Friday, September 15, 2017
Skilled Birth Attendant
Skilled Birth Attendant
Neonatal Resuscitation Training
Latter-day Saint Charities
Based on the Textbook of Neonatal Resuscitation
5th Edition
American Heart Association
American Academy of Pediatrics
Rev. 09/18/2008
TABLE OF CONTENTS
Lesson 1: Which Babies Require Resuscitation? 3
How does a baby receive oxygen before birth? 4
What happens with normal transition? 6
What are the signs of an abnormal transition? 7
Why premature babies are at higher risk 8
How do you prepare for resuscitation? 8
Key Points 9
Lesson 2: Initial Steps of Newborn Care: The First 30 Seconds 10
Is there meconium? 10
Provide warmth 10
Position by slightly extending the neck 11
Clear mouth and nose 11
Dry, stimulate to breathe, and reposition 12
Evaluate the baby to determine if resuscitation is needed 13
Key Points 15
Lesson 3: Positive-Pressure Ventilation: The Second 30 Seconds 16
When to ventilate 16
Equipment for positive-pressure ventilation: Self-inflating bag and mask 17
Important characteristics of face masks 20
Testing a self-inflating bag 21
Preparing for positive-pressure ventilation 21
What if the heart rate, color, breathing, and muscle tone do not improve? 24
Key Points 27
Introduction:
The goal of every birth is a healthy baby capable of making the transition from life with the mother to life in the world. The key to the transition is being able to breathe and get oxygen to the body through the lungs instead of from the mother through the placenta. The birth attendant must do all possible to assist the baby in making that transition as soon as possible.
Lesson 1: Which Babies Require Resuscitation?
What is resuscitation?
Neonatal resuscitation means to revive or restore life to a baby. This course is designed to teach the steps necessary to ventilate a newborn baby that is not breathing.
Basic steps in resuscitation
90% of newly born babies make the transition from intrauterine to extrauterine life without difficulty. They require little to no assistance to begin spontaneous and regular respirations. Approximately 10% of newborns require some assistance to begin breathing at birth and only about 1% need extensive resuscitative measures to survive.
The diagram below illustrates the relationship between resuscitation procedures and the number of newly born babies who need them. At the top are the procedures needed by all newborns. At the bottom are procedures needed by very few.
ABCs of resuscitation
The ABCs of resuscitation are the same for babies as for adults.
Ensure the airway is open and clear.
Be sure there is breathing, whether spontaneous or assisted.
Make certain there is adequate circulation of oxygenated blood.
Risk factors associated with need for resuscitation
Maternal Risk Factors Before Labor
Pre-eclampsia and eclampsia Previous fetal or neonatal death
Maternal infection (HIV, STD, Malaria) Multiple gestation
Premature rupture of membranes Diminished fetal activity
Post-term gestation Bleeding in second or third trimester
Maternal diabetes Age <16 or >35 years
Anemia No prenatal care
Risk Factors During Labor
Foul smelling amniotic fluid Unusual vaginal bleeding before delivery
Prolonged rupture of membranes Precipitous labor
(>18 hours before delivery) Shoulder dystocia
Prolonged labor (>24 hours) Prolapsed cord
Fetal bradycardia (slowing of heart rate) Forceps or vacuum-assisted delivery
Meconium Narcotics administered to mother
Premature labor within 4 hours of delivery
Breech or other abnormal presentation Cesarean section
Prolonged second stage of labor (>2 hours) Uterine tetany
Maternal complications are often unpredictable, but newborn complications are usually predictable based on these factors. Therefore, it is usually possible to anticipate and prepare for resuscitation.
How does a baby receive oxygen before birth?
Oxygen is essential for survival both before and after birth.
