kg is having a convulsion. What is the anticonvulsant that you
   would give and what dose? How would you administer this?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



5) Management of LBW and VLBW babies – Case Studies

a. Case Study 1:

A 1.9 kg baby is delivered by NVD at 34 weeks. The baby is well with an Apgar score of 7
at 1 minute and 10 at 5 minutes. Soon after this baby was born there is an emergency in
the delivery room and he is left on the resuscitaire. When you come back to take him to
the neonatal unit you find that he is wrapped in a wet towel and he seems quite cold.

1) What clinical features could suggest hypothermia?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) His axillary temperature is 35.5°C. What would your management be?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                           29
3) What should the incubator temperature be in this situation?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) He recovers quickly and his temperature returns to normal. He is being nursed in an
   incubator and is pink and active. When should feeding start? What will you feed him
   and how?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) How much feed does the baby need and how often should he be fed?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) When would he be able to go to his mother for kangaroo mother care?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) Should this baby be given BCG and Polio? If so, when?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) When can he be discharged?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



b. Case Study 2:

A 1200 g baby is delivered at 29 weeks gestation. He requires resuscitation with a bag
and mask at delivery but has established regular respirations at 10 minutes of age with
Apgars of 6 at 1 minute, 8 at 5 minutes and 9 at 10 minutes. He is quickly transferred to
the neonatal unit.

1) If you are receiving this baby, what will you do initially?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                            30
2) What should be the temperature in the incubator?
   ____________________________________________________________________
   ____________________________________________________________________



3) What should this baby wear in the incubator?
   ____________________________________________________________________
   ____________________________________________________________________


4) When you check the oxygen saturation you find that the saturation varies between 80-
   85% although the baby appears well, active and pink. Would you give this baby
   oxygen? If so, how? How much oxygen should you give and how will you monitor this?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) How would you feed this baby for the first 24 hours? What are the fluid requirements?
   (give mls/kg and total mls required for this baby).
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) What medications should be started routinely for this baby?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) At six hours of age the baby seems jittery and the blood sugar is 1.4 mmol. What
   would be your management?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) Should this baby’s condition continue to deteriorate, how would you prepare for
   transfer and what documentation would you include?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) The baby is now 2 weeks old and the weight is 1.5 kg. He no longer requires oxygen
   and is being fed with expressed breast milk via NGT. How much feed does he
   require? How frequently should he be fed?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


                                           31
10) When can transfer to continuous kangaroo mother care be considered?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


11) Describe how you would start kangaroo mother care?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


12) Once on kangaroo mother care, what monitoring is required?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



c. Case Study 3:

A low birth weight infant is born at term and weighs 1.8 kg. The baby does well over the
first 24 hours and is maintaining oxygen saturations of over 90% in air. On the second
day of life the baby seems less vigorous and now needs head box oxygen to maintain
saturations over 80%. There is nasal flaring and mild recession.

1) What could be the cause of this change in the baby’s condition?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) What investigations would you do?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


3) What would be your initial management?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) The mother is admitted on the ward with high fevers and is on intravenous antibiotics.
   The membranes ruptured at home more than 24 hours before delivery so you suspect
   sepsis in this baby. What antibiotics would you start? Give the doses per kg for this
   baby.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



                                            32
5) The CSF result shows a white cell count of 21. What does this mean and how will it
   affect your management?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) How much fluid should be given to this baby on day 2? (give mls/kg and total amount
   for this baby)
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) The next day the baby is doing well (day 3) but is noticeably jaundiced.
   What would your initial management be?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


8) The TSB is 200. What would be your management now and what further
   investigations should be done?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) Describe how a baby should be safely nursed under phototherapy.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) When should the TSB be repeated?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                          33
6) Report on low birth weight baby

Write a report on a low birth weight baby where you have been involved in the care. This
could be at the learning site or at your own neonatal unit. Try to choose a case that
shows some of the common problems that you deal with at your site and how these were
managed.

