Normal Newborn Care

International

Introduction• 4 million neonatal deaths per year• 2/3 of neonatal deaths occur in 1st week of life• Must improve maternal education in basic newborn

care and recognition of danger signs• Improve training in neonatal resuscitation and

recognition and management of sick neonates

International

Main Causes of Infant Mortality

7%15%

9%1%

29%

24%

10% 5%

Neonatal tetanus 7%

Pneumonia 15%

Sepsis/Meningitis 9%

Diarrhea 1%

Birth asphyxia and trauma 29%

Prematurity 24%

Congenital anomalies 10%

Others 5%

Main Causes of Mortality

International

Essential Care for Newborn Health• Care of future mothers• Care during pregnancy• Care at time of birth• Care after birth

International Immediate Care of the Newborn

At birth, ask yourself the four following questions. If any answer is NO, THE BABY REQUIRES RESUSCITATION

•Breathing or crying?•Good muscle tone?•Color pink?•Term gestation?

Routine care

-Warmth

- Dry

IF YES

IF NO-Provide warmth

-Position; clear airway

-Dry, stimulate

Evaluate:

-Respirations

-Heart rate

-Color

RAPID INTERVENTION…for resuscitation

International

Apgar Scores• A tool used to document the clinical

status of the newborn• NOT used to identify newborns that

require resuscitation• A score of 0 to 10 is assigned at 1, 5,

and 10 minutes

International

Sign Score0 1 2

Heart rate Absent Slow (< 100 beats/minute)

=> 100 beats/min

Breathing Absent Slow, irregular Good, crying

Muscle Tone Limp Some flexion Active motion

Reflex irritability

No response Grimace Cough, sneeze

Color Blue or pale Pink body with blue extremities

Completely pink

Apgar ScoringApgar Scoring

International

Cleanliness for the Newborn• Clean hands, perineum and delivery

surface• Immediate tying and clean cutting of

cord• Clean cloth to wrap baby in after delivery• Clean cord care

- nothing applied to cord stump- cord stump to be left uncovered to dry

International Thermal Protection of the Newborn

• Warm delivery room• Immediate drying• Skin to skin contact• Breastfeeding• Delay weighing and bathing• Appropriate clothing and bedding• Keep mother and newborn together• Warm transportation and resuscitation

Newborn ResuscitationNewborn Resuscitation

International

• Be prepared for resuscitation – 10% of babies require resuscitation

• 30-40% of babies that require resuscitation are a surprise

International

What is Necessary to Prepare for Resuscitation?

• Appropriate equipment • Skill to use equipment• Learn to recognize which baby needs

resuscitation

International

At birth, ask yourself the four following questions. If any answer is NO, THE BABY REQUIRES RESUSCITATION

Breathing or crying?Good muscle tone?Color pink?Term gestation?

- Provide warmth- Position; clear airway- Dry, stimulate

Evaluate:- Respirations- Heart rate- Color

Supportive care

Provide breathing assistance

RAPID INTERVENTION…for resuscitation

HR > 100 & pink

Abnormal respirations or HR < 100

Routine care- Warmth- Dry

IF NONormal breathing

International

Meconium Babies (10 – 12%) may be born through meconium stained

amniotic fluid

Meconium can plug the airway

A vigorous baby is: - breathing or crying - heart rate > 100 bpm - good tone If baby not vigorous then clearing the airway by intubating

and suctioning of the trachea may be life saving.

International

How to Assess a Baby in a Health Care Facility

Breathing or Crying : -Watch babies chest rise -Normal rate 40-60/bpm - A vigorous indicates breathing Abnormal breathing may be: - absence of breathing - shallow respirations, poor chest movement - gasping respirations – extreme effort to inhale

associated with a slow respiratory rate

International

Muscle tone - healthy term babies have a flexed position

Color – Normal is pink lips and mucous membranes. A dusky blue hue of lips and mucous membranes indicates central cyanosis.

Term gestation – by history Heart rate – normal heart rate 120 – 160 bpm

determined by auscultation of the heart.