Before birth, the placenta provides all of
Thursday, September 14, 2017
ASEBE TEFERI IS NEITHER LOCAL NAME NOR OFFICIAL NAME OF CHIRO
Chiro (town)
| Chiro/Ciroo ciroo Ciroo Golaa |
|
|---|---|
| Town | |
| Nickname(s): Shuguxii Lolaa | |
Chiro/Ciroo
|
|
| Coordinates: 9°5′N 40°52′E | |
| Country | Ethiopia |
| Region | Oromia |
| Zone | West Hararghe |
| Government | |
| • City manager | Wozir jemal |
| Elevation | 1,826 m (5,991 ft) |
| Population (2014) | |
| • Total | 56,900 |
| Time zone | EAT (UTC+3) |
| Climate | Aw |
Contents
Overview
Although by the 1930s a road existed which connected the town with the railroad station at Mieso, another road was constructed connecting Chiro with Mata Hara with Swedish funds in 1966History
Chiro was founded around 1924 by Fitawrari Tekle Hawariat Tekle Mariyam on the site of a village named Chiro.[1] It was the capital of the former "model" province of Chercher, created as part of Emperor Haile Selassie's campaign of modernization in the 1930s.[2] Most part of present-day West Hararge zone which was known by its mountainous tract on the rift valley edge was commonly known as cărĉar. It is inhabited by the Itu Oromo. Nole, Ala, Jarso wacalee etc. inhabit different part of the region. The Wacale specifically inhabit Ciro area (Hasan: 1985; informants Wozir). When Menelik’s expansion to the east began to the east, the Ittu land became militarily important because it was considered as a spring board, a sanctuary for the much pressed campaign against the Arsi Oromo. The campaign against Ittu, then, began in 1883 through 1884. The campaign was led by one of Menelik’s general Walda-Gabrel Abba Satan. By 1886 the whole cărĉar came under Wolde Gabriel and he became its governor (Caulk: 1971; Hasan: 1985; Tsehay: 1969). Ever since the period of conquest, the Eastern provinces remained principalities for the Showan royal house. After Harar came under Menelik’s occupation Ras Mekonnen Wolda-Mikael became its governor. Then the whole Hararge became the hereditary fief of the family of Ras Mekonen. This was true to cărĉar. The Showan army that marched to cărĉar went through Gubba-Qoricha, from Baddessa to Galamso and then too Borama. Though Wolde-Gabrel also established garrisons at Galamso the main seat of the neftegna force governing cărĉar was at Qunni where they established Qunni Georgies church (informants 3, 6; Tsehay 1969). Qunni then remained the capital of cărĉar until the foundation of Ciro town (informants 1, 2). During the regence of Tafari Mekonen (later Emperor Haile Sellassie) cash crop and money began to dominate the Ethiopian’s political economy. The previous traditional provincial administration began to give way to money-economy. In Hararge, including cărĉar the a royal families, including Tafari conducted commercial agriculture from which they derived great profit. To realize the development along cash economy, model provinces were set-up. These model provinces were to be controlled by western educated men responsible to the Ministry of Interior in the capital. One such model province was cărĉar, which was governed by Western educated men, first Takle Hawariat Takle-Mariam and later Dr Martin or Azazh Workneh (Greenfield 1969).Foundation and Growth
Bejrond Takla Hawariat Takla Mariam was assigned as governor of cărĉar in 1923. As soon he became a governor, Takle Hawariat wanted to shift the capital to somewhere else because he did not found Qunni, a site that fulfill a pre request for capital. Located on a mountain massive, Qunni was often very cold and windy. It also suffered from shortage of water and building materials. All these forced Takla Hawariat to shift the capital from Qunni to a more favorable area. First he wanted to establish the capital at Hirna, where he had stayed from about 1912 or 1913. However, he could not get the necessary permission from Ras Tafari. After looking at a number of alternatives he finally decided Ciro to be the center (Bahiru 2002; Hasan 1985; informants 1, 2, 4). In 1923 Takla Hawariat bought plots of land from some land holders and began constructing buildings where to start administrative work. Known figures or notables were then allotted land and house construction continued. This marked the foundation of the town. The news of the foundation soon disseminated and migration to the town began. Another important issue after the foundation of the town is the naming of the town. Takla Hawariat preferred to retain the old local name of the site, Ciro or to name it after a nearby hill, Motti. According to tradition, the area where the town was found was called Ciro, after an indigenous settler named Ciro Sire, from Itu Wucale clan. However, Takla Hawariat was ordered by Ras Tafari Mekonen, to name town as Asebe Teferi. The attempt to use the name Ciro during the Derg remained unsuccessful due to opposition from some who did not like the change. Then, the name Asebe Teferi remained in use until 1991 (Hasan 1985; informants 1, 2, 4).As mentioned above, migration to the town began as soon as news of its foundation was heard. New settlers came not only from the surrounding areas but also from distant places, all over the country. The town of Ciro was found, built up and developed into one of the best planned town in the country within a short period of time. This is attributed to different factors. First and foremost, compared to the previous capital, Ciro was found on a beautiful setting, heavily forested and green hills on the side of the town. This made the town attractive for life. Moreover, the reforms underwent in the province where Ciro became a center also helped its fast development. Takla Hawariat had begun his reform work while he was conducting his personal farm work at Hirna before the 1920s. Some of the reforms he had carriedout then were the opening of