essential newborn care 2013

Essential Newborn CareFacilitator:

Almera H. Garcenila RN,MAN

Objectives:At the end of an hour lecture the participants will be able to:

1.apply the steps in the immediate newborn care procedure,

2.apply the steps in resuscitation of newborn,

3.value human life.

Immediate Newborn Care (first 90

minutes)

Every Newborn Has NeedsTo breathe normally

To be warm

To be protected

To be fed

At the of the discussion, the learner will be able to:

1. To describe in sequence, the step-by-step procedures that a health worker should perform to meet the immediate basic needs of every newborn.

Immediate Newborn Care (first 90 minutes)

Providing Warmth: Check the Environment

Preparation for vaginal birth 1. Ensure privacy at the delivery area

Check temperature of the delivery room Ideal temp: 25 – 28°C

Check for air drafts

Turn air conditioner off at an appropriate time before delivery


Preparation for vaginal birth 2. Prepare your needs:

Lay out two pairs of surgical gloves to be worn by the health worker that does both perineal support and cord clamping.

Two warm blankets A bonnet A sterile plastic clamp And a sterile pair of scissors


3. WASH YOUR HANDS following the prescribed 1-2-3-4-5 method.

4. Put both sets of gloves. This is a double-gloving step.

5. Remember that more than 90% of newborn breath on their own without problems. If the baby is crying or breathing normally, do not

suction because routine suctioning is potentially harmful

Suction only if the airway is obstructed.


During the 1st 3 minutes within birth, here are the correct procedures prescribed by the EINC protocol: Once the baby is out, call out the time of birth

and sex of the baby.


After a baby is born, what should be the first action performed?

During the 1st 3 minutes within birth, here are the correct procedures prescribed by the EINC protocol: Lay the newborn on the mother’s abdomen.

TOWEL-DRY THE BODY of the newborn. Dry the baby for at least 30 seconds. This will stimulate the baby to breathe.


Immediate Thorough DryingImmediate drying:

Stimulates BreathingPrevents hypothermia

Hypothermia can lead toInfectionCoagulation defectsAcidosisDelayed fetal to newborn circulatory adjustmentHyaline membrane diseaseBrain hemorrhage

Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London, UK. p. 207-220;

TollinM,etal.. Cell Mol Life Sci 2005

Drying should be the first action,

IMMEDIATELYfor a full 30 seconds

Drying may be interrupted if, after a few seconds, the newborn

remains both floppy/limp and apneic

Immediate Thorough Drying

Dry the newborn thoroughly for at least 30 seconds

Follow an organized sequenceWipe eyes, face, headFront and backArms and legs

Wipe gently, do not wipe off the vernix

Remove the wet cloth, replace with a dry one

Immediate, Thorough DryingDo a quick check of breathing while

drying90-95% of newborns breathe normally after birth

If a baby is not breathing;Stimulate by drying thoroughlyDo not slap the babyDo not shake the babyDo not rub the baby vigorously

Immediate, Thorough DryingDo not suction unless the

mouth/nose are blocked by secretions

Do a quick check of the baby’s breathing and tone

Do not ventilate unless the baby is floppy/limp and not breathing

If after drying, the baby is limp and not crying, support breathing by bag and mask ventilation. Continue to keep the baby warm.

http://upload.wikimedia.org/wikipedia/commons/thumb/6/67/Stop.svg/500px-Stop.svg.png

Washing the Baby in the First 6 Hours is Protective.

Early Washing Can Lead To:Hypothermia which can lead to

Infection, coagulation defects, acidosis, delayed fetal to newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage

InfectionThe vernix is a protective barrier to bacteria such as

E.coli and Group B Strep; so is maternal bacterial colonization

No crawling reflex

Tunell R., Cell Mol Life Sci 2005; 62:2390-99; Righard L, Alade M. Lancet 1990; 336: 1105-07.

Summary:Do not wash or bathe the baby within his first 6

hours of life.Washing could lead to hypothermia and infection.


During the 1st 3 minutes within birth, here are the correct procedures prescribed by the EINC protocol:Remove the wet cloth.Initiate skin-to-skin contact by placing the baby

prone on the mother’s abdomen….or between her breast.

Use the second linen to cover the baby’s back and place the bonnet on the newborns head. Both to keep the infant warm.


