Intact Survival Blog

INTACT SURVIVAL INTACT SURVIVAL STARTED FROM BIRTHSTARTED FROM BIRTH

M.Sholeh KosimM.Sholeh Kosim

Chairman of Perinatology Working GroupChairman of Perinatology Working GroupIndonesian Society of PediatricianIndonesian Society of Pediatrician

(UKK Perinatologi IDAI)(UKK Perinatologi IDAI)

Presented in 13 rd National Congress of Child HealthBandung Indonesia July 6, 2005

IntroductionIntroduction

Human Life Cycle : Started from intrauterine life Result of reproductive system. Survival of the human species depends

upon the female and male reproductive systems Functioning and control : dependent on the

neuro-endocrine system

LIFE CYCLELIFE CYCLE

Stages of Human Life Cycle Stages of Human Life Cycle after being a new born :after being a new born :

Infancy : 0 – 1 year

Childhood : 1 year --- adolescence

Adolescence : Body becomes sexually mature.

- Changes were happened due to hormonal and

physically origins.

Adulthood : Body slowly slows down

- Certain changes such as hair falling out and

physical activity are decreasing

– Survive after a period of birth and continue to Survive after a period of birth and continue to next steps of the cycle by growing up next steps of the cycle by growing up optimally and healthy. optimally and healthy.

– Belong to babies who have no prominent Belong to babies who have no prominent malformation or congenital anomaly :malformation or congenital anomaly :

• especially central nerve system malformation especially central nerve system malformation

• born as preterm or term but not immature or born as preterm or term but not immature or extremely low birth weight babiesextremely low birth weight babies

Human Life Cycle is being to occur successfully

Human is such different species

• Characteristics :

– Separate the Human Organism from Lower species

– Enhance `survivorship' of the species:

1. Intra-uterine development

2. Post-natal nutrition of the newborn through lactation

by the mother;

3. Development of the limbic portion of the brain

4. Development and expression of homeostatic

mechanisms

Birth Period or Intrapartum

• Most important times within Human Life Cycle. • “The critical minutes and the critical days”. • Failure to prevent or treat affect :

• child’s growth• physical and mental abilities, • School performance.

• Increased burden and strain on– Family– Community– Various social institutions.

Birth Asphyxia as Starting Disasters

• Major cause of neonatal death, stillbirth

• Significant of severe neurological disability.

• In industrial countries : reduced

• In developing countries : still high

• Case fatality rates for neonatal encephalopathy may

40% higher

Asphyxia-related sequellaeAsphyxia-related sequellae

‘Birth asphyxia’

Not breathing at birth

Intrapartum Stillbirth

Neurological Disability

Severe

Mild

Other factors, e.g., preterm birth

Intrapartum factors

Pre-delivery factors

Asphyxia-related neonatal death

Not resuscitable

Healthy development

Neonatal Encephalopathy

Severe

Moderate

Mild

Lawn J, et al 2005

www.thelancet.com March, 2005

Recent estimates...

Date Source Intrapartum stillbirths

Asphyxia-related neonatal deaths

Asphyxia-related neonatal disability

1991 WHO a Not assessed 800,000 ‘at least an equal number’ to the 800,000 neonatal

deaths

1996(1990 data)

WHO GBOD I Not assessed 770,000 Cases/year not specified3,525,000 years of life

disabled

1996(1990 data)

WHO RHR c Not assessed 1.6 million[32% of 5.0 million

neonatal deaths]

Not assessed

2001(around 1999)

WHO RHR Not assessed 1.16 million(Of 4.0 million neonatal deaths, 29% due to birth

asphyxia)

Not assessed

2001 WHO RHR 1.6 million [40% of 3.9

Million stillbirths]

Not assessed

2001(around 2000)

WHO GBOD I version 2

Not assessed 691,000 Cases/year not specified7,565,000 years of life

disabled Methods not yet published

Lawn J,et al 2005

Indonesia

www.thelancet.com March, 2005

82 2% 18

Lawn J et al (2005)

• Intra partum-related neonatal death annuallyIntra partum-related neonatal death annually

– ++ 0.94 million 0.94 million ~~23% of the global total of 4 million. 23% of the global total of 4 million.

