primary newborn care

8/7/2019 Primary Newborn Care

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A ann pa pna

PaNn Ca

Developed by the

Perinatal Education Programme

EBWElectric Book Works

www.electricbookworks.com


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Primary Newborn Care: A learning programmeor proessionals

Version .0.0

First published by Electric Book Works in 00

ext Perinatal Education Programme 00

Getup Electric Book Works 00

ISBN: 9--90--0

No part o this publication may be reproduced,

stored in a retrieval system, or transmitted in anyorm or by any means without the prior permissiono Electric Book Works, Station Road,Observatory, Cape own 9.

Visit our website at www.electricbookworks.com

VERY IMPORTANT

We have taken every care to ensure that drug

dosages and related medical advice in this book

are accurate. However, drug dosages can change

and are updated oten, so always double-check

dosages and procedures against a reliable,

up-to-date ormulary and the given drugs

documentation beore administering it.


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Contents

Acknowledgements

Introduction Aim o the Perinatal EducationProgramme Perinatal education Perinatal Education Programme books Book 1: Maternal Care Book 2: Newborn Care Book 3: Perinatal HIV/AIDS Book 4: Primary Newborn Care Book 5: Mother and Baby Friendly Care 9Book 6: Saving Mothers and Babies 9Book 7: Birth Deects 9Book 8: Primary Maternal Care 9Format o the Perinatal EducationProgramme 9Study groups 0Te importance o a caring andquestioning attitude Copyright Final assessment

Obtaining an exam code Managing your own course step-by-step Updating o the programme Using the book as a work manual Perinatal Education rust Further inormation Comments and suggestions

1Care o inants at birth

Management o a normal inant at birth Management o the inant with neonatal asphyxia

Resuscitation 0

Management o the meconium-stained inant Case study 1 Case study 2 Case study 3 Case study 4

2Care o normal inants 9Caring or normal inants 9Feeding the normal inant Te baby riendly approach 0

Discharging a normal inant Case study 1 Case study 2 Case study 3 Case study 4

3Care o low birth weight inants Prevention o hypothermia Prevention o hypoglycaemia 9Recurrent apnoea

Feeding low birth weight inants Anaemia Kangaroo mother care (KMC) Keeping good patient notes Assessing patient care Case study 1 Case study 2 Case study 3 9Case study 4 9Case study 5 0

4Emergency management o inants Te management o hypothermia Te management o hypoglycaemia Management o respiratory distress


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Te correct use o oxygen therapy 9ranserring a newborn inant Case study 1 Case study 2 Case study 3

Case study 4 Case study 5

5Management o important problems Management o an inant with jaundice Inection in the newborn inant rauma in the newborn inant Te management o bleeding in thenewborn inant Management o convulsions (ts)

Congenital abnormalities Case study 1 9Case study 2 9Case study 3 90Case study 4 9

Tests 9est 1: Care o inants at birth 9est 2: Care o normal inants 9est 3: Care o low birth weight inants 9est 4: Emergency management o

inants 9est 5: Management o important problems 99

Answer sheet 0Using this answer sheet 0Your details 0Your answers 0

Answers 0est 1: Care o inants at birth 0est 2: Care o normal inants 0est 3: Care o low birth weight inants 0est 4: Emergency management oinants 0est 5: Management o important problems 0


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Acknowledgements

We acknowledge all the participants o

Primary Newborn Care courses who havemade suggestions and oered constructivecriticism. It is only through constant eedbackrom colleagues and participants that thecontent o Perinatal Education Programmecourses can be improved.

Editor-in-chief of the Perinatal EducationProgramme: Prof D L Woods

Editor oPrimary Newborn Care:

Pro D L Woods

Contributors to Primary Newborn Care:

Dr D Greeneld, Pro G Teron,Pro H de Groot, Ms H Louw


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Introduction

Aim of the PeriNAtAl

eduCAtioN ProgrAmme

Te aim o the Perinatal EducationProgramme (PEP) is to improve the care opregnant women and their newborn inants inall communities, especially in poor periurbanand rural districts o southern Arica.Although the Programme was written as adistance-learning course or both midwives

and doctors in district and regional healthcare acilities, it is also used in the training omedical and nursing students.

Te authors o the Perinatal EducationProgramme consist o nurses, obstetricians andpaediatricians rom South Arica. Tis ensuresa balanced, practical and up-to-date approachto common and important clinical problems.Many colleagues in South Arican universitiesand health services were also consulted with a

view to reaching consensus on the managemento most perinatal problems.

PeriNAtAl eduCAtioN

I all three levels o perinatal care are tobe eciently provided within a perinatalhealth care region, continuous education andtraining o all proessional sta is essential.

Unortunately this oen is achieved in thelarge, centralised tertiary-care hospitals onlyand not in the rural secondary- or primary-care centres. Te providers o primary care in

rural areas usually have the least continuing

education as they are urthest away romthe training hospitals in urban centres. Itis not possible to send teachers to all theserural areas or long periods o time whilesta shortages and domestic reasons makeit impractical to transer large numberso doctors and nurses rom primary- andsecondary-care centres to centralised tertiaryhospitals or training.

Ideally all medical and nursing sta should

have regular training to improve and updatetheir theoretical knowledge and practical skills.One way o meeting these needs in continuingeducation is with a sel-help, outreacheducational programme. Tis decentralisedmethod allows health care workers to takeresponsibility or their own learning andproessional growth. Tey can study at a timeand place that suits them. Participants in theprogramme can also study at their own pace.

Te education programme should be cheapand, i possible, not require a tutor.

PeriNAtAl eduCAtioN

ProgrAmme books

Initially the Perinatal Education Programmewas presented as two books only. Te rst PEP

book, Maternal Care, deals with problemsexperienced by women during and aerpregnancy while the second PEP book,Newborn Care, deals with problems in thenewborn inant. Both books should be studied


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primarynewborncare

to improve your knowledge o all aspects operinatal care.

Now six additional, supplementary books havebeen prepared to address urther common andimportant problems related to both pregnantwomen and their newborn inants.

book 1: mAterNAl CAre

Tis book addresses all the common andimportant problems that occur duringpregnancy, labour and delivery, and thepuerperium. It includes booking or antenatal

care, problems during the antenatal period,monitoring and managing the mother, etusand progress during labour, medical problemsduring pregnancy, problems during thethree stages o labour and the puerperium,amily planning aer pregnancy, andregionalised perinatal care. Skills workshopsteach the general examination, abdominaland vaginal examination in pregnancy andlabour, screening or syphilis and HIV,

use o an antenatal card and partogram,measuring blood pressure and proteinuria,and perorming and repairing an episiotomy.Maternal Care is aimed at proessional healthcare workers in level hospitals or clinics.

book 2: NewborN CAre

Newborn Care was written or health

proessionals providing special care or inantsin regional hospitals. It covers resuscitationat birth, assessing inant size and gestationalage, routine care and eeding o both normaland high risk inants, the prevention,diagnosis and management o hypothermia,hypoglycaemia, jaundice, respiratory distress,inection, trauma, bleeding, and congenitalabnormalities, as well as communicationwith parents. Skills workshops address

resuscitation, size and gestational agemeasurement, history, examination andclinical notes, nasogastric eeds, intravenousinusions, use o incubators, measuring

blood glucose concentration, insertion oan umbilical catheter, phototherapy, apnoeamonitors and oxygen therapy.

book 3: PeriNAtAl hiV/Aids

Te HIV epidemic is spreading at analarming pace through many developingcountries, increasing the maternal and inantmortality rates, and adding to the nancialburden o providing health services to allcommunities. Nowhere is the devastating

eect o this inection more obvious than inthe transmission o HIV rom mothers totheir inants. In order to decrease this risk, allhealth care workers dealing with HIV positivemothers and inants will need to receiveadditional training. Perinatal HIV/AIDS waswritten to address this challenge.

Tis book will enable midwives, nurses anddoctors to care or pregnant women and theirinants in communities where HIV inection

is present. Special emphasis has been placedon the prevention the mother-to-inanttransmission o HIV.