During drying and stimulation of the baby, your rapid assessment shows that the baby is crying.

What is your next action?

Skin-to-Skin ContactGenerally perceived to be an intervention for

provision of warmth and bonding

Less well appreciated are its contributions to Overall success of breastfeeding/colostrum feedingStimulation of the mucosa-associated lymphoid

tissue systemProtection from hypoglycemiaColonization with maternal skin flora

Moore E, et al. Cochrane Rev. 2007 Jul 18;(3). Anderson GC, et al. Cochrane Rev 2003;(2).

Brandtzaeg P. Ann N Y AcadSci 2002;964:13–45

Early Skin-to-Skin ContactIf newborn is breathing

or crying:Position the newborn

prone on the mother’s abdomen or chest

Cover the newborn’s back with a dry blanket

Cover the newborn’s head with a bonnet

Use a warm cover if room temp <25°C

During the 1st 3 minutes within birth, here are the correct procedures prescribed by the EINC protocol:Place the ID bands around the newborn’s ankle.Skin-to-skin contact is essential to provide warmth

and create the bond between mother and child.Increasing the chances of overall success of

breastfeeding allows colonization with good bacteria.

Protects the baby from low blood sugar levels.Wipe the soiled gloves with the wet cloth used to wipe

the baby.


When should the cord be clamped after birth?

Properly-Timed Cord ClampingWhen preparing for delivery,

don 2 pairs of gloves after thorough handwashing

Remove the first set of gloves

Palpate the umbilical cord

After cord pulsations have stopped, clamp the cord using a sterile plastic clamp or tie at 2 cm from the umbilical base

Properly-Timed Cord ClampingClamp again at 5 cm from the base

Cut the cord close to the plastic clamp

BABY

3cm2cm

Properly-Timed Cord-ClampingDo not milk the cord

towards the baby

After the 1st clamp, you may “strip” the cord of blood before applying the 2nd clamp

Cut the cord close to the plastic clamp so that there is no need for a 2nd trim

Care of the CordDo not use a binder or “bigkis”

Do not apply any substance onto the cord

Observe for the oozing of blood. If blood oozes, place a second tie between the skin and the clamp

During the 1st 3 minutes within birth, here are the correct procedures prescribed by the EINC protocol:While maintaining skin-to skin contact

Check on the mother’s conditionTo deliver the placenta, ensure that the uterus is

well contracted.With one hand apply controlled traction on the

cord while the other hand is positioned at the area of the woman’s symphysis pubis to provide counter traction.


During the 1st 3 minutes within birth, here are the correct procedures prescribed by the EINC protocol:

Proceed to cheek on heavy bleeding and examine the mother’s perineum, lower vagina and vulva for tears.

Clean the mother and keep her comfortableInspect the placenta


What is the approximate capacity of a newborn’s stomach?

A

BC

D

How long after birth is a newborn ready to breastfeed?

Early and Appropriate

Breastfeeding Initiation

Leave the newborn between the mother’s breasts in continuous skin-to-skin contact

The baby may want to rest for 20-30 mins and even up to 120 mins before showing signs of readiness to feed

Early and Appropriate Breastfeeding Initiation

Health workers should not touch the newborn unless there is a medical indication

Do not give sugar water, formula or other prelacteals

Do not give bottles or pacifiersDo not throw away colostrumLet the baby feed for as long as he/she wants on

both breasts

Help the mother and baby into a comfortable position

Observe the newborn

Once the newborn shows feeding cues, ask the mother to encourage her newborn to move toward the breast

Early and Appropriate Breastfeeding Initiation

After delivery, mother is moved onto a stretcher with her baby and transported to Recovery Room, mother-baby ward or private room

Breastfeeding support is continued

Support Continued and Exclusive Breastfeeding

Counsel on positioningNewborn’s neck is not

flexed or twistedNewborn is facing the

breastNewborn is close to

mother’s bodyNewborn’s whole body is

supported


Counsel on attachment and sucklingMouth wide openLower lip turned

outwardsBaby’s chin touching

breastSuckling is slow,

deep with some pauses


Proper Breastfeeding HoldLook for a quiet place

Find most relaxed position for mother

Provide adequate back support

Support feet

Do not hunch shoulders

Do not “scissor” the breast

Breastfeeding:Counsel on positioning .