Describe the history from the time of delivery, the initial management of the baby and
ongoing care. Describe any complications that arose and how these were managed.

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


7) Quality improvement for management of premature babies

During the completion of the topic on management of premature babies you may have
noticed that some points are not being routinely implemented at your site.

Note below any actions that should be taken at your site to improve management of low
birth weight babies

   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                            34
35
4. Prevention of Mother to Child Transmission of HIV (PMTCT)

1)   Objectives

 On completion of this topic you should have the following knowledge and skills to
 undertake the following:

           Identify an infant on the PMTCT program
           Arrange late enrolment in the PMTCT program
           Reduce the risk of mother to child transmission during routine delivery by
           using safe delivery practices
           Reduce the risk of mother to child transmission by appropriate administration
           of anti-retroviral drugs
           Aadvise the mother about her feeding choice
           Support the mother in her feeding choice
           Arrange appropriate follow-up for the infant of an HIV-infected mother


2) Self assessment questionnaire


1) If an HIV-infected mother does not know her status and so does nothing to prevent
   HIV transmission to her baby, but she does not breastfeed - what is the chance that
   the baby will become infected?
   ____________________________________________________________________
     ____________________________________________________________________


2) If she breastfeeds for 2 years, what is the chance that the baby will be infected?
   ____________________________________________________________________
     ____________________________________________________________________


3) An HIV-infected mother gets tested during her pregnancy and finds that she is HIV
   positive. She takes nevirapine and does not breastfeed her baby - what is the chance
   that this baby will become infected?
   ____________________________________________________________________
     ____________________________________________________________________


4) What can you do during the delivery of the baby of an HIV-infected mother, or a
   mother who does not know her status, to reduce the chance of transmission?
   ____________________________________________________________________
     ____________________________________________________________________
     ____________________________________________________________________


5)   When should the mother take nevirapine?
     ____________________________________________________________________




                                            36
6) A 1.8 kg baby is admitted to the neonatal unit, the mother is HIV positive and has
   taken nevirapine 3 hours before delivery. What dose of nevirapine should be given to
   the baby and when should it be given?
   ____________________________________________________________________
   ____________________________________________________________________


7) A baby of an HIV-infected mother is admitted to the neonatal unit. The baby was born
   at term and weighs 3.2 kg. The mother did take her nevirapine when she started
   having contractions but the contractions stopped and the baby was only born 4 days
   later. What dose of nevirapine should be given to the baby and when should it be
   given?
   ____________________________________________________________________
   ____________________________________________________________________


8) Define what is meant by exclusive breastfeeding.
   ____________________________________________________________________
   ____________________________________________________________________


9) Describe the different types of HIV tests that could be used to determine whether a
   baby born to an HIV-infected mother is infected. When should these tests be done?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) An HIV-infected mother has chosen to breastfeed her baby. The baby is tested at 6
    weeks with a PCR test and the test is negative. What does this mean? Does the baby
    need another test and if so, when should this be done?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


11) An HIV-infected mother does not breastfeed. The baby is tested at 3 months with a
    rapid test. What does this mean? Does the baby need another test and if so when
    should this be done?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


12) Give reasons why it is important for the infant of an HIV-infected mother to attend
    regular follow-up.
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                          37
3) Prevention of Mother to Child Transmission – Case study

a. Case 1: Ntombi

1) Ntombi is 18 years old. She comes into the labour ward at term and in early labour.
   How can you find out whether she is on the PMTCT program?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


2) She says that she did have an HIV test but she was too frightened to go back for the
   result. Now she is worried because her boyfriend has been very sick and if she is HIV
   positive she wants her baby to get nevirapine.
   Can you test her for HIV during her labour? Explain your answer.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


3) The baby is delivered and is admitted to the neonatal unit with low Apgars. The
   counsellor comes to see Ntombi the next morning and the HIV test is positive.
   The baby is now 24 hours old. Describe what can be done to reduce transmission to
   this baby.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