Chapters have been written on HIV inection,antenatal, intrapartum and inant care, andcounselling. Colleagues rom a number ohospitals and universities in South Arica wereinvited to review and comment on the dradocument in order to achieve a well balanced

text. It is hoped that this training opportunitywill help to stem the tide o HIV inection inour children.

book 4: PrimAry

NewborN CAre

Tis book was written specically or nurses

and doctors who provide primary careor newborn inants in level clinics andhospitals. Primary Newborn Care addresses thecare o inants at birth, care o normal inants,care o low birth weight inants, neonatal


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introduction

emergencies, and important problems innewborn inants.

book 5: mother ANd

bAby frieN dly CAr e

With the recent technological advances inmodern medicine, the caring and humaneaspects o looking aer mothers and inantsare oen orgotten. Tis book describes better,gentler, kinder, more natural, evidence-basedways that care should be given to womenduring pregnancy, labour and delivery. It

similarly looks at improved methods oproviding inant care with an emphasison kangaroo mother care and exclusivebreasteeding. A number o medical andnursing colleagues in South Arica contributedto this book.

book 6: sAViNg mothers

ANd bAbies

Saving Mothers and Babies was developed inresponse to the high maternal and perinatalmortality rates ound in most developingcountries. Learning material used in thebook is based on the results o the annualcondential enquiries into maternal deathsand the Saving Mothers and Saving Babiesreports published in South Arica. It addresses

the basic principles o mortality audit,maternal mortality, perinatal mortality,managing mortality meetings, and ways oreducing maternal and perinatal mortalityrates. Tis book should be used togetherwith the Perinatal Problem IdenticationProgramme (PPIP).

book 7: birth defeCts

Tis book was written or health careworkers who look aer individuals withbirth deects, their amilies, and women who

are at increased risk o giving birth to aninant with a birth deect. Special attentionis given to modes o inheritance, medicalgenetic counselling, and birth deects dueto chromosomal abnormalities, single

gene deects, teratogens and multiactorialinheritance. Tis book is being used in theGenetics Education Programme which hasbeen developed to train health care workers ingenetic counselling in South Arica.

book 8: PrimAry

mAterNAl C Are

Tis book addresses the needs o health careworkers who provide both antenatal andpostnatal care but do not conduct deliveries.Te content o these chapters is largely takenrom the relevant chapters in Maternal Care. Itcontains theory chapters and skills workshops.Tis book is ideal or sta providing primarymaternal care in level district hospitals andclinics.

formAt of the PeriNAtAl

eduCAtioN ProgrAmme

Troughout this Programme the participanttakes ull responsibility or his or her ownprogress. Tis method teaches participants tobecome sel-reliant and condent.

1. The objectives

At the start o each chapter the learningobjectives are clearly stated. Tey help theparticipant to identiy and understand theimportant lessons to be learned.

2. Questions and answers

Teoretical knowledge is taught by a

problem solving method which encouragesthe participant to actively participate in thelearning process. An important question isasked, or problem posed, ollowed by thecorrect answer or explanation. In this way,


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10 primarynewborncare

the participant is led step by step throughthe denitions, causes, diagnosis, prevention,dangers and management o a particularproblem.

It is suggested that the participant cover theanswer or a ew minutes with a piece o paperor card while thinking about the correct replyto the question. Tis method helps learning.Simplied fow diagrams are also used, wherenecessary, to indicate the correct approach todiagnosing or managing a particular problem.Copies o these fow diagrams may be o valuein the labour ward or nursery.

Dierent orms o text are used to identiy

particular sections o the Programme:

Each question is written in bold, like this,

and is identied with the number o the

chapter, ollowed by the number o the

question, e.g. 5-23.

Important practical lessons are emphasized by

placing them in a box like this.

note Additional, non-essential information is

provided for interest and given in notes like this.

These facts are not used in the case studies or

included in the multiple-choice questions.

3. Case problems

A number o clinical presentations in story-orm are given at the end o each chapter sothat the participant can apply his/her newly

learned knowledge to solve some commonclinical problems. Tis exercise also gives theparticipant an opportunity to see the problemas it usually presents itsel in the clinic orhospital. A brie history and/or summary othe clinical examination is given, ollowed bya series o questions. Te participant shouldattempt to answer each question beore readingthe correct answer. Te knowledge presentedin the cases is the same as that covered earlier

in the chapter. Te cases, thereore, serve toconsolidate the participants knowledge.

4. Multiple-choice questions

An in-course assessment is made at thebeginning and end o each chapter in theorm o a test consisting o 0 multiple-choice

questions. Tis helps participants manage theirown course and monitor their own progressby determining how much they know beorestarting a chapter, and how much they havelearned at the end o the chapter. Te resultswill help the participant decide whetherthey have successully learned the importantacts in that chapter and will also draw theparticipants attention to the areas where theirknowledge is inadequate.

In the multiple-choice tests the participantis asked to choose the single, most correctanswer to each question or statement romour possible answers. A separate loose sheetshould be used to record the test answersbeore (pre-test) and aer (post-test) thechapter is studied. Te list o correct answersalso indicates which section should berestudied or each incorrect post-test answer.

On the website, the multiple-choice questionsare only made available to participants whowish to complete a PEP course and haveobtained an exam code (more on this below).

study grouPs

It is strongly advised that the Programmecourses are studied by a group o participants

and not by individuals alone. Each group o to 0 participants should be managed by alocal co-ordinator who is usually a member othe group, i a ormal trainer is not available.Te local co-ordinator arranges the time andvenue o the group meetings (usually onceevery three weeks). At the meeting the chapterjust studied is discussed and the pre-testsand post-tests are done. Te skills workshopsshould also be demonstrated and practiced at

the meetings. In this way the group managesall aspects o their course. Te principles opeer tuition and co-operative learning play alarge part in the success o PEP.


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11introduction

the imPortANCe

of A CAriNg ANd

questioNiNg Attitude

A caring and questioning attitude isencouraged. Te welare o the patient is othe greatest importance, while an enquiringmind is essential i participants are to continueimproving their knowledge and skills. Teparticipant is also taught to solve practicalproblems and to orm a simple, logicalapproach to common perinatal problems.

CoPyright

o be most eective, the Perinatal EducationalProgramme course should be used underthe supervision o a co-ordinator. Using parto the Programme out o context will be olimited value only, while changing part o theProgramme may even be detrimental to theparticipants perinatal knowledge. Tereore,

copyright on all PEP materials means thatno portion o the Programme can be altered.However, or teaching and managementpurposes only, parts or all o the Programmemay be photocopied provided that recognitionto the Programme is acknowledged. I theroutine care in your clinic or hospital diersrom that given in the Programme, you shoulddiscuss it with your sta.

fiNAl AssessmeNt

On completion o each book, participantsmay apply to write a ormal multiple-choiceexamination on the course website www.ebwhealthcare.com to assess the amounto knowledge that they have acquired. Allthe questions will be taken rom the testsat the end o each chapter. Te content o

the skills workshops will not be included inthe examination. Successul examinationcandidates will be able to print their owncerticate which states that they have

successully completed that course. Credit orcompleting the course will only be given ithe nal examination is successully passed. Aseparate examination is available or each bookand a certicate will be given to participants

who pass each nal examination. A mark o0% is needed to pass the nal examinations.Any ocial recognition or completing a PEPcourse will have to be negotiated with yourlocal health care authority.

o write the examination on the website, aparticipant rst has to obtain an exam code,which can be obtained through the coursewebsite.

obtAiNiNg AN exAm Code

o obtain an exam code, visit this website:

www.ebwhealthcare.com

An exam code is a unique number or oneparticipant and one course. An exam codeenables a participant to test their knowledge

and write the nal examination online. Te eeand how to pay or exam codes is explained onthe website.

mANAgiNg your owN

Course steP-by-steP

1

Beore you start each chapter, take the test orthat chapter at the back o the book. Do thetest by yoursel even i you are studying witha group o colleagues. Choose the best answeror each multiple-choice question and noteyour answers on a piece o loose paper. Tis iscalled your pre-test or that chapter. Tere isan answer sheet that you should use to markyour completed pre-test. Record your pre-test

mark out o a possible 0.


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2

Now work through the chapter. Read eachquestion and answer, and make sure youunderstand it. Pay particular attention to

the acts in grey boxes as these are the mainmessages. Read the case studies to checkwhether you have learned and understand theimportant inormation.

3

I you are part o a study group, use thisopportunity to discuss with your colleaguesany diculties you may have experienced.alking about what you have read is a very

important part o the learning process. Ithe book includes skills workshops, theseshould be conducted at the time o the groupmeetings. Invite an experienced colleague whocan help you master the particular skill.

4

When you have learned all the knowledge inthat chapter, take the same test again. Tis

second test is called your post-test. Nowmark the post-test and compare your pre-testand post-test marks. Your marks should haveimproved considerably. In the answers sectiono the book, opposite each correct answer, isthe number o the section where the questionwas taken rom. Re-read and learn the sectionsor any post-test answers you got incorrect.Now you are ready to move on to the nextchapter.

5

Repeat steps to or each chapter as youwork your way through the book. Tis enablesyou to obtain the knowledge, monitor yourprogress, and measure how much you arelearning. Most people will take about to weeks per chapter.

6Once you are condent that you havemastered all the main lessons in the book,you can write the nal examination online at

www.ebwhealthcare.com. o write the nalexamination you will need to have an examcode. Tis is a unique number that entitlesyou to write the examination or a course. Iyou dont have one yet, you or your group can

buy exam codes. Te ee and how to pay isdescribed on the website. Tis exam code willonly work once or one examination.

You will be able to write the examination,consisting o multiple-choice questions,on the website. You will only have a limitedtime to answer each question and you willnot be able to go back and check previousquestions. Set aside at least an hour towrite the examination. When you write theexamination, do not use the book to look upthe correct answers. Remember, you are yourown teacher, so be strict with yoursel!

7

Your examination answers will automaticallybe marked as soon as you have completedthe last question. I you get 0% or better youhave passed and will be able to print your

own certicate which states that you havesuccessully completed the course. However,i you have ailed to achieve 0%, you canpurchase another exam code to write theexamination again.

Tips

Work through the course with a group oriends or colleagues.