The newborn’s neck should not be flexed nor twisted.

The newborn’s whole body should be facing the mother’s breast

The newborn’s body should be close to the mother’s body

The newborn’s body should be supported


Underarm Hold

Football hold

Baby is held like a clutch bag

Nose further away from the breast

Baby’s trunk is secure beside mother’s trunk

Side-Lying Position

E.O. 51 and its rIRR: The DON’Ts

Gifts of any sortSamples or products covered under the Milk CodePosters, other promotional materials or direct

promotions of products covered under the code within your Health Facility, Community, Barangays, Events, etc.

Sponsorships without permission from FDAEndorsements of products covered by the Milk Code

DO NOT REQUEST or ACCEPTfrom Milk Companies or their representatives:

After the baby completes his first breastfeed and detaches from the breast, while he is with his mother, perform a thorough physical examination and check for birth injuries, malformations and defects.

Carry out the eye care procedures.


Add the eye ointment, vitamin k, hepatitis B and vaccines.

Let the infant remain in the mother’s arms as she recovers from giving birth.


While the mother and the newborn are together in the skin-to-skin contact the mother should be in semi-upright position so that the baby’s head is higher than the rest of the baby’s body.


Within the 1-2 hours after a vaginal delivery, the mother and the baby should not be left unattended. Both mother and the baby are monitored for bleeding and breathing and other signs of problems.


When the mother is transferred from delivery table and transported to the room or ward, the newborn is the best positioned prone on the mother’s chest with the head turned to one side .

The baby may be washed but only after at least six hours.


The step-by-step method of essential intrapartum and newborn care is doable even for a cesarean section birth.

The baby is first positioned in between the mother’s thighs where drying is carried out.

Next, the cord is palpated and once pulsations have stopped, it is clamped and cut as previously demonstrated.


The baby is then brought and assisted for skin to skin contact on the mother’s chest.

Non-separation of the mother and baby follows to allow for early initiation of breastfeeding.


Non-separation of Newborn from Mother for Early Breastfeeding

Weighing, bathing, eye care, examinations, injections should be done after the first full breastfeed is completed

Postpone bathing until at least 6 hours

Non-separation of Newborn from

Mother

Never leave the mother and baby unattended

To summarize here are the step-by-step methods outlined in the essential newborn care protocol according to w.h.o. Standards:

Drying for at least 30 secs with rapid assesment of breathing and tone .

Early skin-to-skin contact.Properly timed cord clamping.Non-separation of the newborn from mother for

early breastfeeding initiation.


Essential Newborn Care (from 90 mins to 6 hours)

At the of the discussion, the learner will be able to:1. To describe in sequence, the step-by-step

procedures that a health worker should perform within 90 minutes to 6 hours after birth.


This time band covers the essential interventions which should be done after the after the baby completes his first breastfeed.

Healthy newborns will typically complete the first breastfeed within the first 1 to 2 hours of life.


After the newborn has completed the first breastfeed, the health worker washes his/her hands.

After the newborn has located the breast, preferably after the first breastfeed .

With the baby beside or on the abdomen of the mother, the health worker provides Eye Care then does a thorough physical examination.


Possible birth injuries like: bumps on either or both sides of the head,abnormal positioning of legs after breech

presentation, and asymmetrical arm movements

Likely to disappear in a week or two and do not need special treatment.


Malformations like: cleft palate or lip, club feet, or unusual appearance

Should be referred for evaluation and special treatment if available.

If there is any open tissue over the spine or exposed internal organs like intestines, cover the tissue with sterile gauze before referral.


The vaccines are prepared next.Prepare the eye ointment, Vitamin K,

Hepatitis B and BCG vaccines.The Vitamin K ampule, Hepatitis B and

BCG vials must be prepared with separate sterile needles and syringes.

Ensure vaccine safety and proper closing.


The recommended sites for administration are the outer mid-thighs for the Vitamin K and Hepatitis B shots, and the right upper arm for the BCG shot.

The mother must be counseled about the possible side effects f the vaccines. Close observation of her newborn must be advised.


After injections, newborns who are beside or on their mother chest are more easily consolable. At this point, counsel the mother on dry cord care.