• Intra partum stillbirths 1.02 million (0.66–1.48 million) occur Intra partum stillbirths 1.02 million (0.66–1.48 million) occur

annually, comprising 26% of global stillbirths annually, comprising 26% of global stillbirths

• Intra partum-related neonatal deaths account for almost 10% Intra partum-related neonatal deaths account for almost 10%

of deaths in children aged under 5 yearsof deaths in children aged under 5 years

• Intra partum stillbirths are a huge and invisible problem, but Intra partum stillbirths are a huge and invisible problem, but

are potentially preventable. are potentially preventable.

• Programmatic attention and improved information are Programmatic attention and improved information are

requiredrequired

Perinatal hypoxic-ischemic brain injuryPerinatal hypoxic-ischemic brain injury

• + 10% to 20% of all cases of Cerebral Palsy ( CP )

• Most distinctive sequelae : intrapartum asphyxia.

• Magnitude of the changes in the blood gas (term infant) remains unclear.:

• would necessitate knowledge about:

» fetal Cerebral Blood Flow (CBF)

»and cerebral metabolism.

• Severe asphyxia Residual neurologic sequelae

FACTORS INFLUENCING FACTORS INFLUENCING CEREBRAL BLOOD FLOW ( CBF)CEREBRAL BLOOD FLOW ( CBF)

IN ASPHYXIA NEWBORN IN ASPHYXIA NEWBORN

:

.

Asphyxia InsultAsphyxia Insult

Maintaining cerebral perfusionMaintaining cerebral perfusion

• Systemic adaptation Systemic adaptation • Cerebral circulatory responseCerebral circulatory response

ResponsesResponses

• Biochemical response Biochemical response

• Autoregulation responseAutoregulation response

• Circulatory response Circulatory response

• Major priority in perinatal medicineMajor priority in perinatal medicine::

– Early and accurate identification Early and accurate identification

– Highly relevant clinical issue : newer Highly relevant clinical issue : newer

therapies were investigated to reduce therapies were investigated to reduce

subsequent hypoxic-ischemic cerebral injury subsequent hypoxic-ischemic cerebral injury

and long-term neurologic deficits. and long-term neurologic deficits.

Major Adverse Outcome Major Adverse Outcome Related To Birth AsphyxiaRelated To Birth Asphyxia

• StillbirthStillbirth

• Neonatal death Neonatal death

• Severe neurological disability.Severe neurological disability.

• Birth trauma. Birth trauma.

• Brain hypoxic – ischemic injuryBrain hypoxic – ischemic injury

To define specific outcomes for estimation of the To define specific outcomes for estimation of the

burden more precise epidemiological case definitionburden more precise epidemiological case definition

is required.is required.

Major conditions or sequel associated Major conditions or sequel associated with birth asphyxiawith birth asphyxia

• Intra partum stillbirth Intra partum stillbirth

• Birth Asphyxia Birth Asphyxia

• Newly born live infant who can not be resuscitated Newly born live infant who can not be resuscitated

• Neonatal encephalopathy Neonatal encephalopathy

• Neonatal death as a consequence of an asphyxia-Neonatal death as a consequence of an asphyxia-

related condition related condition

• Neurological disabilityNeurological disability

Birth as an Additive or Potentiating factor in Hypoxic injury

• Process of birth :

– Perinatal Hypoxic – Ischemic injury

– Profound alteration of biochemical and physiological homeostasis:

• Transient hypoxemia and hypercapnea, variable in severity and duration are consistence occurrences.

• Transient disturbances in cerebral blood may also occur

– Whether biochemical state of the brain is affected the major systemic alteration that take place at birth ?