One person in your group (your co-ordinator or convenor) should takeresponsibility or organising meetings todiscuss each chapter beore you write thepost-test.Set yoursel targets, such as two units amonth.Keep your book with you to read wheneveryou have a chance.Write the examination only when you eel

ready.
http://www.childhealthcare.co.za/http://www.childhealthcare.co.za/


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13introduction

uPdAtiNg of the

ProgrAmme

Based on the comments and suggestions

made by participants and other authorities,the chapters and skills workshops o theProgramme will be regularly edited to makethem more appropriate to the needs operinatal care and to keep the Programmeup to date with new ideas and developments.Everyone studying the Programme is invitedto write to the editor-in-chie with suggestionsas to how the books could be improved. Youcan also send your comments on parts o the

books on the website www.ebwhealthcare.com.

usiNg the book As A

work mANuAl

It is hoped that as many participants aspossible will use these books as work manualsaer they have completed the course. Te

fow diagrams should be most useul inmanaging dicult problems and or planningmanagement. A urther benet o the bookswill be to standardise the documentation andmanagement o certain clinical problems.Tis is particularly useul when patients arereerred within or between health care regions.It is urther hoped that all those who use thesebooks will enjoy learning about new and bettermethods o caring or mothers and newborn

inants. Every opportunity to share knowledgewith both patients and colleagues should beused. By doing this you will nd your careermore ullling and you will help to improvethe perinatal care in your region.

PeriNAtAl eduCAtioN

trust

Books developed by the Perinatal EducationProgramme are provided as cheaply as possible.Writing and updating the Programme is both

unded and managed on a non-prot basis bythe Perinatal Education rust.

further iNformAtioN

Further inormation on the PerinatalEducation Programme can be obtained in theollowing ways:

By post

Te Editor-in-Chie, Perinatal EducationProgramme, P O Box 0, Groote Schuur,Observatory 9, South Arica

By ax

0 00 (rom South Arica)+ 00 (rom outside SouthArica)

By phone

From within South Arica:

0 00 (PEP Distribution Manager)0 9 (Editor-in-Chie)

By email

[email protected]

Online

www.ebwhealthcare.com

www.pepcourse.co.za

CommeNts ANd

suggestioNs

Te Perinatal Education Programme has beenproduced by a group o perinatal specialistsin South Arica, aer wide consultation withcolleagues who practice in both rural and

urban settings, in an attempt to reach consensuson the care o mothers and newborn inants.Te Programme is designed so that it can beimproved and altered to keep pace with currentdevelopments in health care. Participants using


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books developed by the Programme can makean important contribution to its continualimprovement by reporting actual or languageerrors, by identiying sections that are dicultto understand, and by suggesting improvements

to the contents. Details o alternative or betterorms o management would be particularlyappreciated. Please send any comments orsuggestions to the Editor-in-Chie at the aboveaddress.


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ocvWhen you have completed this unit you

should be able to:

Manage a normal inant at birth.

Promote early bonding between mother

and inant.

Diagnose neonatal asphyxia at birth.

Assess an Apgar score.

Prepare or resuscitation.

Resuscitate an inant.Prevent meconium aspiration.

mANAgemeNt of A

NormAl iNfANt At bir th

1-1 What care should you give a normal

inant immediately ater delivery?

Dry the inant, especially the head, witha warm towel. Ten wrap the inant in asecond warm, dry towel. Tis will help toprevent the inant rom getting cold aerdelivery.It is not necessary to suction the nose andmouth o a normal inant who is breathingwell. I the inant has a lot o secretions, turnthe inant onto the side or a ew minutes.Clamp the umbilical cord.Assess the Apgar score at minute.

.

.

..

A quick physical examination should be

done to assess the inant or size, seriouscongenital abnormalities or other obviousclinical problems.When the above have been completed, givethe inant to the mother.

1-2 When is the best time to clamp the

umbilical cord?

It is best to allow the inant to cry well a ewtimes beore clamping the cord. Tereore, dry

the inant well rst and only then clamp thecord with surgical orceps. Drying the inantusually stimulates crying.

Delaying clamping the cord, until the inantbreathes well, allows the inant to receivesome extra blood rom the placenta. Tisextra blood may help prevent iron deciencyanaemia later in the rst year o lie. Beoreclamping the cord, keep the inant on the bed

at the same level as the mother.he umbilical cord must be clamped or tiedabout to cm rom the inants abdomen.Once the inant has been dried and assessed,the surgical orceps can be replaced with asterile, disposable cord clamp or a sterilecord tie.

1-3 When should you give the inant to the

mother?

It is important or the mother to see and holdher inant as soon as possible aer delivery. I

.

.

1

Care of infantsat birth


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the inant appears to be normal and healthy,the inant can be given to the mother aer the minute Apgar score has been assessed andthe initial examination made. Aer delivery,both the inant and mother are in an alert

state. Te inants eyes are usually open andlooking around.

Te mother will usually hold the inant sothat she can look at its ace. She will talk toher inant and touch the ace and hands. Tisinitial contact between a mother and herinant is an important stage in BONDING.Bonding is the emotional attachment thatdevelops between mother and child, and is animportant step towards good parenting later.Where possible, it is important that the atheralso be present at the delivery so that he canbe part o this important phase o the bondingprocess.

1-4 When should the normal inant be put

to the breast?

I possible the mother should put the inantto her breast within minutes aer delivery

because:

Studies have shown that the sooner theinant is put to the breast, the greater is thechance that the mother will successullybreast eed.Nipple stimulation, by putting the inantto the breast, may speed up the third stageo labour by stimulating the release omaternal oxytocin.

It reassures the mother that her inant ishealthy and helps to promote bonding.

Some women want to hold and look attheir inants but do not want to breast eedsoon aer delivery. Teir wishes should berespected. During a complicated third stage,or during the repair o an episiotomy, somemothers would rather not hold their inants.

1-5 How should the mother keep her inant

warm?

When the inant is given to the mother, sheshould hold the inant, skin-to-skin, againsther chest and cover the inant with the towel.

.

.

.

Tis will keep the inant warm. Skin-to-skincare (kangaroo mother care) is importantto promote bonding and breast eeding. Teinant must not be le alone in a cot.

1-6 When do you identiy the inant?

Once the parents have had a chance tomeet and inspect their new inant, ormalidentication by the mother and sta mustbe done. Labels with the mothers name andolder number, together with the inants sex,date and time o birth are then attached tothe inants wrist and ankle. wins must belabelled A and B. Once correctly identied,

other routine care can then be given.

1-7 Should all inants be given vitamin K?

Yes. It is important that all inants be given mg o vitamin K

(0. ml o Konakion) by

intramuscular injection into the anterolateralaspect o the mid-thigh aer delivery. Nevergive the Konakion into the buttock as it maydamage nerves or blood vessels that are justunder the skin in inants. Konakion will

prevent haemorrhagic disease o the newborn.Be very careul notto give the inant themothers oxytocin (Syntocinon) in error.o avoid this mistake, some hospitals giveKonakion in the nursery and not in the labourward. Do not use oral Konakion.

All inants must be given vitamin K ater delivery.

1-8 Should antibiotic ointment be placed in

the inants eyes?

Yes, it is advisable to place chloromycetinointment routinely into both eyes to preventGonococcal conjunctivitis as an inantseyes may become inected when the inantpasses through the cervix and vagina. Tisis particularly important i gonorrhoea iscommon in that community. Many women

with Gonococcal inection have no symptoms.


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17careofinfantsatbirth

1-9 Should all inants be weighed and

measured?

Yes, it is important to measure the inantsweight and head circumerence aer birth.

Te parents are usually anxious to know theinants weight. Te inants length is usuallynot recorded, as it is very dicult to measureaccurately. Weighing all inants helps toidentiy low birth weight inants (less than00g) who may need special care.

1-10 What care and management should

be documented?

Accurate notes should be made aer the

inant has been delivered. It is important todocument the ollowing observations andprocedures:

Apgar scoreAny action taken to resuscitate the inantAny abnormality or clinical problemnoticedIdentication o the inantWhether the inant is male or emale

Administration o KonakionWhether prophylactic eye ointment wasgivenBirth weight and head circumerence

1-11 Should the inant stay with the

mother ater delivery?

Yes. I the mother and inant are well, theyshould not be separated. Te inant should bekept skin-to-skin on the mothers chest, as this

is the best way to keep an inant warm. Teinant can stay with the mother in the labourward and should be transerred with her tothe postnatal ward. I the inant is cared orby the mother, the sta will be relieved o thisadditional duty.

The mother and inant should remain together

ater delivery, i both are well.

...

..

..

.

1-12 Should the inant be bathed ater

delivery?

Tere is no need to bath an inant immediatelyaer delivery. It is much better i the inant

stays with the mother and only be bathed later.Vernix protects the inants skin and helps toprevent skin inection.

mANAgemeNt of the

iNfANt with NeoNAtAl

AsPhyxiA

1-13 When does a normal inant start

breathing ater delivery?

Te normal, healthy newborn inant usuallystarts to breathe immediately aer birth.Sometimes gentle stimulation, such as drying,is needed beore the inant breathes well. By minute aer delivery the inants should bebreathing well or crying.

1-14 What is neonatal asphyxia?

