1. DR O.A EWEDEMIDR O.A EWEDEMI
B.Sc; MBBSB.Sc; MBBS
Department of Obstetrics and Gynaecology,
LAUTECH Teaching Hospital,
Ogbomoso, NIGERIA

2. OBJECTIVES
 Know The Physiologic Changes At Birth;
 Be Aware of The Resuscitation Flow Diagram/Strategy;
 Be Aware Of Equipment & Personnel Needed;
 Be Able To Decide When To Resuscitate [High-Risk]; &
 Understand the Sequelae of BA

3. INTRODUCTION
The successful transition from
intrauterine to extra-uterine life is
dependent upon significant physiologic
changes that occur at birth.
 6-10% of 130 milliom newborns
NEED some intervention at birth, 1%
require extensive resuscitation
 4 million die & similar number develop
sequelae from BA:
CP, Mental Retard, Microcephaly,Epilepsy, etc
 PA Remains Very Common & Serious
Clinical Problem Worldwide
o 85/1000 Live births - Nigeria
o 58/1000 Live births – Libya
o 11.5/1000 Sweden
o 1.2/1000 Japan

4. FETAL CIRCULATION
IN THE FETUS
 Placenta; lowest vascular resistance –
40% fetal cardiac output
 Fetal lungs are filled with fluid -
resulting in a high vascular
resistance – 10% cardiac output
 2 right-to-left shunts occur in the
fetus
1. Foramen ovale
2. Ductus arteriosus

5. FETAL OXYGENATION
 Low intrauterine oxygen tension compared to extra-uterine life.
The highest oxygenated fetal
 adequate tissue oxygenation:
* Fetal hemoglobin
* Decreased fetal oxygen consumption:
- no need for thermoregulation
- reduced physiologic functions
 Differential blood flow
 Liver - directly from the umbilical vein
 Brain and heart — high degree of oxygen saturation;
differential velocities of incoming venous blood streams and
directing of oxygenated blood to the foramen ovale.
 The low fetal oxygen tension maintains the architecture of the
fetal circulation by causing pulmonary vascular constriction

6. TRANSITION AT DELIVERY
When the umbilical cord is clamped at
birth, the neonate must rapidly make
physiologic changes in cardiopulmonary
function:
 Alveolar fluid clearance
 Lung expansion
 Circulatory changes with increases in
pulmonary perfusion and systemic
pressure, and closure of the right-to-left
shunts of the fetal circulation

7. TRANSITION AT DELIVERY
 Alveolar fluid clearance:
* Labor — increased catecholamine and oxygen tension= active resorption
of sodium and liquid
* Initial breaths —high trans-pulmonary pressures; drives alveolar fluid
from the air spaces into the interstitium and subsequently the pulmonary
vasculature.
* Thoracic squeeze —pressure upon the chest wall
 Lung expansion — 1st
effective breath, intrathoracic pressure falls, air
movement begins Increasing inspiratory pressure expands the alveolar air
spaces and establishes functional residual capacity. Surfactant release
stimulated, reduces alveolar surface tension, increases compliance, and
stabilizes the FRC.
 Circulatory changes — With the clamping of the umbilical cord, the
placenta with its low vascular resistance is removed from the neonatal
circulation, resulting in a rise in neonatal systemic blood pressure.
* closure of the ductus arteriosus.
* closure of the foramen ovale

8. DIFFICULTIES IN TRANSITION
 Lack of respiratory effort:
- suggests that the infant is neurologically depressed (usually brain
asphyxia) or has impaired muscular function
 Blockage of the airways:
- congenital airway malformation , presence of meconium or mucus in
the airway
 Impaired lung function:
- External causes —pneumothorax , pleural effusions
- Pulmonary hypoplasia — congenital diaphragmatic hernia,
oligohydramnios
- Intrinsic lung disease —hyaline membrane disease, acquired
pneumonia, transient tachypnea of the newborn
 Persistent increased pulmonary vascular resistance (also referred to as
persistent pulmonary hypertension or persistent fetal circulation)
 Abnormal cardiac structure and/or function