a new caravan route connecting Hirna with Dire Dawa, establishing a new market place and establishing telephone line. He soon started introducing these innovations to Ciro as the town founded. Electricity, water, supply, telecommunication, and postal services were all introduced to Ciro as soon as he became governor. He also divided cărĉar into more rational administrative units in which the province was divided into Tulo, Doba, Qunni, Ya’a-Bishani, Harawacha, Boke, Gubba-Qoricha, Balbaletie, Adal and Ciro. This administrative division also imparted the development of the town as large number of people began to frequent it. A number reforms including land holding system which encouraged producers were also introduced in cărĉar during the administrative tenure of Takla Hawarit between 1923-1930 (Bahiru 2000; informants 1, 2, 4). In 1928 the road that linked Ciro with the railway at Mi’esso very well served the whole province, connected with Dire Dawa-Harar road. The assignment in 1930, of another Western educated figure, Hakim Worqineh Eshete, as governor of cărĉar might have contributed to the development of Ciro town. According to some sources, Worqineh is remembered for introducing a number of services in Ciro town. These include the opening of school, building internal roads and roads to neighboring province. The pioneer primary school in Ciro was opened in 1931, in which the former student of Worqineh, Emmanuel Abraham was one of pioneer teacher and a director.
In addition to the regular school subject the school involved the students in carpentry, sport competitions and other activities. This attracted a number of young children to Ciro (Bahiru 2000; Emmanuel: 1995). This school laid a foundation for later expansion of education (informants 1, 2, 3, 4). According to our informants, a hospital was opened during this period. According up 1930s, government establishments including the palace and offices, the school and private residence houses were in existence. As the result of increased settlement different quarters had also emerged by the 1930s. These include Itu-Safar, Mehal-Safar, Qollegna Safar, Gimjabet safar, Sigabet-Safar, Qes-Amba etc. Qes Amba Safar emerged as the result of the establishment in 1923, of the Church of Egziaber Ab built on a hill overlooking the town of Ciro other neighborhoods including sheek Harar, Ganda Basha, Ganda Lele and Ganda Kolo had already emerged (informants 1, 3, 4). During occupation (1936-1941) the Italians made their center at Arba-Rakkate, a few km away from Chiro town. However, they introduced some innovations for their own purpose which was a contribution for the town. This includes constructing some houses and roads. The town of Chiro was connected to other towns as the Italians improved the mule tracks to all-weather roads (Alula 1972; informants 1, 2, 4).
Post – 1941 Developments
As post-war Administrative rearrangement cărĉar was organized as cărĉar, Adal and Gara-Gurracha province (Awarja). A number of government offices were opened and Ciro began to serve people from different areas. Furthermore, the services that had already introduced before the war were now improved. These include education, health services and services such electricity, water, and postal services were improved (informants 1, 2, 3, 4, 5, 6; official document of Chiro municipality). Furthermore, the seventh sub-division (Shaleqa) of the 3rd Division Army at Harar established its camp at Chiro. This contributed to the increase of population of the town as a number of people began to frequent the town regularly. Settlement also increased as the result of this establishment. The number of foreigners coming to the town also increased. The Greeks, and Arabs mainly dominated business until the late 1960s (informants 1, 4, 5, 6). Chiro was one of the forty towns in the country to get development master plan. It got modern telephone service and other improved services since the 1960s. The trend of development continued in the same trend until 1974. During the Derg regime additional residence house, Qebele offices and houses for other services were constructed. All these added to the expansion of the town towards both to west and the east directions. However, extraordinary growth and expansion of the town began to take place very recently. In conclusion, Chiro town is one of the fast growing cities of Oromia which can easily be promoted with good planning and commitment to implement the plan. Its very location and the nearby Jallo forest, the Grand Mosque (Masqida Raham) etc. makes it can ideal town for tourism.Nega Mezlekia described the town when he came to live there in 1977 as "a melancholic small town whose drab conditions are accentuated by the black roads, laid with crushed basaltic rocks" which "snakes along the edge of the main highway that links the city of Harar with the capital city". He describes the buildings in the town as unkept and rundown: "Generations of neglect were written into the faces of these derelict buildings. The walls had shed their meagre mud linings, and a few of the buildings tilted to one side or another, making it as dangerous a proposition to stand in their scant shade as to live in them." His opinion of the inhabitants is equally unkind, detailing how at night the marketplace was transformed into a stage where drunken peasants perpetuated blood feuds generations old. "Peasants didn't go to police or courts for justice. Blood called for blood."[3]
Landmarks in Chiro include Mazigid Rahama,Igzeabeher abe and Ledeta Mariyam Bete Kristian, Chercher comprehensive secondary school,Haromaya Universality chiro Camps,Chiro Hospital stadium, Feres Megala,Total Mesgid, Gashegna camp, Adarash, Kuter ande, Kuter hulet, and Kuter soset temehert bet. It is the closest town to the Kuni-Muktar Wildlife Sanctuary.