I an inant does not breathe well by minuteaer birth, the inant is said to have neonatalasphyxia (asphyxia neonatorum).

Neonatal asphyxia is dened as the ailure to

breathe well within one minute ater delivery.

1-15 What important clinical signs shouldbe looked or in the inant ater delivery?

Tere are important clinical signs, whichshould be present aer birth. Tese are calledvital signs:

BreathingHeart rateColourone

Response

....

.


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1-16 What is the Apgar score?

Te Apgar score uses the vital signs atbirth to give a score, which is very useul inassessing an inants condition aer delivery.

It also helps to decide which inants needresuscitation. Te amous Apgar score isnamed aer Virginia Apgar, who described thescore in 9.

1-17 How is the Apgar score measured?

Each o the vital signs is given a score o0, or . I the sign is normal a score o is given. Mildly abnormal signs are given ascore o . I the vital sign is very abnormal a

score o 0 is given.

Te scores or each vital sign are then addedtogether to give the Apgar score out o 0.Te best possible Apgar score is 0 and theworst is 0.

1-18 How should you assess an inants

breathing ater birth?

Look at the inants chest movements. Both

sides o the chest should move well when theinant breathes. A normal inant will cry ortake at least 0 breaths a minute.

I the inant breathes well or cries a score o is given. I there is poor or irregular breathing,or the inant only gives an occasional gasp, ascore o is given. A score o 0 is given i theinant makes no attempt to breathe.

1-19 How should you count an inantsheart rate ater birth?

Feel the base o the umbilical cord or listen tothe inants heart with a stethoscope to countthe heart (pulse) rate. It oen is very dicultto eel peripheral pulses immediately aerbirth. Te normal inant has a heart rate o 0(0 to 0) beats per minute. It saves time tocount the heart rate or 0 seconds and thenmultiply the rate by to give the heart rate perminute. A wall clock is useul when countingthe heart rate.

I the heart rate is above 00 per minute ascore o is given. A score o is given i a

heart beat is present but the rate is slower than00 per minute, while a score o 0 is given i noheart beat can be heard or umbilical pulse elt.


colour ater birth?

Look at the inants tongue and also at the handsand eet. Te tongue should always be pink. Itis not helpul to look at the colour o the lipsor mucus membranes. I the tongue is blue theinant has central cyanosis. Tis shows thatimportant organs like the brain are not gettingenough oxygen. Almost all newborn inantshave peripheral cyanosis with blue hands and

eet immediately aer delivery. Tis is normaland within minutes the hands and eet shouldbecome pink. A pink tongue indicates thatenough oxygen is reaching the brain.

I the hands and eet are pink a score o isgiven. I the tongue is pink,but the hands andeet are still blue, a score o is given. Whenthe tongue, hands and eet are all blue a scoreo 0 is given.

1-21 How should you assess an inantstone ater birth?

Normal inants should have good muscle toneat birth and move their arms and legs actively.Tey should not lie still. Normally the armsand legs are fexed and held above the body,with the knees held together, in a term inant.

I the inant moves well a score o is given.I there is only some movement, and the arms

and legs are not pulled up against the body orlied o the surace, a score o is given. Ascore o 0 is given i the inant is completelylimp and does not move at all.


response to stimulation ater birth?

I you handle or gently stimulate the inantthere should be a good response. Usually the

inant moves a lot or cries. Te best methodo stimulation is to dry the inant well with atowel. Smacking the inant or ficking the eetare not recommended.


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I the inant responds well to stimulationand cries or moves a lot a score o is given.I there is only some response a score o isgiven while a score o 0 is given i the inantdoes not respond to stimulation at all.

See the table Calculating an Apgar score.

1-23 When should the Apgar score be

measured?

All inants should have their Apgar scoremeasured at minute aer delivery. Te minute Apgar score is a good method omeasuring the inants general condition aerbirth and is one o the best ways o decidingwhether the inant needs resuscitation. I theApgar score is normal, the score usually doesnot need to be repeated. However, in manyclinics and hospitals the Apgar score is stillrepeated routinely at minutes. Unortunatelymany o these normal inants are needlesslyremoved rom their mothers skin-to-skin careto have the minute Apgar score determined.

However, i the minute Apgar score is low,the score must be repeated every minuteswhile the inant is being resuscitated. Tisgives a very good assessment o the success orailure o the attempts at resuscitation. Withsuccessul resuscitation the Apgar score willincrease to normal.

1-24 What is a normal Apgar score?

Te Apgar score at minute should be ormore out o a possible 0. As almost all inantshave blue hands and eet immediately aer

birth, a minute Apgar score o 0 is rare.Te Apgar score at minutes, and thereaer,should be or more.

A minute Apgar score o to indicates

moderate asphyxia while a score o 0 to indicates severe neonatal asphyxia.

A low minute Apgar score is worrying as itsuggests that the inant is not responding wellto resuscitation. Te longer the score remainslow, the greater is the risk o death or braindamage.

The Apgar score should be 7 or more at 1 minute.

1-25 What are the important causes o a

low Apgar score?

Fetal hypoxiaMaternal general anaesthesiaMaternal sedation or analgesia withpethidine or morphine given within thelast hoursExcessive suctioning o the inants mouthand throatDelivery o a low birth weight inantDicult or traumatic deliverySevere respiratory distress

...

.

...

1 MINUTE 5 MINUTES

Heart rate

per minute

None

Less than 100

More than 100

0

1

2

None

Less than 100

More than 100

0

1

2

Respiratory rate AbsentWeak or irregular

Good or cries

01

2

AbsentWeak or irregular

Good or cries

01

2

Colour Centrally cyanosed

Peripherally cyanosed

Peripherally pink

0

1

2

Centrally cyanosed


Peripherally pink

0

1

2

Muscle tone Limp

Some exion

Active and well exed

0

1

2

Limp

Some exion


0

1

2

Response to

stimulation

None

Some responseGood response

0

12

None


0

12

TOTAL SCORE: /10 /10

Table 1: Calculating an Apgar score

1 MINUTE 5 MINUTES

Heart rate

per minute

None

Less than 100

More than 100

0

1

2

None

Less than 100

More than 100

0

1

2

Respiratory rate AbsentWeak or irregular

Good or cries

01

2

AbsentWeak or irregular

Good or cries

01

2

Colour Centrally cyanosed


Peripherally pink

0

1

2

Centrally cyanosed


Peripherally pink

0

1

2

Muscle tone Limp

Some exion


0

1

2

Limp

Some exion


0

1

2

Response to

stimulation

None


0

12

None


0

12

TOTAL SCORE: /10 /10

Table 1: Calculating an Apgar score


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1-26 What is hypoxia?

Hypoxia is dened as too little oxygen in the cellsof the body. I the inant ailures to breathe wellaer delivery the inant will develop hypoxia.

As a result o hypoxia, the inants heartrate alls, breathing is poor, central cyanosisdevelops and the inant becomes hypotonic(foppy) and unresponsive. Neonatal asphyxia,i not correctly managed, will lead to hypoxiaand possible brain damage or death.

1-27 What is etal hypoxia?

I the placenta ails to provide the etus withenough oxygen, etal hypoxia will result. Fetal

hypoxia presents with meconium stainedliquor and late etal heart rate decelerationsor bradycardia. Tese are the signs o etaldistress (or more accurately, stress). Tereore,etal hypoxia results in etal distress. Ashypoxia may damage or kill the etus, it is veryimportant that each inant is well monitoredduring labour so that any signs o etal distresscan be detected, as soon as possible, so that thecorrect management can be given.

Fetal hypoxia is an important cause oneonatal asphyxia.

1-28 Are neonatal asphyxia and etal

hypoxia the same condition?

No. Neonatal asphyxia and etal hypoxia are notthe same although severe etal hypoxia usuallyresults in neonatal asphyxia aer delivery. Someinants with mild etal hypoxia breathe well

aer birth and do not have neonatal asphyxia.Tere are also many causes o neonatal asphyxiaother than etal hypoxia. Tereore, someinants have neonatal asphyxia even thoughthey have not had etal hypoxia.

1-29 Can neonatal asphyxia be prevented?

Good management during labour and theearly detection o etal distress are the best

methods o preventing neonatal asphyxia.However, some cases o neonatal asphyxiacannot be predicted nor prevented.

1-30 How is neonatal asphyxia managed?

Neonatal asphyxia is corrected by resuscitatingthe newborn inant. Only about % onewborn inants have asphyxia and, thereore,

need resuscitation.

resusCitAtioN

1-31 What is resuscitation?

Resuscitation is a series o actions taken toestablish normal breathing, heart rate, colour,tone and response in an inant with abnormal

vital signs, i.e. a low Apgar score.

1-32 Which inants need resuscitation?

All inants who do not breathe well by minute aer delivery, or have a minuteApgar score below , need resuscitation. Telower the Apgar score the more resuscitationis usually needed. Any inant who stopsbreathing or has abnormal vital signs at any

time aer delivery or in the nursery alsorequires resuscitation.

All inants with neonatal asphyxia, or a 1 minute

Apgar score below 7, require resuscitation.

1-33 Can you anticipate which inants will

need resuscitation at birth?