Biochemical mechanisms of neuronal death with Hypoxic – Ischemia

• Principal biochemical mechanisms of cell death with Principal biochemical mechanisms of cell death with

hypoxemia, ischemia and asphyxia are presumably very hypoxemia, ischemia and asphyxia are presumably very

similar,similar,

– initiated with oxygen deprivationinitiated with oxygen deprivation

• Current concepts concerning the mechanism for cell Current concepts concerning the mechanism for cell

death :death :

– the disturbances of brain glucose and energy the disturbances of brain glucose and energy

metabolismmetabolism

Characteristics Of Hypoxic-Ischemic Characteristics Of Hypoxic-Ischemic Brain DamageBrain Damage

• An evolving processAn evolving process• Begins : during insult and extends into the recovery Begins : during insult and extends into the recovery

period (reperfusion interval). period (reperfusion interval). • Tissue injury takes the form of selective neuronal Tissue injury takes the form of selective neuronal

necrosis or infarction,necrosis or infarction,– the latter with destruction of all cellular elements the latter with destruction of all cellular elements

including neurons, glia, and blood vessels. including neurons, glia, and blood vessels. • When infarction occurs, area surrounding the infarct When infarction occurs, area surrounding the infarct

(penumbra) consists of neurons :(penumbra) consists of neurons :– necrosis or apoptosis (programmed cell death).necrosis or apoptosis (programmed cell death).

• Penumbral area that appears most amenable to Penumbral area that appears most amenable to reversal of cellular injury through therapeutic interventionreversal of cellular injury through therapeutic intervention

Risk Factors During Intrapartum PeriodRisk Factors During Intrapartum Period

• Kind of delivery Kind of delivery • Respiratory morbidityRespiratory morbidity• Titapant V and Sirimai K, 2002 : Titapant V and Sirimai K, 2002 :

– Low education levelLow education level– Past history of previous deliveryPast history of previous delivery– Past history of preterm deliveryPast history of preterm delivery– No antenatal care, unawareness of symptoms of No antenatal care, unawareness of symptoms of

true labor and present preterm deliverytrue labor and present preterm delivery– The risk factors : should have further study to get The risk factors : should have further study to get

more information that can apply to control birth more information that can apply to control birth before arrival before arrival

• Born at night and during weekends and holidaysBorn at night and during weekends and holidays

Survival Condition

Most likely importance factors which influence the

survival of neonates after having experience of birth

asphyxia actually depend on:

• Gestation period,

• Birth weight

• Proper and prompt management.

• If neonates could survived and most of them will be If neonates could survived and most of them will be suffered from disabilities. suffered from disabilities.

• Recent International Consensus ( ICIDH-2, WHO 1999 Recent International Consensus ( ICIDH-2, WHO 1999 clarified terminology for disability by outlining three clarified terminology for disability by outlining three components of disablement : components of disablement :

• Impairment : defined as “ any loss or Impairment : defined as “ any loss or abnormality of psychological, physiological and abnormality of psychological, physiological and anatomical structure or function “anatomical structure or function “

• Activity limitation Activity limitation

• Participation restriction Participation restriction

Categories of impairmentCategories of impairment

• Motor function ( Cerebral palsy ) Motor function ( Cerebral palsy )

• Visual function ( Blindness) Visual function ( Blindness)

• Hearing ( deafness) Hearing ( deafness)

• Mental ability ( Intelligence Quotion < 70 ) Mental ability ( Intelligence Quotion < 70 )

Vanhaesebrouck et al (2004)

• Studied a total of 525 infants in NICU .• Life-supporting care : 322 liveborn infants, 303

admitted for intensive care. • Overall survival rate of liveborn infants was 54%.• Of the infants who were alive at the age of 7 days,

82% survived to discharge

– Among the 175 survivors, • 63% had 1 or more of the 3 major adverse

outcome –serious neuromorbidity– chronic lung disease at 36 weeks'

postmenstrual age– treated retinopathy of prematurity.

– The chance of survival free from serious neonatal morbidity at the time of hospital discharge was <15% (21 of 158) for the admitted infants with a gestation <26 weeks.

Finner et al ( 1999)• Studied the feasibility of Cardiopulmonary resuscitation

(CPR) on Extremely Preterm Babies.

• Previous report : none of the 20 previously reported infants

weighing <750 g at birth who received CPR in the delivery

room (DR) survived.

• To clarify whether such resuscitation is futile or not

• Evaluated experience with DR-CPR over a 4-year period.