How to Assess a Baby in a Health Care Facility

International

Heart rate Hold the base of the umbilical cord with your thumb

and index finger. The cord pulsations felt are the heart

rate of the baby. The baby’s heart rate should be more than your own heart rate.

All other assessments are similar to health facility

How to Assess a Baby in the Community

International

How to Provide Resuscitation in a Health Care Facility

Warmth - warmer - warm delivery room - temperature – 25oC to 28oC (77 – 82.4o F) - no fans or draughts - warm linen including 2 blankets/sheets, cap and clothing for baby -Dry baby immediately and remove wet linen - kangaroo care: even premature babies can maintain temperature

with skin to skin contact

International

How to Provide Resuscitation in a Health Care Facility

Suction - suction mouth and nostrils before delivery of baby - suction mouth and nostrils after delivery of baby.

Remember mouth is to be suctioned before the nose Stimulate – If the baby is not breathing provide: - tactile stimulation by gently rubbing the back - stroking the feet - drying also provides tactile stimulation

International

How to Provide Resuscitation in the Community

Warmth - deliver baby in a room that is warm and has no draughts - may

need heating. - dry baby immediately and remove wet linen - warm linen including 2 blankets/sheets, cap and clothing for baby - baby’s body can be wrapped in a towel and then covered by

plastic. Ensure baby’s head is not covered by plastic. - kangaroo care: even premature babies can maintain temperature

with skin to skin contact

International

How to Provide Resuscitation in the Community

Suction if you do not have a suction catheter or bulb syringe then wipe the

mouth gently with a cloth - deep suctioning may cause bradycardia

Stimulate - If the baby is not breathing provide: - tactile stimulation by gently rubbing the back - stroking the feet - drying also provides tactile stimulation

International

Breathing Assistance in a Health Care Facility

Bag and Mask Ventilation Indication: - not breathing - heart rate < 100 bpm

Equipment: - self inflating bag with oxygen reservoir - infant mask

International

Breathing Assistance in a Health Care FacilityTechnique:

- connect O2 to reservoir - cover mouth and nostrils with mask - squeeze bag 40-60 times/minute

WATCH for chest movement. If no movement: - check for seal - reapply mask -reposition head - check for blocked airway and continue bag and mask ventilation

International

  Breathing Assistance in the Community

- If you have a self inflating bag and mask, follow instructions in health care facility section.

- You may use a tube and mask:• - get a good seal covering the mouth and nostrils• - breathe 40 times/minute into the tube by blowing into the

tube - make sure the chest rises

International

When does the baby require continuing observation and additional attention?

Danger signs: - ineffective breathing/labored respiration – respiration rate >

60/min - heart rate < 100 bpm - cyanosis - pale, mottled or gray - abnormal tone - jitteriness - seizures - cool/warm baby - not feeding - at risk for infection

International

Successful Resuscitation BABY SHOULD BE:• WARM• PINK• BREATHING COMFORTABLY

Preventative Care for the Newborn

International

Breastfeeding• Within one hour of birth• Feed on demand to stimulate milk production• 8 to 12 feeds in 24 hours• Feeding is appropriate if: 6-8 wet diapers per day, frequent

bowel movements and weight gain• No supplements needed• Empty breast completely to use hind milk• Mother must increase caloric and fluid intake

International

Proper LatchProper Latch

International

Eye Care• Helps prevent infectious conjunctivitis in 85

to 90% of newborns• Clean eyes in all newborns within 1 hour of

birth• Prophylactic agents:

• Silver nitrate 1% solution (2 drops per eye)• Tetracycline ointment 1%• Erythromycin ointment 0.5%• Provilodone solution – iodized 2.5%

International

Other Measures Vitamin K

• 1 mg IM to prevent haemorrhagic disease Cord Care

• Keep stump clean and uncovered• No traditional medicines, herbs, etc

Immunizations• BCG if at risk of TB• One dose of oral polio vaccine (OPV) <2 wks after

birth• Hepatitis B if available

International

Recognition and Management Recognition and Management of Problems Following of Problems Following

Resuscitation or Presenting Resuscitation or Presenting During the First Week of LifeDuring the First Week of Life

International

IMPORTANT PRINCIPLES• Training

• neonatal resuscitation• post resuscitation management• prompt recognition of danger signs• prompt management of danger signs

• Maternal education• Urgency of assessment and management of

a sick newborn

International

DANGER SIGNS• A danger sign is a sign or a symptom identified from

history (mother, pregnancy, delivery, baby) as well as physical exam of the baby, which indicates that he/she is at risk for, or is in trouble and needs urgent evaluation.