4) Ntombi is distressed after her post-test counselling and still very unsure about how to
   feed her baby. Give three questions that you could ask in order to decide what might
   be the best feeding choice for Ntombi and her baby.
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


5) The baby is doing well and Ntombi has decided to breastfeed. What advice can you
   give her to help her to breastfeed safely?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


6) When should she stop breastfeeding?
   ____________________________________________________________________
   ____________________________________________________________________


7) When should Ntombi bring her baby back for follow-up?
   ____________________________________________________________________
   ____________________________________________________________________


                                            38
8) Just as the baby was about to be discharged, he developed respiratory distress. What
   could the cause of this be?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


9) When should routine cotrimoxazole prophylaxis be started?
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________


10) The baby has a PCR test at 6 weeks and the test is positive. What does this mean?
    The baby is still being breastfed. Should the test be repeated if so, when?
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________



4) Report on PMTCT

Write up the case for a baby that was admitted to the neonatal unit, either at the learning
site or at your own facility, where the mother was enrolled in the PMTCT program.
Describe whether all safe obstetric practices were observed during the delivery and how
and when the nevirapine was given. Mention the plan for ongoing management of this
infant.
    ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________
   ____________________________________________________________________




                                            39
40
C. QUALITY IMPROVEMENT PROJECT



                                Identify and analyse
                                      problems




     Measure outcomes                                         Define aims




                                    Plan solutions




The aim of using a quality improvement approach is to provide a framework for you to look
critically at the service you are providing in your unit. The quality improvement cycle
guides you through a process of deciding if good standards of care are being achieved
and if not what the reason is for this. Having determined where the failings are, you can
then analyse the reasons for these gaps in the provision of good quality care, decide what
you are aiming for and make a plan for improvements.

You first need to identify a problem with your service. This may be something that you
have observed while at the learning site that you realise is not being done optimally at
your site. Look carefully at the current situation and decide the reason for this poor
quality. You need then to set out an adequate standard of care that you would aim for
and plan a solution that would allow you to achieve this in a given time frame. At the end
of the time frame you should look at the situation again in order to evaluate whether your
plan was successful. This should be an ongoing process in your service whereby you
look critically at the care being rendered and look for ways to improve this.

You are expected to undertake a simple quality improvement project in your neonatal unit
and describe this on the following pages.

An example might be that you observe that hypothermia is a common problem among
infants being admitted to the neonatal unit.

The first step is to define the problem and record how many infants were admitted with
hypothermia over a particular time period.
Then analyse the possible reasons for this, which may involve talking to labour ward staff
or staff in the neonatal unit to find out the circumstances that lead to the infants
developing hypothermia. You may find that infants of mothers having a caesarean section
are being kept on the resuscitaire in the air conditioned theatre for long periods of time.
The solution may be to agree with management that infants should be taken immediately
to the nursery after delivery, where it is warm, and be given to the mother when she
returns to the postnatal ward. Some training of staff in this new policy will be required and
nursery staff should also agree.
In order to evaluate the plan and to see if the solution has been effective you should
review the number of admissions with hypothermia for a period some time after the policy
has been implemented to see if there is an improvement. If not, then look for the reasons
why the problem remains.




                                              41
The following headings might assist you in formulating your program:

Define aims

1) Plan your program
2) Establish a standard
3) Communicate the standard to all involved parties

Identify and analyse problems

1) Assess or evaluate current practice (using a checklist / tool)
2) Define and prioritise problems (using gap between desired and actual performance)
3) Identify team (teamwork is vital - involve all key role-players e.g. infection control or
   management)
4) Analyze the problem (using a cause and effect chart/ flowchart)

Plan solutions

1) Choose a solution
2) Implement this solution (using an action plan with time frames)

Measure outcomes

1) Re-evaluate




                                                   42

								
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