• Retrospective : Outcome infants with birth weights <1000 g

at University of California, San Diego Medical Center from

January 1993 to December 1996. 

• Surviving infants and matched control infants were

followed for 40 months' adjusted age using standardized

neurodevelopmental assessments

• Results : 

• Infants with birth weight <1000 g : 29% (51/177) died :

– 44% : <750 g

– 16% : 750 g.

• Overall, 19 infants received DR-CPR : 12  < 750 g.

• Of the infants received DR-CPR, 79% (15/19) survived,

– 10 of 13 infants < 750 g

– 5 of 6 infants 750 g.

• Of 15 survivors, 10  followed up :– 70% : normal neurologically and developmentally– 2 : CP + mild cognitive and severe motor

developmental delay.– 7 infants <750 g, 6 normal neurodevelopmental

outcomes. – Mean composite mental and motor scores of DR-CPR

survivors were 93 ± 10 and 89 ± 25, respectively. – No differences were found in neurologic or

developmental outcome between DR-CPR survivors and control infants

• Conclusion : intact survival is possible for infants weighing <750 g at birth after DR-CPR.

Intervention Intervention

• Needed to overcome the problem and improve Needed to overcome the problem and improve

the survival.the survival.

• Should be comprehensive and continuum Should be comprehensive and continuum

approach ( Maternal ---- Neonatal )approach ( Maternal ---- Neonatal )

• Consist of :Consist of :

• Hospital based Hospital based

• Community basedCommunity based

Both mother and newborn can be Both mother and newborn can be improvedimproved

– Good antenatal care and antenatal steroidGood antenatal care and antenatal steroid

– Shared between community centers and local hospitals Shared between community centers and local hospitals

with good lines of communication. with good lines of communication.

– Management of labor by use of partogram,. Management of labor by use of partogram,.

– Detection, prevention, and management of fetal Detection, prevention, and management of fetal

asphyxia : still a prime targetasphyxia : still a prime target

– Best possible liaison between obstetric and pediatric Best possible liaison between obstetric and pediatric

teams should be fostered to ensure the optimal teams should be fostered to ensure the optimal

managementmanagement

– All high-risk deliveries should be attended by someone All high-risk deliveries should be attended by someone

who is skilled in resuscitation .who is skilled in resuscitation .

Hospital Based InterventionHospital Based Intervention

• Increased prenatal/antenatal steroid therapy,Increased prenatal/antenatal steroid therapy,

• Cesarean section delivery in the right and proper Cesarean section delivery in the right and proper reason reason

• Assisted ventilation in the delivery roomAssisted ventilation in the delivery room

• Surfactant therapySurfactant therapy

• Postnatal steroid use. Postnatal steroid use.

• Therapeutic interventions for hypoxic-ischemic Therapeutic interventions for hypoxic-ischemic encephalopathy Neuroprotective encephalopathy Neuroprotective

Neuroprotective Strategy Neuroprotective Strategy

Decrease Cerebral metabolism totally and supress Decrease Cerebral metabolism totally and supress

specific targetted neurotoxine agentspecific targetted neurotoxine agent

• Within 6-12 hours post asphyxia by giving neuroprotective Within 6-12 hours post asphyxia by giving neuroprotective

agent agent decrease or prevent brain damage decrease or prevent brain damage

• Prevent brain damage depend on the initial status of fertal Prevent brain damage depend on the initial status of fertal

brainbrain

The therapeutic window

• Interval after resuscitation from hypoxia-ischemia• Efficacious in reducing the severity of the ultimate

brain damage.• In adult process : slow ( hours -- a day or more)• Human infants : process more rapid than adults • Full-term infant: shortly no longer than 1 to

2 hours. • In immature animals : No drug efficacious > 2 hrs

after termination of the hypoxic-ischemic insult

Community Based Intervention

• To achieve the (MDG-4), neonatal deaths need to be prevented.

• Issues : addressed and related to improving neonatal survival :– availability of skilled care during childbirth – family/community-based care – Integrated management of neonatal illness into the

integrated management of childhood illness initiative (IMCI)

– Engagement of the community and promotion of demand for care.