Advise her to put nothing on the stump so that it dries and falls off in a few days.


Again do not put on any substance, medicine, or bandage on the cord fold diaper below stump. Keep cord stump loosely covered with clean clothes.If umbilicus is red or draining pus or blood, seek care.


“Small babies should be provided with additional care.

A “small” baby refers to a newborn delivered two months early or weighs less than 1.5 kilograms at birth.A “ very small” baby refers to a newborn delivered two months early or weighs less than 1.5 kilograms at birth.


In summary:1.Care of the newborn after the first 1-2 hours until

6 hours after birth has been done .2.Routine procedures like eye care, examination,

weighing and injections should be performed after the newborn has completed his/her first breastfeed, preferably in the company of the baby’s mother.

3.Care of the small and very small baby or twin has also been done.


Basic Resuscitation of the Newborn

More than 95% of newborns in the Philippines will require no assistance to breath at birth

Around 5% will require some assistance and less than 1% will require advanced resuscitation


The learner will be able to learn about the;

Guidelines set for Basic Resuscitation set with the Essential Newborn Care protocol

The equipment and supplies, and

Monitoring needed when resuscitation is required


Before every delivery, it is necessary to have the

following basic equipment and supplies ready:

A wall clock or watch with a second hand

A dry, clean, flat surface with a light and heat source near birthing area

At least 2 dry towels

A non-mercury thermometer


Before every delivery, it is necessary to have the following basic equipment and supplies ready:Electric suction machine with pressure gauge (with the suction pressure regulated between 80-100cm of water)Suction cathetersFace masks for term and preterm newbornsOxygen source with flow meter




Newborn sized and self-inflating resuscitator bag with an oxygen reservoir attachedIt is important to test the bag for leaks. Place palm

against the outlet of the self inflating bag and squeeze the bag. There must be a ready return to the inflated state after squeezing.


For those with facilities and skilled personnel, in addition to the basic equipment and supplies, ready:• Sterile gloves• Disposable face mask• Laryngoscope with blade size 0 and 1 ( make

sure to check the batteries. Ensure that the light works and the bulb is not loose.)


For those with facilities and skilled personnel, in addition to the basic equipment and supplies, ready:• Endotracheal tubes• Adhesive tape• Scissors• suction tubes

Check that all these equipment are readily available at all times. It must be routine to replace stock after each delivery.


After delivery, call out the time of birth and sex of the baby.

Do a quick check of the baby’s breathing efforts while drying for at least 30 seconds.

The normal respiratory rate of newborn is between 30-60 breaths per minute.


If the newborn is not breathing or crying but has tone, stimulate breathing by immediate and thorough drying.

Call for help and start bag and mask ventilation if:After 30 secs to 1 minute of drying, the baby

is still not breathing or is gasping. If necessary, immediately clamp and cut the cord.


Place the baby in a dry surface with a light and heat source. It is important to keep warm.

Position the newborns head and neck so it is slightly extended. If the newborn is still not crying and not breathing begin supporting the newborn’s breathing by using a manual resuscitator, or what is more commonly known as self-inflating bag.


Choose the appropriate sized faced mask and attach to the manual resuscitator. Place mask over the newborn’s mouth and nose.

Ensure that the mask is tightly sealed. Hold the mask down with one hand using the C shaped hold with thumb and index finger. The other finger should be resting along the line of the jaw, lifting the chin.

c


Squeezed the bag attached to the mask and deliver manual breaths by using the count, “Breath-two-three-, breath-two-three..for 30 seconds.


While giving supported breaths with the bag and mask, observe for the chest rise. If there is no chest rise, check the following:The position of the baby's headThe adequacy of the mask sealThe airway for obstruction


While giving supported breaths with the bag and mask, observe for the chest rise. If there is no chest rise, check the following:That the bag resuscitator is intactIf there is pneumothorax or air leakThe need to deliver more pressure by

squeezing the bag harder


Assess the airway for blockage or obstruction. If the airway is blocked by thick material or profuse secretions, clear the blocked airway by using a large bore suction catheter connected to a suction machine with the suction pressure regulated to 80-100 centimeters water.


Insert the catheter 5cm into the mouth and suck while withdrawing. Then insert 3cm into each nostril and suck while withdrawing. Repeat once if needed but take no more than 20 seconds at each time.


