Essential Newborn Care

MARY ANNE L. ILAO, M.D.,FPPS,DPSNbM

2010

MDG 4: Reduce Child Mortality

Target : Reduce by two thirds, between 1990 and 2015, the child mortality rate:

- Reduce Under 5-mortality rate from 80.0 to 26.7 (per 1,000 LB)

- Reduce Infant mortality rate

from 57.0 to 19.0 (per 1,000 LB)

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What is the Essential Newborn Care Protocol?

• Series of time bound chronologically ordered, standard procedures that a baby receives from birth

• Simple, to-the-point, user-friendly, globally accepted evidence-based protocol to essential newborn care focusing on the 1st week of life

• Doable even by a single health worker caring for both mother and newborn

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How is the Newborn Care Protocol organized?

• By time bands

• With cross references to sections of the WHO PCPNC Manual (2006)

• With algorithms that represent clinical pathways

Immediate Essential Newborn Care

The First 90 Minutes

Immediate Essential Newborn Care

Time band: 2nd stage of labor • At perineal bulging, with presenting part visible

Intervention:Prepare for the delivery

Action: • Ensure that delivery area is draft-free and room

temperature between 25–28oC.• Wash hands with clean water and soap. • Double glove just before delivery.

Preparing to Meet the Baby’s Needs

“Good care of the newborn begins with good preparation”

• Ensure all delivery equipment and supplies, including newborn resuscitation equipment, are available.

• Line up materials for delivery according to sequence of use

Prepare for Delivery

• 2 sets of sterile gloves• Two clean and warm towels or cloth• Self inflating bag and mask (normal and small

newborn)• Suction device • Sterile cord clamp or ties• Sterile forceps and scissors• Rolled up piece of cloth• Bonnet • Clean dry warm surface

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Broken equipment is dangerous

• Equipment must be checked daily and well before a delivery takes place.

• Resuscitation equipment should always be close to the delivery area

• Health workers must know how to use the equipment.

• D11

STANDARD PRECAUTIONS A4

• Always remember the importance of observing precautions to help protect the mother and baby and ourselves from infections with bacteria, viruses including HIV

Immediate Essential Newborn Care

• Deliver the baby in prone position on the mother’s abdomen, face turned to the side

• Call out time of birth.

• Dry the newborn thoroughly. Check the baby’s breathing while drying. Remove wet cloth.

• Place the newborn on the mother’s abdomen in skin-to-skin contact. Cover the back with a dry blanket.

Time: WITHIN THE 1ST 30 SECS

Intervention: Dry and provide warmth.

Action:

• Use a clean, dry cloth to thoroughly dry the baby by wiping the face, eyes, head, front and back of the trunk, arms and legs.

• Do a quick check of newborn’s breathing while drying.

• Remove the wet cloth.

Drying The Newborn

•Stimulates the newborn to breathe normally•Minimizes heat loss

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Drying the newborn

• During the 1st 30 seconds of drying/stimulation:– Do not suction unless mouth/nose are

obstructed with secretions or other material– Do not ventilate unless the baby is floppy

and not breathing

Do not remove the vernix!!!

Time band: If after 30 secs of drying, newborn is breathing or crying

Intervention: Skin -to-skin (STS) contactAction:• Avoid any manipulation, such as

routine suctioning.• Place the newborn prone on the mother’s

abdomen or chest skin-to-skin. • Cover newborn’s back with a blanket and

head with a bonnet.• Place identification band on ankle

Immediate skin-to-skin contact

Immediate skin-to-skin contact

Skin-to-Skin Contact

• Provides warmth• Improves bonding• Provides protection from infection by

exposure of the baby to good bacteria of the mother

• Increases the blood sugar of the baby• Contributes to the overall success of

breastfeeding

Skin-to-Skin Contact

Effect on Immunoprotection

• Colonization with maternal skin flora

• Stimulation of the mucosa-associated lymphoid tissue system.