Yes. Any o the conditions which causeneonatal asphyxia may result in the inantneeding resuscitation. However, neonatalasphyxia cannot always be predicted beoredelivery. Remember that any inant can beborn with neonatal asphyxia without anyprevious warning. It is essential, thereore, tobe prepared to resuscitate all newborn inants.Everyone who delivers an inant must be ableto perorm resuscitation.

Any inant can have neonatal asphyxia at birth

without warning signs during labour and

delivery.


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1-34 What is needed to resuscitate a

newborn inant?

A suitable, warm area with good lightingTe correct, clean and unctioning

equipmentTe knowledge and skills

1-35 What is a suitable resuscitation area?

A warm area with good light and a workingsurace at a comortable height is needed. Ina clinic or hospital, some source o oxygenand suction should be available together withstorage space or the equipment. Make surethere is no draught. Te temperature o the

resuscitation area should be at least C.

A warm, well lit corner o the delivery room isideal or resuscitation. A heat source, such asan overhead radiant warmer or wall heater, isneeded to keep the inant warm. A good light,such as an angle-poise lamp, is essential sothat the inant can be closely observed duringresuscitation. A rm, fat surace at waist heightis best or resuscitating an inant. Tere is no

need to have the inant lying head down, andthe neck must not be overextended. It is veryuseul to have warm towels to dry the inant.

1-36 What equipment do you need or

inant resuscitation?

It is essential that you have all the equipmentneeded or basic inant resuscitation. Teequipment must be clean, in working orderand immediately available. Te equipment

must be checked daily.

Te ollowing essential equipment must beavailable in the delivery room:

Suction apparatus: An electric or wallvacuum suction apparatus is ideal but thevacuum pressure should not exceed 00 cmwater. So F 0 end-hole suction cathetersare needed. A simple mouth suctionapparatus (mucus extractor) can also be

used. It consists o a so plastic cathetersattached to a 0 ml plastic container.Although it is eective, there is a small riskthat the sta could become inected with

..

.

1.

HIV i the secretions get into the mouth othe person suctioning the inant.Oxygen: Whenever possible, a cylinderor wall source o 00% oxygen should beavailable. However, oxygen is not essential

or resuscitation.Sel-inating bag and mask: A simpleneonatal sel-infating bag and mask, e.g.Samson, Laerdal, Ambu, Penlon or Cardiresuscitator, must be available to providemask ventilation. Direct mouth-to-mouthresuscitation is dangerous due to the risk obecoming inected with HIV.Naloxone: Ampoules o naloxone (Narcan0. mg in ml). Small syringes and needles

will be needed to administer the drug.Neonatal Narcan is no longer used, as theconcentration o drug is too small.Wall clock or watch: o time theassessment o the Apgar score.

Although not essential or basic resuscitation,it is very useul to have an inant laryngoscopeand endotracheal tubes so that inants withsevere neonatal asphyxia can be intubated, ibag and mask ventilation is not adequate. Ipossible, everyone who regularly resuscitatesnewborn inants should learn how to intubatethem.

1-37 How should you stimulate respiration

immediately ater birth?

Aer birth, all inants must be quickly driedin a warm towel and then placed in a secondwarm, dry towel. Tis must also be done to

inants with neonatal asphyxia, beore startingresuscitation. Drying the inant prevents rapidheat loss due to evaporation. Handling andrubbing the newborn inant with a dry towelis usually all that is needed to stimulate theonset o breathing. Stimulation alone will startbreathing in most inants.

1-38 Should all inants be routinely

suctioned ater delivery?

No. Inants who breathe well at deliveryshould nothave their mouth and throatroutinely suctioned, as suctioning sometimes

2.

3.

4.

5.


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causes apnoea. Inants born by caesareansection also need not be routinely suctioned.

It is not necessary to routinely suction the mouth

and nose o inants ater delivery.

1-39 Which inants should be suctioned

ater delivery?

Inants who do not breathe well aerstimulationMeconium-stained inants

1-40 When should you start to resuscitate

an inant?

I the inant does not breathe well and ailsto respond to stimulation aer drying andclamping the umbilical cord, then the inantmust be actively resuscitated. Drying andclamping the cord usually takes about minute. Tese inants will have a low minuteApgar score. Although resuscitation usuallystarts aer minute, i the inant obviously has

severe neonatal asphyxia, resuscitation shouldbe started sooner.

1-41 Can resuscitation o an inant with

severe neonatal asphyxia result in survival

with brain damage?

Some people are worried that resuscitationmay result in a live, but brain damaged inant,who would have died without resuscitation.Tis is very uncommon. Not all inants with

severe neonatal asphyxia die. Tereore, it isbetter to give good resuscitation early to allinants with neonatal asphyxia and reducethe risk o brain damage that may occur i noresuscitation is given. Te only inants whomay not be oered resuscitation are thosewith a lethal congenital abnormality, such asanencephaly.

1-42 Who should resuscitate the inant?

Te most experienced person, irrespective orank, should resuscitate the inant. However,everyone who conducts deliveries must havethe skills and equipment to resuscitate inants.

.

.

It is very helpul to have an assistant duringresuscitation.

1-43 How do you resuscitate an inant?

Tere are main steps in the basicresuscitation o a newborn inant. Tey can beeasily remembered by thinking o the rst letters o the alphabet, ABCD:

AirwayBreathingCirculationDrugs

Step 1: Clear the airway

Gently clear the throat. Te inant may beunable to breathe because the airway isblocked by mucus or blood. Tereore, i theinant ails to breathe aer stimulation, gentlysuction the back o the mouth and throat witha so F 0 catheter. oo much suctioning,especially i too deep in the region o the vocalcords, may result in apnoea and bradycardia.Tis can be prevented by holding the catheter cm rom the tip when suctioning the inants

throat. Tere is no need to suction the nose.Simply turning the inant onto the side willoen clear the airway.

I wall suction or a suction machine are notavailable, a mucus extractor can be used tosuction the inants mouth and throat. Becauseo the small risk o HIV inection, wall suctionor a suction machine is best.

Correctly position the head. Te upper

airway (pharynx) can be opened by placingthe inants head in the correct position.With the inant lying on its back on a fatsurace, slightly extend the neck so that theace is pointing towards the ceiling. Do notoverextend the neck.

I the inant is not breathing well aer theairway have been suctioned and the headcorrectly positioned, stop suctioning andmove to step .

Step 2: Start the inant breathing

I stimulation and suctioning and correctposition o the head ail to start breathing,

....


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mask and bag ventilation must be started.Giving mask oxygen alone oen does not help.Keep the inants neck slightly extended andhold the mask rmly over the inants ace.Most inants can be adequately ventilated

with a neonatal bag and mask, such as aSamson, Laerdal, Ambu, Penlon or Cardiresuscitator. Ventilation is the most importantpart o resuscitation. Usually mask and bagventilation is given with room air.

Ventilation is more important than oxygen.

Respiratory stimulants, such as Vandid, must

not be used, as they are dangerous and do nothelp.

Step 3: Obtain a good circulation

I the heart rate remains below 0 beats perminute aer eective ventilation has beenstarted, apply external cardiac massage atabout 0 times a minute.

Step 4: Drugs to reverse pethidine and

morphine

I the mother has received either pethidineor morphine during the hour period beoredelivery, the inants poor breathing may bedue to drug depression. I so, the respiratorydepression caused by the analgesic can berapidly reversed with Narcan (a ml ampoulecontains 0. mg naloxone). Narcan 0. mg/kg(i.e. 0. ml/kg) can be given by intramuscular

injection into the anterolateral aspect o thethigh. Intramuscular Narcan takes a ewminutes beore it starts to act. Do not useNeonatal Narcan, as this preparation requirestoo big a volume.

Narcan will not help resuscitate an inanti the mother has not received a narcoticanalgesic during labour, or has received anon-opioid general anaesthetic, barbituratesor other sedatives.

Mask and bag ventilation is the most important

step in resuscitating an inant.

1-44 How do you give oxygen to an inant?

Oxygen is given i the inant is centrallycyanosed. Usually wall oxygen is used.Otherwise an oxygen cylinder or an oxygen

concentrator is needed. Oxygen is best givenby mask and bag ventilation. It is saer to onlyuse room air or resuscitation and only giveoxygen i the central cyanosis is not correctedby mask ventilation.

Room air is saer than oxygen or most

resuscitations.

1-45 How should you use a sel-inatingbag and mask to ventilate an inant?

Te position o the inant: Te inantmust lie ace up on a fat surace. Teinants neck should be slightly extended.Do not over extend the neck. Te inantsace should look towards the ceiling.Inants should be kept in a warm towelduring resuscitation.Te apparatus: A number o bag andmask sets are suitable, such as the Samson,Laerdal, or Ambu resuscitators. Makesure that both the bag and mask aredesigned or newborn inants. I required,the bag should be attached to an oxygensource providing litres per minute. Itis important that the correct size mask isused to cover the nose and mouth.Te position o the mask: Te mask mustbe placed over the inants mouth, nose andchin. Hold the mask tightly against the aceso that there are no air leaks.Using the sel-ination bag: Te maskshould be held in place with the le handwhile the bag is squeezed at about 0breaths per minute with the right hand. Ithe little and ring nger o the le hand areplaced under the angle o the jaw, the jawcan be gently pulled upwards to keep thetongue rom alling back. Te position othe mask is the same with all types o bag.When giving mask and bag ventilation,watch the movement o the chest. Squeezethe bag hard enough to move the chest

.