After making the necessary adjustments in supporting breathing, resume delivery of manual breaths, observe good chest rise and reassess the newborn every 30 seconds until there is crying or breathing.


When the newborn starts to breathe at a rate more 30 minute or starts to cry, has no chest indrawing, and the color is pink, put the newborn skin to skin on the mother’s chest while continuing to monitor the newborn’s breathing and warmth.

The mother is in a semi-sitting position and the newborn’s head is turned to one side.


Support the mother and explain the newborn’s condition.

When the newborn does breathing or is gasping but a rate less than 30 per minute, or breathes at more than 30 per minute but has severe chest in-drawing, continue bag and mask ventilation and reassessment every 30 seconds. Arrange for referral and transport.


Proceed to intubation if thee is skilled personnel and equipment available.

If after 20 minutes of effective ventilation with good chest rise observed and the newborn still does not cry and gasp, the baby is presumed dead.


Explain to the mother that the newborn did not survive, as well as to the family of the newborn. Make a record of the event.


In summary:The additional care for a small number of

newborns that may require assistance to initiate or sustain adequate breathing after immediate and thorough drying.

These steps in Basic Newborn Resuscitation are applicable from primary health care settings through to tertiary settings.

The equipment and supplies and monitoring during resuscitation process.


ACTION:Start resuscitation if the newborn:

is not breathing or is gasping after 30 seconds of drying or before 30 seconds of drying if the baby is

completely floppy and not breathing.Clamp and cut the cord immediately, if necessary.Transfer the newborn to a dry, clean and warm surface.Keep the newborn wrapped or under a heat source if available.Inform the mother that the newborn needs help to breathe.

INTERVENTION:

INTERVENTION:

INTERVENTION: Open airwayACTION:Position the head so it is slightly extended.Introduce the suction tube:

- First, into the newborn’s mouth 5 cm from the lips and suck while withdrawing.

- Second, 3 cm into each nostril and suck while withdrawing.

- Repeat once, if necessary taking no more than a total of 20 secs.

Note:- Do not suction mouth and nose prior to delivery

of the shoulders of babies with meconium stained amniotic fluid.

INTERVENTION:

INTERVENTION: Ventilate, if still not breathingACTION:Place mask to cover chin, mouth and nose to achieve a seal.Squeeze bag attached to the mask with 2 fingers or whole hand, according to bag size, 2 or 3 times.Observe rise of chest.

If chest is not rising:- First, reposition baby’s head- If baby’s chest is still not rising- Check for adequate mask seal- If chest is still not rising, squeeze bag harder.

INTERVENTION:

If chest is rising, ventilate at 40 breaths per minute until newborn starts crying or breathing.

Reassess at 30-second intervals.

INTERVENTION:

If baby still fails to improve, check the following:Failure To Improve Checklist

- Face-mask seal tight?- Airway clear of secretions?- Head positioned properly?- Is contact with the soft tissue of the

infant’s anterior neck being avoided?- Resuscitator working properly?- Adequate pressure being used?- Air distending the stomach?- Air leak (pneumothorax)?

If baby starts crying or breathing >30 per minute and has no chest-in-drawing, stop ventilating:- Put the newborn in skin-to-skin contact on

mother’s chest and continue care while monitoring breathing and warmth.

- Explain the baby’s condition to the mother.

INTERVENTION:

If after 30 sec of effective bag/mask ventilation, the newborn is gasping/ breathing <30 per min or > 30 per min but has severe chest in-drawing:

- Continue bag/mask ventilation- Continue assessing at 30 sec intervals while

transporting or Proceed to intubation per advanced resuscitation guidelines, if skilled personnel and equipment are available

INTERVENTION:

If after 20 minutes of effective ventilation, the newborn does not start to breathe or gasp at all, stop ventilating.- Explain to the mother that the baby is dead,

give supportive care and record the event.

Notes:- While ventilating, refer and explain to the

mother what happened, what you are doing and why.

- Ventilate, if needed, during transport- Record the event on the referral form and

labor record.

INTERVENTION:

B. Additional Care of a Small Baby (or Twin):If newborn is preterm, 1-2 months early or weighing 1500 - 2499 g (or visibly small where scale not available)

AREA OF CONCERN: Warmth

ACTION:Ensure additional warmth for the small baby.