– Development, implementation, and monitoring of national action plans for neonatal survival is a priority.

• Estimation of the running costs at 90% coverage in the 75 Estimation of the running costs at 90% coverage in the 75 countries with the highest mortality rates to be $4·1billion a countries with the highest mortality rates to be $4·1billion a year :year :

– 30% : improve neonatal survival,30% : improve neonatal survival,

– 70% :improving survival of mothers and older 70% :improving survival of mothers and older children,and at substantially reducing rates of stillbirths.children,and at substantially reducing rates of stillbirths.

• The cost per neonatal death averted is estimated at $2100 The cost per neonatal death averted is estimated at $2100 (range $1700–3100). (range $1700–3100).

• Maternal, neonatal, and child health receive little funding Maternal, neonatal, and child health receive little funding relative to the large numbers of deathsrelative to the large numbers of deaths

• International donors and leaders of developing countries International donors and leaders of developing countries should be made to commit to increasing resources. should be made to commit to increasing resources.

• Skilled care during delivery is universally Skilled care during delivery is universally

recognized as a major long-term priority for recognized as a major long-term priority for

improving the care of mothers and newborns, and improving the care of mothers and newborns, and

plans for advancing health system capabilities for plans for advancing health system capabilities for

providing this care are paramount.providing this care are paramount.

• Based on a consideration of the fact that most Based on a consideration of the fact that most

births and neonatal deaths occur at home during births and neonatal deaths occur at home during

the early neonatal period, the early neonatal period,

– Birth asphyxiaBirth asphyxia

– Infections, Infections,

– LBW infants LBW infants

InterventionsUniversal

Situational Additional

PericonceptualFolic acid

supplementation

Antenatal

Antenatal care packageOutreach visits, including history and physical examination, with assessment of blood pressure, weight gain, and fundal height; urine screen for rotein; screen for anaemia; two doses of tetanus toxoid immunisation; syphilis screening and treatment; counseling on plan for birth, emergencies, breastfeeding; referral in case of complication

Intermittent presumptivetreatment formalaria

Detection andtreatment ofasymptomaticbacteriuria

Evidence-based packages of interventions Evidence-based packages of interventions at different time pointsat different time points

www.thelancet.com March, 2005

InterventionsUniversal

Situational Additional

PericonceptualFolic acid

supplementation

Intrapartum

Skilled maternal and immediate neonatal care package

Skilled attendant at birth; labour surveillance; encouragement of supportive companion; assistance to birth (including vacuum extraction); early detection, clinical management and referral of maternal or fetal complications (emergency obstetric care at .rst level); resuscitation of the newborn baby

Antibiotics forpretermprematurerupture ofmembranes

Evidence-based packages of interventions Evidence-based packages of interventions at different time points (Cont’d)at different time points (Cont’d)

www.thelancet.com March, 2005

Amount of

evidence

Reduction (%)in all-cause neonatal mortality or morbidity/major risk factor if specified (effect range)

Preconception

Folic acid supplementation IVIncidence of neural tube

defects:72%(42 .87%)

Antenatal

Tetanus toxoid immunisation

Syphilis screening and treatment Pre-eclampsia and

eclampsia:prevention (calcium supplementation)Intermittent presumptive treatment for

malaria Detection and treatment of

asymptomaticbacteriuria

V

IVIV

IV

IV

33 .58%Incidence of neonatal

tetanus:88 .100%Prevalence-dependentPrematurity:34%(-1 to 57%)Low birthweight:31%(-1 to 53%)32%(-1 to 54%)PMR:27%(1-47%)(first/second births)Incidence of prematurity/low

birthweight:40%(20 .55%)

Evidence of efficacy for interventions at different time periodsEvidence of efficacy for interventions at different time periods

www.thelancet.com March, 2005

Amount of evidence

Reduction (%)in all-cause neonatal mortality or

morbidity/major risk factor if specified (effect range)

Preconception

Intrapartum

Antibiotics for preterm premature rupture of membranesCorticosteroids for preterm labour Detection and management of breech (caesarian section)Labour surveillance (including partograph)for early diagnosis of complicationsClean delivery practices