9. SIGNS OF THE COMPROMISED NEWBORN
 Poor Muscle Tone/HypotoniaPoor Muscle Tone/Hypotonia
 Depressed Respiratory DriveDepressed Respiratory Drive
 BradycardiaBradycardia
 Vascular Collapse/HypotensionVascular Collapse/Hypotension
 TachypneaTachypnea
 Color Change/CyanosisColor Change/Cyanosis
 Poor Response To Stimulation; Depressed Reflexes
 Seizures & Other Neurological Problems Occur within 1st
12hrs Of Significant Asphyxia
 Overall Clinical Manifestations & Course Vary,
Depending On Occurrence Of/Severity Of Hypoxic-
Ischemic Encephalopathy (HIE)

10. IN UTERO OR PERINATAL COMPROMISE
 Primary Apnea
 When Fetus/Newborn 1st
Becomes Deprived Of O2
, An Initial Period Of
Attempted Rapid Breathing Is Followed By Primary Apnea; PLUS Falling
Heart Rate That Would Improve With Tactile Stimulation
 Secondary Apnea
 If O2
Deprivation continues, Secondary Apnea Ensues, Accompanied By
Continued Fall In Heart Rate & BP
*Secondary Apnea Cannot Be Reversed With Stimulation;
Assisted Ventilation Is A Must.
AN_01_07_02 (2).wmv

11. PATHOPHYSIOLOGYPATHOPHYSIOLOGY

12. 0_________ 1__________ 2_____0_________ 1__________ 2_____
AAppearanceppearance Blue/PaleBlue/Pale Body Pink,Body Pink,Limbs BlueLimbs Blue All pinkAll pink Skin ColorSkin Color
PPulse Rateulse Rate 0 <100 >1000 <100 >100 Pulse RatePulse Rate
GGrimacerimace 0 Slight Good0 Slight Good Reflex IrritabilityReflex Irritability
AActivityctivity Limp Some Movement Active Movements/Limp Some Movement Active Movements/
Limbs Well FlexedLimbs Well Flexed MToneMTone
RRespirationespiration 0 Weak, Irregular Good Reg0 Weak, Irregular Good Reg BreathingBreathing
RespiratnRespiratn
Apgar scores are not used to guide resuscitation but are useful as a
measure of the newborn's overall status and response to
resuscitation. When the five-minute Apgar score is less than seven,
additional scores should be assigned every five minutes for up to
20 minutes. Apgar scores are not good predictors of outcome.
Virginia Apgar - 1953
OVERVIEW OF RESUSCITATIVE STEPS

13.  The 2010 AHA/AAP/ILCOR guidelines include a
rapid assessment of the neonate's clinical status based
on the following questions:
●Is the infant full-term?
●Is the infant breathing or crying?
●Does the infant have good muscle tone?
 If the answer to all three questions is yes, the
newborn does not need resuscitation, should not be
separated from the mother, and is managed by routine
neonatal care.
OVERVIEW OF RESUSCITATIVE STEPS

14. THE WHO Guidelines
 ANTICIPATE
 Be Prepared For Every Birth By Having Skill To Resuscitate
 Review The Risk Factors, If Any, For Perinatal Asphyxia
 Clearly Decide On The Responsibilities Of Each Hlth Care Provider During NR
 Remember That The Mother Is Also At Risk Of Complications
 The Following Questions Should Be Answered After Every Birth:
 Is The Amniotic Fluid Clear Of Meconium?
 Is The Newborn Baby Breathing Or Crying?
 Is There A Good Muscle Tone?
 Is The Color Pink?
 Is The Newborn Baby Born At Term?
 If Answer=No To Any Of These, Then Consider Resuscitation Immediately

15. ANTICIPATION OF NEED
 Training: Neonatal resuscitation program; all healthcare
providers who care for newborn infants
 High risk delivery:
o Maternal conditions
o Fetal conditions
o Ante-partum complications
o Delivery complications
.

16. PREPARATION
Necessary equipment should be assembled prior to the
birth of at-risk newborns:
●The radiant warmer is turned on and is heating.
●The oxygen source is open with adequate flow through
the tubing.
●The suctioning apparatus is tested and is functioning
properly.
●The laryngoscope is functional with a bright light.
●Testing of resuscitation bag and mask demonstrates an
adequate seal and generation of pressure.
In high-risk deliveries of multiple gestations, each
infant will require a full complement of personnel and
equipment.
.