• Ingestion of colostrum

Risks of Hypothermia

• Hypothermia can lead to :–Infection–Coagulation defects–Acidosis–Delayed fetal to newborn

circulatory adjustment–Hyaline membrane disease –Brain hemorrhage.

[i] Tunell R. Hypothermia: epidemiology and prevention, in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London, UK. p. 207-220.

When should the cord be clamped

after birth?A. When the cord pulsations stop

B. Between 1 and 3 minutes

C. Between 30 secs - 1 minute in preterms

D. All of the above are appropriate

Time band: If after 30 secs of drying,

newborn is NOT breathing or is gasping

Intervention: Re-position, suction and ventilate

Action:• Clamp and cut the cord immediately• Call for HELP• Transfer to a warm firm surface• Inform the mother• Start resuscitation protocol

Time Band: 1 – 3 minutes

Intervention: Delayed or non-immediate cord clamping Action:• Remove the first set of gloves immediately

prior to cord clamping.

• Clamp and cut the cord after cord pulsations have stopped ( at 1 to 3 minutes)

Action: Initial Cord care-Put ties tightly around

the cord at 2 cm & 5 cm from the abdomen.

-Cut between ties with sterile instrument.

-Observe for oozing blood.• Do not apply any

substance to the stump• Do not bind or bandage

the stump• Leave the stump

uncovered

Properly timed clamping of the umbilical cord

Reduces the risk of anemia in both term and preterm babies

• Term babies: less anemia in the newborn 24-48 hrs after birth

– RR 0.2 (95% CI 0.06, 0.6)– NNT 7, (4.5- 20.8)

• Preterms: less infant anemia – RR 0.49 (95% CI 0.3, 0.81)– NNT 3 (1.6 - 29.6)

Preterms: less intraventricular hemorrhage RR 0.59 (95% CI 0.35, 0.92)NNT 2 (1.4 - 9.8)

No significant impact on incidence of Post-partum hemorhage

Ceriani Cernadas ,et al. 2006;Rabe H, et al. 2004; McDonald SJ, et al. 2008; Hutton EK, et al. 2007; Kugelman A, et al. 2007 Van Rheenen PF, et al. 2006 Van Rheenen PF & Brabin BJ. 2006

Properly timed clamping of the

umbilical cord

Washing should be delayed until after 6 hours

• Washing exposes to hypothermia

• The vernix is a protective barrier to bacteria such as E. coli and Group B Strep

• Washing removes the crawling reflex

[i] Tollin M, Bergsson G, Kai-Larsen Y, Lengqvist J, Sjovall J, Griffiths W, Skulavottir G, Haraldsson A, et al. Vernix Caseosa as a multicomponent defense system based on polypeptides, lipids and their interactions. Cell Mol Life Sci 2005; 62:2390-2399

[ii] Righard L, Alade M. Effect of delivery room routines on success of first breastfeed. Lancet 1990; 336: 1105-07

Time: WITHIN 90 min of age Intervention: Provide breastfeeding

support for initiation of breastfeeding

Action:• Leave the baby on the mother’s chest in

skin-to-skin contact.

• Observe the newborn.

• Place identification tag / bracelet on the baby’s ankle

Maintain skin-to-skin contact

- uninterrupted for at least 90 minutes after birth and until the first thorough breastfeed is complete

Monitor the mother and baby during the first hour after complete delivery of the

placenta

• Never leave the woman and newborn alone• Keep the mother and baby in the delivery room • Record findings, treatments and procedures in

the labor record• Monitor every 15 minutes:

Baby• Breathing • warmth

SKIN TO SKIN CONTACT & INITIATION OF BREASTFEEDING

• To begin with the baby will want to rest.

• Rest period may take from a few minutes to 30 or 40 minutes before the baby shows feeding cues.

SIGNS OF READINESS TO BREASTFEED

• Only once the newborn shows feeding cues (e.g. opening of mouth, tonguing, licking, rooting), make verbal suggestions to the mother to encourage her newborn to move toward the breast e.g. nudging.