-Ensure the room is maintained 25-28oC.-Teach the mother how to keep the small baby warm in skin-to-skin contact via Kangaroo Mother Care-Provide extra blankets for mother and baby, plus bonnet, mittens and socks for baby.

Notes:-Do not bathe the small baby. Keep the baby clean by wiping with a damp cloth but only after 6 hours.

INTERVENTION:

AREA OF CONCERN: Feeding SupportACTION:Give special support for breastfeeding:

- Encourage the mother to breastfeed every 2-3 hours.

- Assess breastfeeding daily: positioning, attachment, suckling, duration and frequency of feeds, and baby satisfaction with the feed.

Weigh baby daily.When mother and newborn are separated, or if the baby is not sucking effectively, use alternative feeding methods.Refer to Dealing with Feeding Problems

INTERVENTION:

AREA OF CONCERN: Kangaroo Mother Care (KMC)(Adapted from WHO. ENCC Jan 2009)

ACTION:Start kangaroo mother care when:

– The baby is able to breathe on its own (no apneic episodes).– The baby is free of life-threatening disease or malformations.

Notes:-The ability to coordinate sucking and swallowing is not a pre-requisite to KMC. Other methods of feeding can be used until the baby can breastfeed.-KMC can begin after birth, after initial assessment and basic resuscitation, provided the baby and mother is stable.

If kangaroo mother care is not doable, wrap the baby ina clean, dry, warm cloth and place in a crib. Cover witha blanket. Use– a radiant warmer if room is not warm or babysmall.

INTERVENTION:

If kangaroo mother care is not doable, wrap the baby in a clean, dry, warm cloth and place in a crib. Cover with a blanket. Use: a radiant warmer if room is not warm or baby small.

Explain KMC to the mother:- continuous skin-to-skin contact- positioning her baby- attaching her baby for breastfeeding- expressing her milk- caring for her baby- continuing her daily activities- preparing a ‘support binder’

INTERVENTION:

Position the baby for KMC:

- Place the baby in upright position between the mother’s breasts, chest to chest

- Position the baby’s hips in a ‘frog-leg’ position with the arms also flexed.

- Secure the baby in this position with the support binder

- Turn the baby’s head to one side, slightly extended

- Tie the cloth firmly

Notes:

-KMC should last for as long as possible each day.

-If the mother needs to interrupt KMC for a short period, the father, a relative or friend should take over.

INTERVENTION:

AREA OF CONCERN: Discharge PlanningACTION:Plan to discharge when:-Breastfeeding well and gaining weight adequately for 3 consecutive days-Body temperature between 36.5 and 37.5°C for 3 consecutive days-Mother is able and confident in caring for baby

INTERVENTION:

“Life is not measured by the years that you live, but by

the deeds that you do and the joy the you

give”

Thanks….GOD bless you…all…

Ma’am Mimi

The learner will be able to learn about the;

Guidelines set for Basic Resuscitation set with the Essential Newborn Care protocol

The equipment and supplies, and

Monitoring needed when resuscitation is required




A wall clock or watch with a second hand

A dry, clean, flat surface with a light and heat source near birthing area

At least 2 dry towels

A non-mercury thermometer


Before every delivery, it is necessary to have the following basic equipment and supplies ready:Electric suction machine with pressure gauge (with the suction pressure regulated between 80-100cm of water)Suction cathetersFace masks for term and preterm newbornsOxygen source with flow meter




Newborn sized and self-inflating resuscitator bag with an oxygen reservoir attachedIt is important to test the bag for leaks. Place palm

against the outlet of the self inflating bag and squeeze the bag. There must be a ready return to the inflated state after squeezing.


For those with facilities and skilled personnel, in addition to the basic equipment and supplies, ready:• Sterile gloves• Disposable face mask• Laryngoscope with blade size 0 and 1 ( make

sure to check the batteries. Ensure that the light works and the bulb is not loose.)


For those with facilities and skilled personnel, in addition to the basic equipment and supplies, ready:• Un-cuffed endotracheal tubes• Adhesive tape• Scissors• suction tubes

Check that all these equipment are readily available at all times. It must be routine to replace stock after each delivery.