IV

IVIV

IV

IV

Incidence of infections:32%(13 .47%)

40%(25 .52%)Perinatal/neonatal death:71%(14 .90%)

(early neonatal deaths):40%

58 .78%Incidence of neonatal tetanus:55 .99%

Evidence of efficacy for interventions at different time periodsEvidence of efficacy for interventions at different time periods

www.thelancet.com March, 2005

Amount of

evidence

Reduction (%)in all-cause neonatal mortality or

morbidity/major risk factor if specified (effect range)

Preconception

Postnatal

Resuscitation of newborn baby Breastfeeding Prevention and management of hypothermia Kangaroo mother care (low birthweight infants in health facilities)Community-based pneumonia case management

IVVIVIV

V

6 .42%55 .87%18 .42%13Incidence of infections:51%(7 .75%)

27%(18 .35%)

Evidence of efficacy for interventions at different time periodsEvidence of efficacy for interventions at different time periods

www.thelancet.com March, 2005

Indonesian PerspectiveIndonesian Perspective

• As a developing country : Neonatal problems As a developing country : Neonatal problems – High rate of neonatal morbidity and mortality High rate of neonatal morbidity and mortality

especially Birth Asphyxia . especially Birth Asphyxia . • Main cause of Neonatal Death (Household Survey 2001)Main cause of Neonatal Death (Household Survey 2001)

– Birth Asphyxia (27.0%)Birth Asphyxia (27.0%)– Low Birth weight and Premature Birth (29.2 %), Low Birth weight and Premature Birth (29.2 %), – Infection including Tetanus, Sepsis, Diarrhea and Infection including Tetanus, Sepsis, Diarrhea and

Pneumonia (14.9 %),Pneumonia (14.9 %),– Feeding Problems (9.5%),Feeding Problems (9.5%),– Hematological problems: Kern Icterus and Neonatal Hematological problems: Kern Icterus and Neonatal

Jaundice (5.6%) Jaundice (5.6%)

27%

29%10%

5%

6%

10%

13%

Asphyxia

Low Birth Weight

Tetanus

Infection

HematologicalproblemsFeeding Problem

Others

Table 1: Cause of Neonates Mortality in Indonesia in 2001Table 1: Cause of Neonates Mortality in Indonesia in 2001

Newborn baby

Survive for a while

Does not get optimum care

Serious health problem & developmental delayed

InterventionIntervention

Right intervention to overcome the problems is neededRight intervention to overcome the problems is needed

Most of deliveries ( 80%) are conducted at home or non Most of deliveries ( 80%) are conducted at home or non

health care facilities. health care facilities.

Many efforts attempted by the Government of Indonesia to Many efforts attempted by the Government of Indonesia to

overcome these problems,n but not optimum and their overcome these problems,n but not optimum and their

coverage are inadequate :coverage are inadequate :

(1) Difficult access due to geographic reason(1) Difficult access due to geographic reason

(2) limited facilities(2) limited facilities

(3) limited human resources. (3) limited human resources.

Skill in implementing resuscitation,: still remains as a big Skill in implementing resuscitation,: still remains as a big questionquestion

Competence and absorption power of pre-service education Competence and absorption power of pre-service education is still not convincing as well as its post service, due to is still not convincing as well as its post service, due to limited budget.limited budget.

Government was support by : Government was support by : Various professional organization : : Indonesian Midwife Various professional organization : : Indonesian Midwife

Association, Indonesian Pediatrician Society and Association, Indonesian Pediatrician Society and Indonesian Obstetrician and Gynecologist Association Indonesian Obstetrician and Gynecologist Association etc.. etc..

NGOs (Non Government Organizations) and Organization NGOs (Non Government Organizations) and Organization with the same interest such as PERINASIA (Indonesian with the same interest such as PERINASIA (Indonesian Perinatology Society) Perinatology Society)

One of its programs is Neonatal Resuscitation Program One of its programs is Neonatal Resuscitation Program (NRP) conducted since 1997.(NRP) conducted since 1997.