.

.

.


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with each inspiration. Continue givingmask and bag ventilation at about 0breaths per minute until the inant starts tocry or breathes well. A small percentage oinants with severe neonatal asphyxia will

not respond to mask ventilation and needintubation and ventilation.

1-46 How do you give cardiac massage?

Place the inant on its back with the headtowards you. Place both hands under theinants back and press on the lower hal othe sternum with both your thumbs. Tiswill depress the sternum by about cm.

Push down on the sternum about 00 timesa minute. Pressing on the sternum squeezesblood out o the heart and causes blood tocirculate to the lungs and body.

It takes people to both mask ventilate andgive cardiac massage. An assistant shouldventilate the inant while you give cardiacmassage. Aer every third push on thesternum the assistant should squeeze thebag to give breath aer every heart beats.

Continue cardiac massage until the inantsheart rate increases to 00 or more beats perminute. I you are resuscitating an inant onyour own, good mask ventilation is moreimportant that cardiac massage.

1-47 How can you assess whether the

resuscitation has been successul?

Te steps in resuscitation are ollowed step

by step until the most important vital signso the Apgar score have returned to normal:

A pulse rate above 100 beats per minute.Easily assessed by palpating the base othe umbilical cord or listening to the chestwith a stethoscope.A good cry or good breathing eorts.Tis assures adequate breathing.A pink tongue. Tis indicates a goodoxygen supply to the brain. Do not rely on

the colour o the lips.

With good resuscitation the Apgar score at minutes should be or more. Tis suggests

.

.

.

that the inant did not suer severe hypoxiabeore delivery.

1-48 When is urther resuscitation

hopeless?

Every eort should be made to resuscitate allinants that show any sign o lie at delivery.Te Apgar scores at and minutes arenot good indicators o the likelihood ohypoxic brain damage or death. I the Apgarscore remains low aer minutes, eorts atresuscitation should be continued. However,i the inant has not started to breathe, oronly gives occasional gasps, by 0 minutes

the chance o death or brain damage is high.Resuscitation is usually stopped i the Apgarscore at 0 minutes is still low with no regularbreathing. It is best i an experienced persondecides when to abandon urther attempts atresuscitation.

Resuscitation will not save all inants withneonatal asphyxia, but it will help most.

1-49 What post resuscitation care is

needed?

All inants that require resuscitation withbag and mask ventilation must be careullyobserved or at least hours. Teirtemperature, pulse and respiratory rate,colour and activity should be recorded andtheir blood glucose concentration measured.Keep these inants warm and provide fuidand energy, either intravenously or orally.

Usually these inants are observed in a closedincubator. Do not bath the inant until theinant has ully recovered.

Careul notes must be made describing theinants condition at birth, the resuscitationneeded and the probable cause o the neonatalasphyxia.

1-50 What about the mother during

resuscitation?

It is very rightening or a mother to know thather inant needs resuscitation. Tereore, it isimportant to tell the mother that her inantneeds some help and to explain to her what is


25/92


being done to the inant. Remember that themother may start bleeding while the sta arebusy resuscitating the inant.

1-51 How is the resuscitation equipment

cleaned?

It is imporant that all the resuscitationequipment is kept clean and in good workingorder. Aer a resuscitation all the equipmentmust be cleaned to prevent the spread oinection. Te masks and mucus extractorsmust be washed with water and soap ordetergent and rinsed. Te sel-infating bags,e.g. Laerdal, Ambu and Penlon must be

sterilised.

mANAgemeNt of the

meCoNium-stAiNed

iNfANt

1-52 Does the meconium stained inant

need special care?Yes. All inants that are meconium stainedat birth need special care to reduce the risko severe meconium aspiration. Wheneverpossible, all these at-risk inants should beidentied beore delivery by noting that theliquor is meconium stained.

1-53 Why does the meconium stained

inant need special care?

As a result o etal hypoxia, the etus may makegasping movements and pass meconium. Beoredelivery, meconium in the amniotic fuid canbe sucked into the upper airways. Fortunatelymost o the meconium is unable to reach thefuid lled lungs o the etus. Only aer delivery,when the inant inhales air, does meconiumusually enter the lungs.

Meconium contains enzymes rom the etal

pancreas that can cause severe lung damageand even death i inhaled into the lungs atdelivery. Meconium also obstructs the airways.

Meconium aspiration results in respiratorydistress aer delivery.

Meconium oen burns the inants skin anddigests away the inants eye lashes! Tereore,imagine the damage meconium can cause tothe delicate lining o the lungs.

1-54 How can you prevent meconium

aspiration at delivery?

Beore delivery o all meconium stainedinants, a suction apparatus and an F 0 endhole catheter must be ready at the bedside. Ipossible, the person conducting the deliveryshould have an assistant to suction the inants

mouth when the head delivers.

Aer delivery o the head, the shouldersshould be held back and the mother askedto breathe ast and not to push. Tis shouldprevent delivery o the trunk. Te inants aceis then turned to the side so that the mouthand throat can be well suctioned. Te nose canbe suctioned aer the mouth and throat. Teinant should be completely delivered only

when no more meconium can be cleared romthe mouth and throat.

I the inant cries well aer delivery, nourther resuscitation or suctioning is needed.However, some inants develop apnoea andbradycardia as a result etal hypoxia o thesuctioning and, thereore, need ventilationaer delivery. I a meconium stained inantneeds ventilation, the throat should again besuctioned beore ventilation is started.

Tis aggressive method o suctioning is verysuccessul in preventing severe meconiumaspiration in meconium stained inants.

The mouth and throat o all meconium stained

inants must be suctioned beore the shoulders

are delivered.

When a meconium stained inant is deliveredby caesarean section, the mouth and throatmust similarly be suctioned with a F0end-hole catheter, before the shoulders aredelivered rom the uterus. Aer complete


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delivery, move the inant immediately tothe resuscitation table. I the inant does notbreathe well, urther suctioning is neededbeore stimulating respiration or startingventilation.

1-55 What care should you give to

meconium stained inants ater birth?

All meconium stained inants should beobserved or a ew hours aer delivery as theymay show signs o meconium aspiration. Mostmeconium stained inants have also swallowedmeconium beore delivery. Meconium is avery irritant substance and causes meconium

gastritis. Tis results in repeated vomits omeconium stained mucus.

Meconium gastritis may be prevented bywashing out the stomach with % sodiumbicarbonate (mix % sodium bicarbonatewith an equal volume o sterile water). Fiveml o % sodium bicarbonate is repeatedlyinjected into the stomach via a nasogastrictube and then aspirated until the gastricaspirate is clear. Tis should be ollowed by

a eed o colostrum. Only heavily meconiumstained inants should have a stomach washouton arrival in the nursery. Routine stomachwashouts in inants with mildly meconiumstained liquor are not needed.

CAse st udy 1

An inant is delivered by spontaneous vertexdelivery at term. Immediately aer birth theinant cries well and appears normal. Te cordis clamped and cut and the inant is dried.Te inant has a lot o vernix. As the inantappears healthy and the mother has no vaginaldischarge, chloromycetin ointment is not putin the inants eyes. Te inant is placed in a cotbeside the mother.

1. When should the inant be given to themother?

As soon as the inant is dried, the cord cut,the minute Apgar score determined and a

brie examination indicates that the inant isa normal, healthy term inant. Te mothersshould give skin-to-skin care o her inant aerbirth. Te inant should not be le in a cot.Te ather should also be present to share this

exciting moment.

2. When should the mother be encouraged

to put the inant to her breast?

As soon as she wants to. Tis is usually aershe has had a chance to have a good look ather inant. Tere are advantages to putting theinant to the breast soon aer delivery.

3. Should the vernix be washed ofimmediately ater delivery?

Inants should not be bathed straight aerdelivery, as they oen get cold, while vernixshould not be removed as it helps protect theinants skin rom inection. It would be betterto bath the inant later, in the mothers presence,when most o the vernix will have cleared.

4. Do you agree that this well inant does

not need chloromycetin eye ointment?

No. All inants should be given chloromycetineye ointment, especially i gonorrhoea iscommon in the community. Gonococcalinection may be asymptomatic in the mother.

5. Should the inant stay with the mother

ater delivery?

Yes, i possible the mother and her inantshould not be separated aer delivery.

CAse study 2

Aer a normal pregnancy, an inant is bornby spontaneous vertex delivery. Tere areno signs o etal distress during labour. Temother received pethidine hours beore

delivery. Immediately aer delivery the inantis dried and placed under an overhead radiantwarmer. At minute aer birth the inanthas a heart rate o 0 beats per minute, givesirregular gasps, has blue hands and eet but a


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pink tongue, has some muscle tone but doesnot respond to stimulation. At minutes theinant has a heart rate o 0 beats per minuteand is breathing well. Te tongue is pink butthe hands and eet are still blue. Te inant

moves actively and cries well.

1. What is the inants Apgar score at 1

minute?