• Signs and symptoms are non-specific in the neonatal period.

International

HISTORICAL DANGER SIGNS maternal history

• maternal fever• incomplete maternal immunization status• maternal HIV, TB, syphilis, malaria

delivery history• prolonged rupture of membranes• prolonged labor• unclean delivery• bleeding, foul amniotic fluid• need for neonatal resuscitation

International

DANGER SIGNS

Not feeding well

(<6 feeds/day) Respiratory

Cardiac

Other

Neurologic

Skin

Risk of infection

General

International

NEONATAL DANGER SIGNS Not feeding well

• After first day of life, a healthy baby should be feeding 8-12 times a day. He/she should wake up for feeding and show interest in feeding.

General appearance• low birth weight <2500g• premature <34 weeks• twins or triplets• dysmorphism• temperature abnormalities

hypothermia <35.5 °C axillary hyperthermia >37.5 °C axillary

International

DANGER SIGNS Respiratory

• tachypnea RR>60, irregular breathing, apnea• labored breathing, grunting, retractions• cyanosis• cough• requiring bag and mask ventilation

Cardiac• tachycardia HR>200, bradycardia HR<100• pale, mottled, capillary refill>3sec• cyanosis

International

DANGER SIGNS Neurologic

• seizures• hypotonia• hypertonia• jitteriness, tremors• irritability• lethargy• poor suck• weak cry or high pitch cry• bulging fontanel, depressed fontanel

International

DANGER SIGNS Skin

• jaundice• pustules• pus from the umbilicus• redness around the umbilicus• purulent eye discharge

Other• abdominal distension, diarrhea• vomiting• bleeding

International

CLINICAL SIGNS Not feeding well (with risk of hypoglycemia)

• irritability•seizures• jitteriness•temperature instability•respiratory distress•poor colour• jaundice

International

CLINICAL SIGNS Sepsis /meningitis

• all the danger signs Pneumonia

• RR>60• retractions, nasal flaring• grunting• cough

International

CLINICAL SIGNS Asphyxia

• abnormality of muscle tone• lethargy, poor activity, irritability• seizures, jitteriness, tremors• poor sucking reflex• poor respiratory effort• poor colour

International

CLINICAL SIGNS LBW/prematurity

•BW<2500g•physical immaturity•risk of respiratory problems, especially the

premature infant•difficult temperature control (risk of

hypothermia)•poor feeding•higher risk of infections•higher risk of jaundice

International

MANAGEMENT Not feeding well with no other danger

signs• evaluate

milk production feeding technique sucking ability of the baby

• spoon feeding of extracted milk or formula• treat oral thrush with gentian violet

International

MANAGEMENT Severe infection (pneumonia, sepsis,

meningitis)• antibiotics: Septra PO for 10 days, and

Gentamicin IM for 7 days• temperature control• nutrition• transfer (with mother) to a hospital, if feasible

International

MANAGEMENT Local infection

•Eyes: IM Cefotaxime or Ceftriaxone, 1dose, or Penicillin for 7 days

•Umbilicus: if mild redness not extending: observation if redness extending or pus draining, or other danger signs: see severe infection

•Skin:hygiene and oral cloxacillin if not improving with oral treatment, or other danger signs present: see severe infection

International

MANAGEMENT Asphyxia/seizures

• treat the seizures with phenobarbital• antibiotics (see severe infection)• nutrition/prevention of hypoglycemia• temperature control• transfer if possible

International

MANAGEMENT LBW/Premature baby

•handle with care•temperature control•early and frequent feedings•spoon feeding of expressed colostrum/breast milk if unable to suck

•close observation for signs of infection•check skin for jaundice