During the 1950s, the coffee plantations around the town were small yet yielded a relatively high production. In 1958, Chiro was one of 27 places in Ethiopia officially ranked as First Class Township. The Ethiopian News Agency reported in mid-July 1976 that negotiations held at Chiro by representatives of hostile groups of the Afars and Issas had led to a peace agreement.[1] When Nega Mezlekia visited the town the following year, he learned that the Ethiopian People's Revolutionary Party and Oromo National Liberation Movement were more active around Chiro than in the rest of the province. "There was a strong peasant base around the town that provided a great deal of support for the party. The forest cover in the areas nearby furnished hideout." However, when he returned in 1978, he found the town far more peaceful. "It seemed that most of the threatening political opponents of the regime were dead, in exile or rotting in prison, and the going was good for those in power."[4]
Demographics
The Oromo people live here along with the Gadabuursi peoples. The 2007 national census reported a total population for this town of 33,670, of whom 18,118 were men and 15,552 were women. The majority of the inhabitants said they were Muslim, with 49.88% of the population reporting they observed this belief, while 43.34% of the population practised Ethiopian Orthodox Christianity and 5.33% of the population were Protestant.[5]The 1994 national census reported this town had a total population of 18,678 of whom 9,218 were males and 9,460 were females. It is the largest town in Chiro woreda. And according to the national census in 2006/7 the total population is m0re than 42,000.
References
- 2007 Population and Housing Census of Ethiopia: Results for Oromia Region, Vol. 1 Archived November 13, 2011, at the Wayback Machine., Tables 2.1, 2.5, 3.4 (accessed 13 January 2012)
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Woredas of the Mirab Hararghe Zone
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| Former woredas |
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| Current woredas | ||
Tuesday, September 12, 2017
Diabetic Ketoacidosis (DKA)
Description
Life-threatening acute Cx of DM characterised by dehydration,
hyperglycaemia, glycosuria,
ketonaemia, ketonuria& acidosis. [Biochem: BSL>11, pH
<7.3, HCO3
-<15mmol/L,
ketonuria/aemia].
Pathophysiology
Inadequate insulin→progressivehyperglycaemia→'cellular
starvation'→ ↑release of
glucagon, catecholamines, cortisol and GH → glycogenolysis&
gluconeogenesis, ↑BSL
The stress response →proteolysis and lipolysis,
forming free fatty acids, which are then
converted to the ketoacids acetoacetate, beta-hydroxybutyrate and
acetone.
The high glucose levels cause a huge osmotic diuresis and gross
dehydration which may
reduce tissue perfusion and further derange metabolism by causing
lactic acidosis
Epidemiology
1-5% T1DM (20% new).T2DM unusual (HONK more likely).Esp young
adults or children. 2F:1M.
