|Basic Newborn Resuscitation: A Practical Guide (WHO - OMS, 1997, 54 p.)|
|7. OPERATIONAL GUIDELINES|
Recognition of birth asphyxia in a newborn and immediate resuscitation require the immediate availability of a qualified person, appropriate equipment and organized action. The following steps are suggested for a country that wishes to strengthen newborn resuscitation. Since resuscitation is needed relatively seldom - at an incidence of 3-5%, a birth attendant who delivers 20 women a year will need to resuscitate probably once a year - it is worth considering training first those birth attendants who deliver more than 20 women a year. In practice, this means that health care institutions should introduce basic newborn resuscitation first. Basic resuscitation should also become part of the pre-service training of health care providers trained in midwifery.
At national level the following activities and policies will help health care institutions improve resuscitation practices:
- legislation that allows every birth attendant to perform newborn resuscitation;
- national recommendations and standards for newborn resuscitation describing the minimum required practices and equipment, for different levels of care (home, health centre, hospital);
- recommendations for selection and purchase of equipment and supplies;
- putting basic newborn resuscitation on the curricula of midwifery, nursing and medical training;
- development of training materials and courses for pre-service and in-service training for different levels of care;
- development of capacity for training;
Every health care institution that provides delivery care must develop its own policies and standards for newborn resuscitation. The manager or supervisor is responsible for ensuring that the institution has a plan of action that includes:
- a written policy, standards, protocol and training course for newborn resuscitation;
- a list of necessary equipment and supplies with instructions on cleaning and maintenance;
- a list of maternal and fetal complications that require the presence of persons specially qualified in newborn resuscitation, agreed by all staff;
- a contingency plan for multiple births and unusual situations;
- instructions on how to document (record) the process and outcome of resuscitation;
- a monitoring and evaluating process;
- a programme for staff training (doctors, midwives, nurses, auxiliary midwives) through initial and refresher courses.
The policy on resuscitation, the protocol and the procedures for recording and evaluation will be observed to be better if they are developed with the participation of the staff. Local conditions and the availability of equipment must be taken into account when developing standards of care. For instance, precise thermal protection procedures will depend on the local climate and warming/cooling facilities, while methods of suctioning will depend on the suction devices available. Stop points (when to stop resuscitation) need to be part of the policy. Resuscitation details should become a part of the patients record.
Gaining skills in newborn resuscitation cannot be left to the real-life situation. It is very important that training in newborn resuscitation concentrates on the essential facts, skills and attitudes, and uses appropriate teaching methods and teaching aids (dolls/manikins). Training must focus on decision-making and problem-solving skills in emergency situations, as well as on manual skills and on counselling skills for communicating with parents. It must emphasize the urgency of the situation and the need for coordinated activities by members of the health care team or, in case of a single health worker, on decision-making skills in dividing attention between the mother and the newborn.
The appropriate level of competence should be achieved through continuing efforts to maintain resuscitation skills by practising the technique and by completing appropriate refresher courses. Regular training sessions help to update present staff and train new ones.
After training, evaluation is needed to see if the standards/guidelines are being implemented in the work situation and if the health workers are doing what they have been trained to do. Re-certification should be institutionalized, with the optimal intervals determined locally. Because newborn resuscitation is a relatively rare procedure, more frequent updating of skills should be considered.
A generic training course with supporting training material on basic and advanced newborn resuscitation should be developed at national level. Locally, training courses and materials should be adapted in accordance with the results of a situation analysis (training needs assessment) carried out before the training.
Monitoring and evaluation
Resuscitation can seldom be observed directly to assess the quality of care provided. The most frequent method of assessment is demonstration using different case scenarios. This method allows for observing both manual and decision-making skill. Actual clinical practice can be evaluated by comparing the skills demonstrated against checklists developed on the basis of local standards and protocols.
Practices should also be evaluated after a resuscitation fails. Staff discussions can provide useful ideas for improving practices. A checklist can be helpful. If problems are found the team should analyse present practice, compare it to standards, make recommendations, and plan and implement them.