Te Apgar score at minute is : heart rate=,respiration=, colour=, tone=, response=0.

2. Does this inant have neonatal asphyxia?

Give your reasons.

Yes, the inant has neonatal asphyxia becausethe inant ailed to establish adequate,sustained respiration by minute. Tediagnosis o neonatal asphyxia is supported bythe low Apgar score at minute.

3. What is the probable cause o the

neonatal asphyxia?

Sedation due to the maternal pethidine given

hours beore delivery. Tese sedated inantsusually respond rapidly to resuscitation. I not,Narcan can be given to reverse the sedativeeect o the pethidine.

4. What should be the rst 2 steps in

resuscitating this inant?

I respiration cannot be stimulated by dryingthe inant then the ollowing steps must be

taken:Clear the airway by gently suctioning thethroat.Breathing must be started with mask andbag ventilation.

5. Should oxygen be given?

Room air is usually adequate or resuscitationunless the inant remains centrally cyanosed.

.

.

6. What is this inants Apgar score at 5

minutes?

Te Apgar score at minutes is 9: heart rate=,breathing=, colour=, tone=, response=.

Tis indicates that the inant has respondedwell to resuscitation.

7. Why is this inant very unlikely to have

sufered brain damage due to hypoxia?

Because there is no history o etal distressto indicate that this inant had been hypoxicbeore delivery.

8. What should be the management o this

inant ater resuscitation?

Te inant should be kept warm and betranserred to the nursery or observation. Assoon as the inant is active and sucking well itshould given to the mother to breast eed.

CAse s tudy 3

A woman with an abruptio placentae deliversat weeks in a clinic. Beore delivery theetal heart rate was only 0 beats per minute.Te inant has a minute Apgar score o and is ventilated with bag and mask. Cardiacmassage is also given. With urther eorts atresuscitation, the Apgar score at minutes is and at 0 minutes is 9.

1. What is the probable cause o neonatal

asphyxia in this inant?

Fetal distress caused by hypoxia. Abruptioplacentae (placental separation beoredelivery) is a common cause o etal distress.

2. What is the signicance o the Apgar

scores at 5 and 10 minutes?

Te good responds indicates that theresuscitation is successul. I the Apgar score isstill low at minutes it is important to repeatthe score every minutes. Te normal scoreat 0 minutes indicates the inants response tothe resuscitation.


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3. Is this child at high risk o brain damage

due to hypoxia?

Te good response to resuscitation suggeststhat this inant will not have brain damage due

to etal hypoxia.

4. When should all attempts at

resuscitation be abandoned?

I the Apgar score remains low at 0 minutes,attempts at resuscitation may be stopped.

CAse st udy 4

Aer etal distress has been diagnosed, aninant is delivered vaginally aer a longsecond stage o labour. At delivery the inantis covered with thick meconium. Te inantstarts to gasp beore minute. Only then arethe mouth and throat suctioned or the rsttime. Te Apgar score at minute is . By minutes the Apgar score is .

1. What are the probable causes o the low1 minute Apgar score?

Fetal distress, as indicated by the passage omeconium beore delivery. Te prolongedsecond stage may have caused etal hypoxia.Inhaled meconium may have blocked theairway and prevented the inant rom breathing.

2. What mistake was made with the

management o this inant?

Te inants mouth and throat should havebeen well suctioned before the shoulders were

delivered. Tis should reduce the risk o severemeconium aspiration as the airway is cleared omeconium beore the inant starts to breathe.

3. What size catheter would you have used

to suction this inants mouth and throat?

A large catheter (F 0) must be used as a smallcatheter will block with meconium.

4. Should this inant be given a bath and

stomach washout in labour ward ater it

starts to breathe spontaneously?

No. Tese should not be done until the inanthas been stable or a number o hours in thenursery.

5. What 2 complications is this inant at

high risk o?

Tis inant may develop meconium aspirationsyndrome as it probably inhaled meconiuminto its lungs aer birth. It may also suerbrain damage due to hypoxia causing etaldistress during labour. Te poor response toresuscitation suggests that some brain damagemay be present. It would be important torepeat the Apgar score every minutes until0 minutes aer delivery.


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ocvWhen you have completed this unit you

should be able to:

Manage normal newborn inants.

Diagnose and treat common minor

problems.

Manage breast eeding.

Promote baby riendly care.

Discharge a normal inant.

CAriNg for NormAl

iNfANts

2-1 What is a normal inant?

A normal inant has the ollowingcharacteristics:

Te inant is born at term ( to weeksgestation).Te minute Apgar score is or more andno resuscitation is needed aer birth.Te inant weighs between 00 g and000 g at birth.On physical examination the inantappears healthy with no congenitalabnormalities or abnormal clinical signs.

Te inant eeds well.Tere have been no problems with theinant since delivery.

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Normal inants are at low risk o developing

problems in the newborn period and,thereore, require primary care only. About0% o all newborn inants are normal.

Normal newborn inants are at low risk o develop

ing problems and require only primary care.

2-2 Should all normal inants be kept with

their mothers?

Yes, all normal inants should stay with theirmothers and not get cared or in the nursery.Tis is called rooming-in. Te inant is eithernursed in a cot next to the mothers bed oris given skin-to-skin care (Kangaroo MotherCare or KMC). Te advantages o inantsstaying with their mothers are:

Te mother remains close to her inant allthe times and gets used to caring or her

inant. Tis strengthens bonding.It encourages breast eeding.It builds up the mothers condence in herability to handle her inant.It prevents the inant being exposed to theinections commonly present in a nursery.It reduces the number o sta needed tocare or inants.

Te ather should be present at the delivery to

share this exciting moment.

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Care of normalinfants


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Mothers and inants should stay together.

2-3 When should the inant receive the rst

bath?

Tere is no need to routinely bath all inantsaer delivery to remove the vernix. Vernixwill not harm the inant and disappearsspontaneously aer a day or two. Vernixprotects the skin and kills bacteria. Manyinants also get cold i they are bathed soonaer delivery. Te only indication or an inantto be washed or bathed soon aer birth issevere meconium staining or contamination

with maternal blood or stool.It is, however, important that all primiparousmothers learn how to bath their inantsbeore they go home. I these inants haveto be bathed on the rst day o lie, it ispreerable that this be delayed until they are aew hours old.

2-4 What is the appearance o a newborn

inants stool?

For the rst ew days the inant will passmeconium, which is dark green and sticky.By day the stools should change rom greento yellow, and by the end o the rst weekthe stools should have the appearance oscrambled egg. Te stools o breast ed inantsmay also be so and yellow-green but shouldnot smell oensive.

Some inants will pass a stool aer every eedwhile others may not pass a stool or a numbero days. As long as the stool is not hard, therequency o stools is not important.

2-5 How many wet nappies should an

inant have a day?

A normal inant should have at least wetnappies a day. I the inant has ewer than wet nappies a day, you should suspect that the

inant is not getting enough milk. However,during the rst days, inants may haveewer wet nappies as inants normally passlittle urine in the rst ew days. Tis protects

them rom dehydration at a time when manymothers produce only small amounts o milk.

2-6 What routine cord care is needed?

Te umbilical cord stump is so and wet aerdelivery and this dead tissue is an ideal site orbacteria to grow. Te cord should, thereore, bekept clean. It should also be dried out as soonas possible by hourly applications o surgicalspirits (alcohol). It is important to apply enoughspirits to run into all the olds around the baseo the cord. Tere is no need to use antibioticpowders. I the cord remains so aer hours, or becomes wet and smells oensively,

then the cord should be treated with surgicalspirits every hours. Do not cover the cordwith a bandage. Usually the cord will come obetween and weeks aer delivery.

Good cord care with surgical spirits is important.

2-7 Can a vaginal discharge be normal in

an inant?

Yes. Many emale inants have a white, mucoidvaginal discharge at birth, which may continueor a ew weeks. Less commonly the dischargemay be bloody. Both are normal and caused bythe secretion o oestrogen by the inant beoreand aer delivery.

2-8 May normal inants have enlarged

breasts?

Yes. Many inants, both male and emale, haveenlarged breasts at birth due to the secretiono oestrogen. Te breasts may enlarge urtheraer birth. Breast enlargement is normal andthe breasts may remain enlarged or a ewmonths aer delivery. Some enlarged breastsmay secrete milk. It is very important thatthese breasts are not squeezed as this mayintroduce inection resulting in mastitis or abreast abscess.

2-9 Which birth marks are normal?

A blue patch over the sacrum is verycommon and is called a mongolian spot.

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31careofnormalinfants

It is seen in normal inants and is due tothe delayed migration o pigment cells intoother areas o the skin. It is not a sign oDown syndrome (mongolism). Sometimessimilar patches are seen over the back,

arms and legs and may look like bruises.Tey need no treatment and disappearduring the rst ew years o lie.It is common or an inant to have a ewsmall pink or brown marks on the skin atbirth. Tese are normal and disappear in aew weeks.Many inants also have pink areas on theupper eyelid, the bridge o the nose andback o the neck that become more obvious

when the inant cries. Tese marks arecalled angels kisses and stork bites. Teyare also normal and usually disappearwithin a ew years.Some inants develop one or more raisedred lumps on their skin during the rstew weeks. Tese strawberry patchesgrow or a ew months and take a ewyears to disappear. Tey are best le aloneand not treated.