Government (M O H ) efforts, Government (M O H ) efforts, strategies and programs:strategies and programs:

• Reducing MMR to 125 per 100,000 living births and

Neonatal Mortality Rate to 16 per 1000 living birth

• Essential Neonate Health Care

• Midwife Allocation in Villages

• Integrated Management of Childhood Illness (IMCI)

for Under Five proposed for Midwives in the Village

and Puskesmas (Community Health Centre),

Government (M O H ) efforts, strategies and programs ( Cont’d) :

• PONED (Pelayanan Obstetri dan Neonatal

Emergensi Dasar/) = Basic Emergency Obstetric

and Neonate Health Care, in Puskesmas

• PONEK (Pelayanan Obstetri dan Neonatal

Emergensi Komprehensif/) = Comprehensive

Emergency Obstetric Neonate Health Care in

Hospitals of Regency/ City and Provincial levels

Cooperation - CollaborationCooperation - Collaboration

MOHMOH

PROFESSIONALPROFESSIONAL

ORGANIZATIONORGANIZATION-IDAIIDAI-POGIPOGI-IBIIBI

WHOWHO

NGONGO•PerinasiaPerinasia•MNHMNH•PathPath•Save the ChildrenSave the Children

MOH – IDAI – MNH MOH – IDAI – MNH

• Developed Manual of Management of Newborn Developed Manual of Management of Newborn

Problems in Referral Hospital,for doctors,nurses Problems in Referral Hospital,for doctors,nurses

and midwivesand midwives

• Supplement Chapter in Normal Delivery care : Supplement Chapter in Normal Delivery care :

Resuscitation Resuscitation

MOH – IDAI – Save The Children- PATH

• Management Asphyxia for Midwives :

– Reference Book

– Guidance book for Trainee

– Guidance book for Trainer

• Video recorder Resuscitation

MOH – PATH – IDAI

• Appropriate Resuscitation Device for Village

Midwives Study : Comparing 4 devices :

– Tube and Mask ( Techno)

– Tube and Mask ( Lerdal )

– Bag and Mask ( Ambu )

– Bag and Mask ( Made in Taiwan)

• Verbal Autopsy Study about Neonatal Death in

Cirebon

SUMMARY SUMMARY

• Intact survival : important things within Human Life’s cycle. Intact survival : important things within Human Life’s cycle. • Intact survival : baby was completely survived and free Intact survival : baby was completely survived and free

from neurological deficit and grew up optimallyfrom neurological deficit and grew up optimally• Birth period : most critical time that babies were exposed Birth period : most critical time that babies were exposed

to several risks and complication such as death and to several risks and complication such as death and disabilities disabilities

• Birth asphyxia as a starting disaster Birth asphyxia as a starting disaster • Birth asphyxia should be early recognized and promptly Birth asphyxia should be early recognized and promptly

managedmanaged• If neonates could survived and most of them suffered from If neonates could survived and most of them suffered from

– disabilities which consists of three component : disabilities which consists of three component : impairment , activity limitation and participation impairment , activity limitation and participation restriction restriction

• Categories of impairment will be focused on severe Categories of impairment will be focused on severe

impairment of : impairment of :

– Motor function ( Cerebral palsy ) Motor function ( Cerebral palsy )

– Visual function ( Blindness)Visual function ( Blindness)

– Hearing ( deafness) Hearing ( deafness)

– Mental ability ( IQ < 70 ) Mental ability ( IQ < 70 )

• Right intervention to overcome the problems and Right intervention to overcome the problems and

improve the problems is neededimprove the problems is needed

SUMMARY ( cont’d)

• Intervention : Hospital based and Community based • Hospital based intervention :

– Therapeutic window – Identification of high risk infants for permanent brain

damage • Community based intervention :

– antenatal care – skilled care during delivery ( major long-term priority )

• High-risk deliveries attended by personnel skilled . • Many efforts and coverage of Government of Indonesia

not optimum and inadequate due to many factors.• Attention should be given in the term of Enhancing the

Human Resource of Indonesian people in the future

SUMMARY ( cont’d) SUMMARY ( cont’d)