Precipitating conditions:
Infection (19–56%) e.g. pneumonia, UTI
Inadequate insulin/non-compliance (15–41%)
Undiagnosed diabetes (10–22%)
Other medical illness (10–12%) e.g. hypothyroidism,
pancreatitis, inborn errors of metab
Cardiovascular disease (3–6%) e.g. PE, stroke, MI
Other physiological stress e.g. pregnancy, surgery
Drugs e.g. corticosteroids, sympathomimetics, α- and β-blockers
and diuretics
Cause unknown (4–33%)
Presentation
History
Insidious onset of ↑thirst (polydipsia), worsening
polyuria, & weight loss. (Rarely ↑hunger)
Nausea and vomiting are common } non-specific abdominal pain
Lassitude, weakness and fatiguability often occur
Global cerebral symptoms such as confusion and disorientation
may be present
Note focal symptoms of infection, dyspnoea, chest pain,
palpitations, abdominal pain,
recent changes in medication, episodes of overdose/ingestion of
poisons, and EtOH use
If on insulin note regimen and compliance
Examination
Check vitals (T,HR, BP, RR, SaO2, GCS)
Signs of gross dehydration
Ketoticfoetor (pear drops or nail-polish remover)
Respiratory compensation of acidosis can lead to tachypnoea or
Kussmaul's respiration
Assess mental status and orientation & neurology
Examine the chest, abdomen, skin for signs of infective
precipitant
Check cardiovascular system for signs of cardiac failure,
pericardial rub and murmurs
Differential Diagnosis
Alcoholic ketoacidosis
HONK
Lactic acidosis
Causes of metabolic acidosis, e.g. OD
Acute pancreatitis
Septicaemia without ketoacidosis
Acute abdomen
Ketoacidosis due to starvation
Investigations
Bloods: FBC, UEC, Glucose, ABG, anion
gap, plasma osmolarity, Trop/CK, amylase, cultures. Note:
Assay of blood ketones is more sensitive and specific but is not
always available
GAD, IAA, IA-2 autoantibodies if new T1DM suspected
WCC, Trop/CK, amylase may all be ↑ by DKA itself rather than by a
precipitant
Na+ may ↑(dehydration), normal or ↓(
pseudohypoNa: Corr.Na=Na + (glu-5.5)/2.75 )
K+ may ↑(acidosis), normal or occ. ↓,
but overall there is depletion of body K+;
Cr & Ur rise with pre-renal RF; bicarbonate ↓.
Plasma Osmolarity = 2([Na] + [K]) + [Ur] + [glucose].
>290mOsm/L in cases of DKA.
Consider HONK if >320 mOsm/l and lack of ketonuria or
glu>30mmol/L.
Anion Gap = ([Na] + [K]) – ([Cl] + [HCO3] )>13 mEq/l in DKA
Urine: urinalysis for glycosuria
and ketonuria. Send for M, C & S
Radiology: CXR (?pneumonia or cardiac
failure), CT/MRI (if LOC, ?CVA), LP (if ?meningitis)
Other: ECG
Management
General:
Triage to resuscitation/acute area. Attach continuous
monitoring, weigh if possible
ABCD. Give O2, consider intubation and ventilation if ↓LOC
Obtain large-bore peripheral IV access + sampling line or insert
central venous catheter
Consider urinary catheterisation } NG
Intravenous fluid and electrolyte replacement:
Adult: may be sig. dehydrated (10%) can give: 1L NS stat, q1h,
q2h unless concern of CCF.
Child: 10-20mL/kg if shocked, beware cerebral oedema.
Maintenance+deficit over 48hrs.
Give potassium replacement when K+<5.5 and urine output
established &chk UEC q2–4h
Insulin therapy:
Initially 6U/hr (child: 0.05/kg/hr if<5y else 0.1U/kg/hr) short-acting
soluble insulin
In adults use a sliding scale for hourly insulin dose based. In
children do not ↓insulin.
Hourly BSL. Aim is to reduce plasma glucose by 3–5 mmol/hr after
initial fluid bolus.
When BSL<15mmol/l add 5%D (child: 0.45% NaCl+5%D) so BSL 8-12
til pH/ketone norm
Further measures:
HCO3 in rare cases (pH≤6.9) - 0.15 x wt x base deficit mmol
(give over 1 hr & reassess)
DKA leads to phosphate depletion but this rarely causes
significant clinical problems.
Any precipitating illness should be managed optimally as per
current guidance
Progression:
When eating dbl infusion rate while eating +1hr (meals) or
+30min (snacks)
If stable (pH>7.3, BSL<12, HCO3>15,
no ketonuria) & eating – convert to an sc insulin
regime and wean off infusion 90min after sc dose.
Give this dose before breakfast, lunch, dinner & about half
this dose at midnight
Dietician, education,
blood testing, and conversion to home insulin
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