17. PREPARATION
Preterm infants: greater challenge than term infants
o Hypothermia
o Inadequate ventilation
o Infection
o Organ damage
o Reduced antioxidant function
.

18. PREPARATION
Additional resources and personnel should be present
when a preterm birth is anticipated
●Equipment to keep the infant warm
●Personnel skilled in intubation
●Equipment and personnel should be available to deliver
positive pressure and to consider administering
surfactant.
●Compressed air sources, oxygen blenders, and pulse
oximeters
●Pre-warmed transport incubator
.

19. PREPARATION
ANTENATAL COUNSELING — Each birth institution
should have a consistent approach . Counseling should
include information regarding prognosis.
American Academy of Pediatrics (AAP) guidelines:
●If there is no chance of survival, resuscitation should not
be initiated.
●When a good outcome is considered very unlikely, the
parents should be given the choice of whether
resuscitation should be initiated, and clinicians should
respect their preference.
●If a good outcome is considered reasonably likely,
clinicians should initiate resuscitation and, together
with the parents, continually reevaluate whether
intensive care should be continued.
.

21.  Basic("ABCDs") in resuscitation still apply in the
newborn period.
 unique and lead to differences in the initial resuscitative
steps.
 The 2010 AHA/AAP/ILCOR guidelines recommend the
following approach:
●Initial steps (provide warmth, clear Airway if
necessary, dry, and stimulate)
●Breathing (ventilation)
●Chest compressions
●Administration of Drugs, such as epinephrine and/or
volume expansion
OVERVIEW OF RESUSCITATIVE STEPS

22.  started within a few seconds of birth and should be applied
throughout resuscitation.
 Provide warmth — Prevent hypothermia; warm towel or blanket and
pre-warmed radiant heat source maintain the infant's temperature at
36.5ºC
●Swaddling the infant after drying
●"Skin to skin" contact with mother and covering the infant with a blanket
●Use of polyurethane bags or wraps in infants with birth weights less than 1500 g
●Raise the environmental (room) temperature to 26˚C (78.8˚F)
●Warming pads
o In infants who require respiratory support, the use of humidified and
heated air versus nonheated air decreases the rate of both mild (36 to
36.4ºC) and moderate hypothermia (<36ºC)
INITIAL STEPS

23.  Airway — back positioned on a flat radiant
warmer bed with the neck in a neutral to
slightly extended position
 neck should not be hyperextended or flexed
 The proper position aligns the posterior
pharynx, larynx, and trachea, and facilitates
air entry.
 If needed, a rolled blanket or towel may be
placed under the infant's shoulder to slightly
extend the neck to maintain an open airway.
 Suctioning immediately after birth is reserved
for babies with obvious obstruction due to
secretions or who require positive pressure
ventilation
 Use bulb syringe or mechanical suction device
INITIAL STEPS

24.  mouth and nose suctioned. mouth is suctioned first
and then the nares to decrease the risk for aspiration.
 Suctioning of either the esophagus or stomach should
be avoided
 Wiping the mouth and nose may be an alternative to
suctioning for removal of secretions in infants who
are greater than 35 weeks gestation.
 Meconium stained amniotic fluid (MSAF)—
aspiration of upper airway demonstrated no benefit
 no longer recommend routine intrapartum suctioning
for meconium-stained infants
 However endotracheal suctioning of non-vigorous
babies with MSAF still recommended.
INITIAL STEPS

25. Suction Of Mouth & Nose
V_02_05_02(2).wmv

26.  Stimulation - after birth, except in "nonvigorous" infant born
with MSAF who first requires endotracheal intubation
 Pulse oximetry — determine oxygen saturation (SpO2) in the
following settings because oxyhemoglobin saturation may
normally remain in the 70 to 80 percent range for several
minutes following birth, which may result in the appearance of
cyanosis, and the assessment of skin color is a poor indicator of
oxyhemoglobin saturation during the immediate neonatal
period:
●When resuscitation is anticipated
●Positive pressure ventilation is used for more than a few breaths
●Persistent cyanosis
●Use of supplementary oxygen
 Placement at preductal location on the right upper extremity,
usually the wrist or medial surface of the palm, as soon as
possible.
INITIAL STEPS