2-10 Are cysts on the gum or palate

normal?

Small cysts on the inants gum or palate arecommon and almost always normal. Tey donot need treatment and disappear with time.Tey must notbe opened with a pin or needleas this may introduce inection.

2-11 Can inants be born with teeth?Yes, some inants are born with teeth. Teseare either primary teeth or extra teeth.Primary teeth are rmly attached and shouldnot be removed. Extra teeth are very small andusually very loose. A tooth that is very loose,and is only attached by a thread o tissue, canbe pulled out. It will be replaced later by aprimary tooth.

2-12 Should tongue tie be treated?

Many inants have a web o mucousmembrane under the tongue that continues tothe tip. As a result the inant is not able to stick

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the tongue out ully and, thereore, is said tohave tongue tie. Tis does not interere withsucking and usually corrects itsel with time.Do notcut the membrane as this may causesevere bleeding. Reer the child to a surgeon i

the tongue does not appear normal by years.

2-13 Does an umbilical hernia need

treatment?

Inants commonly develop a small umbilicalhernia aer the cord has separated. Tis doesnot cause problems and usually disappearswithout treatment when the inant starts towalk. I the hernia is still present at years the

child should be reerred or possible surgicalcorrection.

2-14 Do normal inants commonly have a

blocked nose?

Yes, a blocked nose is common due to the smallsize o the nose in a newborn inant. Normalinants also sneeze. Usually a blocked nose doesnot need treatment. However, some inants maydevelop breathing diculties or apnoea i both

nostrils are completely blocked. Nose dropscontaining drugs can be dangerous as they areabsorbed into the blood stream and can causea rapid heart rate. Sodium bicarbonate % orsaline nose drops can be used. Te blocked noseis usually not caused by a cold.

2-15 Are wide ontanelles and sutures

common?

Many normal inants have wide ontanelles andsutures. Tis is particularly common in lowbirth weight inants. Te anterior ontanellemay also pulsate. I the anterior ontanellebulges and the inants head appears too big, theinant must be reerred to a level or hospitalas hydrocephaly is probably present. I youare uncertain, repeat the head circumerencemeasurement in weeks. It should not increaseby more than 0. cm per week.

2-16 Are extra ngers or toes normal?

Extra ngers that are attached by a thread oskin are common and occur in normal inants.


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Tere is oen a amily history o extra digits.Extra ngers or toes should be tied o as closeto the hand or oot as possible with a piece osurgical silk. I the extra digit contains cartilageor bone and is well attached with a broad base,

it must not be tired o. Tese inants have ahigh risk o other abnormalities and, thereore,should be reerred to a level or hospital.

2-17 Should an inants nails be cut?

I an inants ngernails become long they mayscratch the ace. Long nails should, thereore, becut straight across with a sharp pair o scissors.Do not cut the nails too short. Never bite or tear

the nails. Nail clippers are dangerous.

2-18 Should the oreskin o an inants

penis be pulled back?

No. Te oreskin is usually attached to theunderlying skin and, thereore, should not bepulled back to clean the glans. All newborn,male inants have erections o the penis. Teyalso have larger testes than older inants. Tesesigns usually disappear within a ew months

and are due to the secretion o male hormones.

2-19 When should the normal inant be

ully examined?

Weighing and examining all newborn inantsare important parts o primary care. A ullexamination should be done aer the motherand inant have recovered rom the delivery,which usually takes about hours. Te inant

must be examined in ront o the mother sothat she is reassured that the inant is normal.It also gives her a chance to ask questionsabout her inant. Te inant is also briefyexamined immediately aer birth to identiyany gross abnormalities.

All newborn inants should be weighed and

examined.

2-20 How should the inant be dressed?

It is important that the inant does not gettoo hot or too cold. Usually an inant wears a

cotton vest and a gown that ties at the back or ababy grow. A disposable or washable nappy isworn. I the room is cold, a woollen cap shouldbe worn. Woollen booties are sometimes alsoworn. It is important that the clothing is not too

tight. Inants should be dressed so that they arecomortable and warm. Usually a single woollenblanket is adequate.

2-21 Must the birth be notied?

Te birth o every inant must be notied bythe hospital, clinic or midwie. Te parentslater must register the inants name with thelocal authority.

2-22 Should all inants receive a Road-to-

Health Card?

Yes. All newborn inants must be given aRoad-to-Health Card (preschool card), asthis is one o the most important advancesin improving the health care o children. Terelevant inormation must be entered at birth.Mothers should be told the importance o thecard. Explain the idea o the Road-to-Health

Card to her. She must present the card everytime the inant is seen by a health care worker.It is essential that all immunisations be enteredon the card. A record o the inants weight gainis also very important as poor weight gain orweight loss indicates that a child is not thriving.

All newborn inants must be given a Road to

Health Card.

2-23 Should newborn inants be

immunized?

Te schedule o immunisations varies slightlyin dierent areas but most newborn inants aregiven B.C.G. and polio drops within days odelivery. It is sae to give polio drops to inantso HIV positive mothers. However, theirB.G.G. immunisation is oen delayed until

it can be established that they are not HIVinected. Sick and preterm inants are usuallygiven B.C.G. and polio drops when they areready to be discharged home.


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33careofnormalinfants

feediNg the NormAl

iNfANt

2-24 What milk can be given to a normalinant?

Breast milk. Human breast milk meetsall the nutritional needs o a healthy terminant.Formula eeds. Tese powdered eeds aremade rom cows milk or soya bean and aremodied to have similar constituents tobreast milk.

Whenever possible mothers should breast eed

their inants.

2-25 What are the benets o breast

eeding?

Breast eeding provides many benets to boththe inant and mother. Te main benets are:

Benets to the inant

Breast milk is the ideal eed or terminants as it provides all the nutrients in thecorrect amount and proportion or normalgrowth and development.Breast milk is easily digested and absorbed.Breast milk is clean and warm, and avoidsthe dangers o a contaminated watersupply, inadequately sterilised bottles and

teats, and lack o rerigeration acilities.Breast milk avoids the danger o diluted orconcentrated ormula.Breast milk contains many anti-inectiveactors and decreases the risk o inections,especially gastroenteritis, a major cause odeath o inants in poor communities.Breast milk decreases the risk o allergyin the inant, especially i there is a strongamily history o allergy.

Breast eeding decreases the incidence o

gastroenteritis and lowers the inant mortality

rate in poor communities.

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Benets to the mother

Breast eeding is much cheaper thanbuying ormula eeds.Breast milk is instantly available at alltimes. No sterilising o bottles and teats,and preparation o ormula is needed.It is emotionally satisying or the motherto successully breast eed her inant andhelps to orm a strong bond betweenmother and inant.Breast eeding helps the involution o theuterus and reduces the amount o bleedingduring the puerperium.Breast eeding helps the mother to loseexcessive weight gained during pregnancy.Pregnancy, not breast eeding, alters thebreast shape o a primiparous woman.

Breast eeding is cheap and ensures an adequate,

sae supply o ood. It, thereore, decreases the

incidence o malnutrition.

Breast eeding may increase the risk o HIVtransmission rom mother to inant. Tis mustbe taken into account when discussing breasteeding with a mother.

2-26 Why do some mothers not breast eed

successully?

Breast eeding is not always easy, as thenatural art o breast eeding has to be learned.Some mothers do not breast eed or ail tobreast eed successully because:

Tey believe that they do not have enoughmilk because it takes a number o daysbeore the supply o milk increases.Tey do not know the advantages o breasteeding.Tey think that their milk is too thin, ortheir breasts too large or too small.Tey develop cracked nipples or engorgedbreasts due to an incorrect method oeeding.Tey want to return to work and do notrealise that many working mothers cancontinue to breast eed successully.Tey are araid o breast eeding.

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Tey have fat or inverted nipples.raditional belies may result inunsuccessul breast eeding, e.g. incorrectbelies that colostrum is not good or theinant, intercourse spoils the milk, and

delayed eeding causes the milk to becomesour in the breast.Poor sleeping or excessive crying by theinant is blamed on the quality or supply othe breast milk.Tey are HIV positive and elect not tobreast eed.

2-27 How can breast eeding be promoted?

Breast eeding should be promoted as thenormal, natural method o eeding an inant.Tis can be achieved by:

Encouraging a positive attitude towardsbreast eeding in the home duringchildhood and adolescence by seeing otherinants being breast ed.eaching the advantages o breast eedingin schools.Promoting breast eeding in the media

(radio, V, books).eaching the advantages and method obreast eeding in all antenatal clinics.Starting breast eeding groups run bymothers who have themselves breast ed.Encouraging breast eeding and practicekangaroo mother care in hospitals andclinics.Discouraging bottle eeding in hospital.Rather use cups or expressed breast milk

or ormula eeding.

Further inormation on breast eeding inSouth Arica can be obtained rom a localbreast eeding support group or local brancheso the Breasteeding Association, La LecheLeague, and National Childbirth Educationand Parenting Association.

Breast is best.

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2-28 How can breast ee

primary newborn care

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