Help the mother and baby into a comfortable position

Initiation of breastfeeding

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

• Do not give sugar water, formula or other prelacteals.

• Do not give bottles or pacifiers.• Do not throw away colostrum.• If the mother is HIV-positive, counsel

the mother on breastfeeding

The first breast feed

– Check attachment and positioning when the baby is feeding

– Let the baby feed for as long as he wants on both breasts

– Keep the mother and baby together for as long as possible after delivery

– Delay tasks such as weighing, immunizations, etc. until after the first feed

HIV and Immediate Newborn Care • If the mother has HIV/AIDS:

– universal precautions must be followed as with any other delivery and after care.

– Her baby can have immediate skin-to-skin contact

– Breastfeeding can begin when the baby is ready after delivery

– Do not give the baby any other food or drink

– Good attachment and positioning are vital– If replacement feeding, prepare formula for

the mother for the first few feeds

Time: WITHIN 90 min of age Intervention: Do eye care

Action:

• Wipe the eyes

• Apply an eye antimicrobial within 1 hour of birth:– 1% silver nitrate drops or – 2.5% povidone iodine drops or – 1% tetracycline ointment or erythromycin eye

drops

• Do not wash away the eye antimicrobial

II. Essential Newborn Care

FROM 90 Min – 6 HRS

Time: FROM 90 Min – 6 HRS

Intervention: Give Vitamin K prophylaxis

and Hepatitis B and BCG vaccinations at birthAction:• Wash hands. • Inject a single dose of Vitamin K 1 mg IM.• Inject Hepatitis B vaccine IM and BCG

intradermally.• Record.

Time: WITHIN 90 min of age Interventions:

• Examine the baby

• Check for birth injuries, malformations or defects

Action:

• Thoroughly examine the baby.

• Weigh the baby and record.

• Look for possible birth injury and/or malformation

Time: WITHIN 90 min of age Interventions: Cord careAction:Wash hands before and after cord care.

- Put nothing on the stump.

- Fold diaper below stump. Keep cord stump loosely covered with clean clothes.

- If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth.

Time: WITHIN 90 min of age Interventions: Provide additional

care for a small baby or twin

Action:

• If the newborn is delivered 2 months earlier or weighs <1500 grams, refer to a hospital

Time: WITHIN 90 min of age Interventions: Provide additional care

for a small baby or twin

Action:• If the newborn is delivered 1 month early

of is visibly small (1501 – 2499g)- KMC- Special support for breastfeeding- Discharge planning

Unneccesary ProceduresNot routinely recommended for all neonates1. Routine suctioning

2. Early bathing/washing

3. Foot printing

4. Giving sugar water, formula or other prelacteals and use of bottles and pacifiers

5. Application of alcohol, medicines and other susbstances on the cord stump and bandaging the cord stump or abdomen

SUMMARYEssential Newborn Care Protocol

• Essential interventions in the first 90 minutes of life and up to 7 days of life

• Emphasizes a core sequence of actions, performed methodically, step-by-step

• Some time-bound but doable even by a single health worker caring for both mother and newborn

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Immediate Newborn Care First 90 Minutes of Life

• Call out time of birth.• Deliver the baby prone on the mother’s

abdomen • Dry the newborn thoroughly. Check breathing

while drying.• Remove wet cloth.• Position the newborn on the mother’s abdomen

in skin-to-skin contact. Cover the back with a dry blanket.

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• Remove first set of gloves.• Clamp and cut the cord when pulsations

have stopped ( 1-3 minutes)• Place the newborn on the mother’s chest

in skin-to-skin contact• Cover the baby’s head with a hat. Cover

the mother and baby with a warm cloth.• Initiate breastfeeding while maintaining

skin-to-skin contact.• Place identification band on ankle.• Do eye care

• Pocket guide to the PCPNC Manual (WHO 2006)

• DOH issued Administrative Order 2009-0025on Dec. 1,2009 : Adopting New Policies and Protocol On ENC

• Launched on Dec 7, 2009

Together, we can DoH it…

before 2015