27.  Supplemental Oxygen – improved survival with
resuscitation in room air rather than 100% oxygen
 Positive pressure ventilation – Bag-mask Ventilation
(BMV):
o Self-inflating bag – resource limited settings
o Flow-inflating bag
o T-piece resuscitator
o Laryngeal mask airway
 Position
 Suction
 Air-tight seal: E-C technique
 Initial breaths - Adequacy of ventilation is
demonstrated by improvement in heart rate
NEXT STEPS

28. USE OF ROOM AIRUSE OF ROOM AIR VsVs 100%100% OO22
IN P-P VENTILATIONIN P-P VENTILATION
Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics,Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics,

29. Bag & Mask Are The Most Vital Tool In Newborn ResuscitationBag & Mask Are The Most Vital Tool In Newborn Resuscitation

30.  Further resuscitative efforts are based upon the heart rate response
of the infant after the initial 30 seconds of BMV.
 If >100 beats per minute (bpm) and spontaneous effective
respiration has begun, BMV can be discontinued and free-flowing
oxygen administered as needed, based on the target oxygen
saturations for minutes after birth.
 If between 60 to 100 bpm, continue BMV ventilation and
reevaluate after 30 seconds. Reevaluation includes the following
sequence of M-Mask readjustment, R-Reposition the airway, S-
Suction the mouth and nose, and O- Open the mouth slightly.
 If <60 bpm, immediately begin chest compression and reassess
that adequate positive pressure ventilation is being delivered.
NEXT STEPS

31.  CPAP or PEEP — continuous positive airway (CPAP) or end-
expiratory pressure (PEEP) may be beneficial for adequate lung
recruitment and reduce subsequent lung injury
 Data from observational studies and a single clinical trial appear
to support the use of CPAP versus BMV in the initial resuscitation
of preterm infants
 Infants treated with single inflation/CPAP, when compared with
those who received conventional BMV, were less likely to be
intubated, receive more than one dose of surfactant, or develop
bronchopulmonary dysplasia (BPD).
 However, further studies to confirm these findings are needed
before CPAP versus BMV can be recommended for neonatal
resuscitation.
 After BMV ventilation as the initial resuscitative intervention,
CPAP rather than intubation and mechanical ventilation may be
beneficial in the spontaneously vigorous preterm infants who
require continued respiratory support or at risk for respiratory
distress syndrome.
NEXT STEPS

32.  Chest compressions are initiated if the infant's heart rate remains
<60 beats per minute despite adequate ventilation for 30 seconds
 Thumb technique – In this method, both hands encircle the
infant's chest with the thumbs on the sternum and the fingers
under the infant. This is the preferred method.
 Two-finger technique – In this method, the tips of the first two
fingers, or the middle and ring finger, are placed in a
perpendicular position over the sternum
 pressure is applied downward perpendicular to the chest wall
sufficient to depress the sternum about one-third of the
anteroposterior diameter of the chest, and then pressure is
released to allow the heart to refill.
 Avoid applying pressure directly over the xiphoid, as this may
cause hepatic injury.
NEXT STEPS

33.  Chest compressions must always be accompanied by positive
pressure ventilation (PPV).
 rate is 90 per minute accompanied by 30 ventilations per minute
with one ventilation interposed after every third compression.
 ventilation rate is reduced from the 40 to 60 breaths per minute
used in the absence of chest compression to 30 breaths in the
presence of chest compression.
 After 30 seconds of chest compression and PPV, reassessment of
the infant's heart rate, color, and respiratory rate should determine
whether further interventions are required (eg, intubation or
administration of medications).
NEXT STEPS

34. .

35.  Endotracheal intubation; Two care providers are required, time
needed for intubation should be limited to 20 seconds, and free
flowing oxygen is administered during the procedure.
 indicated in:
●Tracheal suctioning for meconium is required
●BMV is ineffective or prolonged
●Chest compressions are being performed
 congenital diaphragmatic hernia, airway stabilization of the
extremely low birth weight infant, and for administration of
surfactant.
 Initial stabilization – by BMV
 Insertion of the laryngoscope
 Assessment of successful intubation
 Securing ETT
NEXT STEPS

36.  DRUGS —rarely required in neonatal resuscitation. Delivering adequate
ventilation is the most important resuscitative step because the most common
cause of bradycardia is inadequate lung inflation or profound hypoxemia.
 However, if the heart rate remains <60 beats per minute despite adequate
ventilation and chest compressions, administration of epinephrine is
indicated.
 Rarely, volume expansion (normal saline, ringers lactate or O-ve blood) or a
narcotic antagonist (eg, naloxone) may be useful.
NEXT STEPS

37. .
.

38. Heart rate related to 1 min Apgar score
0 1 2 3 4 5
50
70
90
110
130
150
Apgar 1 min >6
Apgar 1 min < 7
Apgar 1 min < 4
Min after birth
heartratebeatspermin

39. Potentially Hazardous Forms Of Stimulation
 Slapping Back Or ButtocksSlapping Back Or Buttocks
 Squeezing Rib CageSqueezing Rib Cage
 Forcing Thighs Onto AbdomenForcing Thighs Onto Abdomen
 Dilating Anal SphincterDilating Anal Sphincter
 Hot Or Cold Compresses Or BathsHot Or Cold Compresses Or Baths
 ShakingShaking
 DRUGS, e.g. Hydrocortisone, NaHCODRUGS, e.g. Hydrocortisone, NaHCO33 - Especially With Apnea- Especially With Apnea

40.  Rarely, infants will not respond to the initial resuscitative
efforts.
 Ensure all the resuscitative steps were fully and properly
administered.
 If the infant fails to respond despite properly executed
resuscitation, the following clinical approach may help ascertain
the cause:
 Resuscitation efforts may be discontinued if the neonate has
demonstrated no signs of life (no heart beat or no respiratory
effort for greater than 10 minutes) after 10 minutes of
resuscitation
 As previously discussed, if additional data obtained after
resuscitation is started demonstrates that neonatal outcome is
almost certain early death or unacceptably high morbidity,
support can be discontinued if agreed upon by the parents and
healthcare team.
FAILURE OF RESUSCITATION

41.  With antenatal screening, it is now possible to identify
conditions associated with high neonatal mortality or poor
outcome.
●The decision not to initiate intensive therapy is made together by
the parents and the healthcare team. Discussion, if possible,
should occur prior to the birth of the infant.
●Non-initiation of resuscitation may be considered if early death is
very likely and survival would be accompanied by
unacceptably high morbidity. infants with gestational age <23
weeks or birth weight <400 g, anencephaly, or chromosomal
abnormalities incompatible with life (eg, trisomy 13 or 18)
●Intensive care including neonatal resuscitation is always
indicated when there is a high likelihood of survival and
acceptable morbidity.
●In settings in which the prognosis of the infant is unclear but
likely poor, and survival may be associated with a diminished
quality of life, parental wishes should determine management
decisions.
WITHOLDING RESUSCITATION

42.  At delivery, if the appropriate course is uncertain, it is
preferable to initiate resuscitation. If additional data
demonstrate that the outcome is almost certain early death or
unacceptably high morbidity, support can be discontinued if
agreed upon by the parents and healthcare team.
 Basic care that provides comfort to the infant must be given at
all times, even when intensive therapy is not initiated.
 When there is disagreement between the parents and healthcare
team, continued discussion is recommended. Other resources in
resolving disagreement include consultation with the hospital's
ethics committee or finding healthcare providers that will
provide care for the infant in the manner desired by the parents.
At times, unresolved disagreement may result in the
involvement of the court system.
 At all times, the clinician must serve as an advocate of the infant
and what he/she judges to be in the infant's best interest.
 The clinician needs to know the relevant laws in his/her local
area of practice.
WITHOLDING RESUSCITATION

43.  Infants who required resuscitation are at risk of developing
postresuscitative complications:
●Hypo- or hyperthermia
●Hypoglycemia (see "Neonatal hypoglycemia")
●Central nervous system (CNS) complications: apnea, seizures, or
hypoxic ischemic encephalopathy
●Pulmonary complications: Pulmonary hypertension, pneumonia,
pulmonary air leaks, or transient tachypnea of the newborn
●Hypotension
●Electrolyte abnormalities: Hyponatremia or hypocalcemia
●Feeding difficulties: Ileus, gastrointestinal bleeding, or
dysfunctional sucking or swallowing
 The longer and the greater the extent of resuscitation, the more
likely that there will be subsequent and serious complications.
POSTRESUSCITATION

44. SUMMARY POINTS
 Preparation & Teaching Is the bedrock of Successful NR
 Ventilation Is The Primary Goal
 Oxygenation can be achieved by Room Air
 Chest Compression & Drugs Are Rarely Needed
 Ethics Should Carefully Be Considered In Our Circumstances
 Each Strategy/Step Should Be Assessed Scientifically - More
Research Is Required

45. SUMMARY POINTS
 The Most Important & Effective Action In NR Is To Ventilate Baby’s Lungs
 Effective P-PV In Secondary Apnea Usually Results In Rapid HR Improvement
 If HR Does Not Increase, Ventilation Could Be Inadequate And/Or Chest
 Compressions & Epinephrine May Be Needed
 HR <60 bpm → Additional Steps Needed
 HR >60 bpm → Chest Compressions Can Be Stopped
 HR >100 bpm & Breathing → P-PV Can Be Stopped
 Time Line: If No Improvement After 30 Seconds, Proceed To Next Strategy/Step

46. V_02_06_01(2).wmv

47. Refs. For Further ReadingRefs. For Further Reading
1.1. AHA/AAP: International Guidelines for Neonatal Resuscitation. (Pediatrics September 2000)AHA/AAP: International Guidelines for Neonatal Resuscitation. (Pediatrics September 2000)
2. Airede AI. Birth Asphyxia and Hypoxic-Ischemic Encephalopathy: Incidence and Severity. Ann Trop2. Airede AI. Birth Asphyxia and Hypoxic-Ischemic Encephalopathy: Incidence and Severity. Ann Trop
Paediatr 1991; 11: 331-5.Paediatr 1991; 11: 331-5.
3. Airede KI Neonatal Seizures and a two-year Neurologic Outcome. J Trop Pediatr 1991; 37: 313-17.3. Airede KI Neonatal Seizures and a two-year Neurologic Outcome. J Trop Pediatr 1991; 37: 313-17.
4. Airede A'KI. Should We Resuscitate? Ethical Dilemmas. Ann Trop Paediatr 1991; 11:169-74.4. Airede A'KI. Should We Resuscitate? Ethical Dilemmas. Ann Trop Paediatr 1991; 11:169-74.
5.5. Apgar, V.: A Proposal for a New Method of Evaluation of the Newborn Infant. Curr Res Anesth Analg 1953;Apgar, V.: A Proposal for a New Method of Evaluation of the Newborn Infant. Curr Res Anesth Analg 1953;
32 (4): 260–267.32 (4): 260–267.
6. Costello AM del. Perinatal Health in Developing Countries. Trans R Soc Trop Med Hyg 1993; 87: 1-2.6. Costello AM del. Perinatal Health in Developing Countries. Trans R Soc Trop Med Hyg 1993; 87: 1-2.
7. Idrisa A, Airede AI and Agida ET. Perinatal Mortality at the University of Maiduguri Teaching Hospital,7. Idrisa A, Airede AI and Agida ET. Perinatal Mortality at the University of Maiduguri Teaching Hospital,
Maiduguri, Nigeria. Nig J Surg Sci 1992; 2: 82-4.Maiduguri, Nigeria. Nig J Surg Sci 1992; 2: 82-4.
8.8. ILCOR: An Advisory Statement From the Pediatric Working Group of the International Liason CommitteeILCOR: An Advisory Statement From the Pediatric Working Group of the International Liason Committee
on Resuscitation - Pediatrics, April 1999.on Resuscitation - Pediatrics, April 1999.
9. Leviton A, Nelson KB. Problems with Definitions and Classifications of Newborn Encephalopathy.9. Leviton A, Nelson KB. Problems with Definitions and Classifications of Newborn Encephalopathy.
Pediatr Neurol 1992; 8(2): 85-90.Pediatr Neurol 1992; 8(2): 85-90.
10. Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group, et al . Ventilation Using 100%10. Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group, et al . Ventilation Using 100%
Oxygen and Room Air Oxygen. Pediatrics, 1998; 102:e1Oxygen and Room Air Oxygen. Pediatrics, 1998; 102:e1
11.11. WHO: Basic Newborn ResuscitationWHO: Basic Newborn Resuscitation
(WHO, Geneva 1998)(WHO, Geneva 1998)

48. 
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