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ESSENTIAL NEWBORN CARE (ENC) Mary Lourdes Nacel G. Celeste, MD, RN

Essential Newborn Care

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Page 1: Essential Newborn Care

ESSENTIAL NEWBORN CARE (ENC)

Mary Lourdes Nacel G. Celeste, MD, RN

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ESSENTIAL NEWBORN CARE (ENC)

Neonatal mortality • remains unacceptably high in developing countries including

the Philippines • accounts for almost 40% of under-five deaths globally• 82,000 Filipino children die annually, with half of newborn

deaths occurring in the first two days of life(according to DOH National Disease Prevention director Dr. Yolanda Oliveros)

• But many of these deaths could have actually been prevented.

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• There is growing evidence for simple interventions that can improve newborn survival.

• These interventions form part of the new Essential Newborn Care protocol of the World Health Organization now being promulgated by the Department of Health.

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Course Description

• This module focuses on the Essential Newborn Care (ENC) protocol endorsed by the World Health Organization, which is comprised of evidence-based interventions aimed at improving newborn care and helping curb neonatal mortality

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OBJECTIVES

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Upon the completion of this module, the students will be able to demonstrate knowledge, skills and proper attitude in rendering essential newborn care

1. Discuss the concept of Essential Newborn Care and its relevance to nursing and health care

2. Identify the causes and timing of child mortality3. Describe the current state of newborn care practices in the

Philippines4. Identify the changes in the new set of newborn care interventions5. Perform the skills in the Essential Newborn Care procedures by

return demonstration6. Discuss the rationale for the time bound , non-time bound and

unnecessary procedures of the Essential Newborn Care protocol7. Value the importance of adherence to the standards of Essential

Newborn Care in the implementation of nursing interventions

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RECOMMENDED PREPARATIONS

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• Knowledge on Anatomy and Physiology, Maternal and Child Health Nursing and NCM 100

• Time allotmentLecture and demonstration: 4 hoursReturn demonstration: 12 hours

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CONTENT

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Scope

• Causes and Timing of Child Mortality

• Current State of Newborn Care Practices

• Steps in Immediate Newborn Care

• Standard Essential Newborn CarePractice Guidelines

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Essential Newborn Care: The DOH/WHO Protocol

• Why do we need this protocol?• What are the four core time-bound steps

of essential newborn care?• What are the standard essential newborn care

practice guidelines?• How are these steps performed?

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• Childhood death rates in the country showed downward trend (40%).

• The decline in neonatal mortality has not improved.• Four million babies die within 30 days of birth.• 98% of these deaths are in developing countries • According to health authorities, the Philippines is

one of the 42 countries in the world where 90% of all global deaths of under 5 year old children are accounted to.

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Quick Facts• Neonatal mortality accounts for 37% of under-

five mortality.• The most common causes of neonatal mortality

are preterm birth, sepsis/ pneumonia and asphyxia.

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Majority of newborns die due to stressful events or conditions during labor, delivery

and the immediate postpartum period

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Quick Facts• Majority of newborns die due to stressful events

or conditions during labor, delivery and the immediate postpartum period.

• 50 percent of neonatal deaths occur in the first two days of life .

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A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life

in Philippine Hospitals (2008)Intervention Percentage and

Median TimeWHO Standards

Cord clamp

DryingImmediate skin-to- skin contactPut on cold surfaceNot driedHead not driedWashing

12 sec99% in <1 min97% at 1 min9.6% at 5 min

12%2.5%6.2%

84% at 8 min

Until pulsations stop (1-3 mins)

100% immediately>90% (except those

needing resuscitation)

NoneNoneNone

>6 hours

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A Minute-by-Minute Assessment of Newborn Care within the First Hour of

Life in Philippine Hospitals (2008)Intervention Percentage and

Median TimeWHO Standards

Breastfeeding

Separated from motherWeighingExaminationHepatitis B vaccineNurseryRooming in

61.3% at 10 min

92.9% at 12 min

100% at 13 min75.7% at 17 min69.4% at 20 min52% at 19 min83% (155 min)

W/in 1 hour (but when baby shows

signs)>1 hour

>1 hour>1 hour>1 hourNEVER

Immediately with mother

Sobel, Silvestre, Mantaring, et al 2008

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Quick Facts: • The usual practice of cord clamping in most

Philippine hospitals is 12 seconds with 99 percent under one minute, whereas WHO standards require one to three minutes or until pulsations stop.

• Ninety-seven percent of them also do drying after one minute, when WHO standards say it should be done immediately.

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• Immediate skin-to-skin contact is not also being observed, with only 9.6% doing it after five minutes when it should be done over 90 percent of the time.

• “Bad habits” or harmful practices include :– putting babies on a cold surface (12 percent)– not drying the baby (2.5 percent)– not drying the head (6.2 percent), and – washing or giving the baby a bath (84 percent of

hospitals do it within eight minutes), when it could actually be delayed until after six hours.

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• Under the newly-approved guidelines, transferring babies to a nursery is no longer necessary — instead, newborns should be roomed in with their mothers immediately.

• Separating the baby from the mother, weighing, and examining the newborn should also be done at least after more than an hour, not in just after 10 minutes, which is the usual practice.

• Other newborn interventions cited include rooming in babies with their mother and immediate breastfeeding (within one hour after birth or as soon as baby shows signs).

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STANDARD ESSENTIAL NEWBORN CARE PRACTICES

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Essential newborn care (ENC)

The Essential Newborn Care (ENC) Protocol is a series of time bound, chronologically - ordered, standard procedures that a baby receives at birth. This includes preventive measures which are needed to ensure the survival of the newborn.

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Four Core Steps of Essential Newborn Care

• Immediate and thorough drying • Early skin-to-skin contact • Properly timed cord clamping • Non-separation of the newborn and mother for

early initiation of breastfeeding

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Rationale

• Immediate drying prevents hypothermia, which is extremely important to survival.

• Instead of immediately washing the newborn, the baby should be placed in skin-to-skin contact with the mother- on the mother’s chest or abdomen to provide warmth (prevents hypothermia), increase the duration of breastfeeding, and allow the “good bacteria” from the mother’s skin to colonize the newborn.

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• Delaying cord clamping two to three minutes after birth or waiting until the umbilical cord has stopped pulsating has been shown to increase the baby’s iron reserves. It also reduces the risk of iron-deficiency anemia in one out of three premature babies and one out of seven term babies; improves blood circulation and prevents brain hemorrhage.

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• Delaying the start of breastfeeding could make the newborn 2.6 times more prone to infection. Breastfeeding within the first hour of life prevents an estimated 19.1% of all neonatal deaths.

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The ENC guidelines are categorized into the time bound, non-time bound and unnecessary procedures.

• Time bound procedures- should be routinely performed first- refer to the four core steps of ENC which are

immediate drying, skin to skin contact followed by clamping of the cord after 1-3 minutes, non-separation of the newborn from the mother and breastfeeding initiation.

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• Non-time bound or non-immediate interventions include:

- immunizations, eye care, Vitamin K administration, weighing and washing

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• Unnecessary Procedures include:- routine suctioning, routine separation of

newborn for observation, footprinting, application of alcohol, medicine and other substances on the cord stump and bandaging the cord stump or abdomen, and administration of prelacteals like glucose water or formula.

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ESSENTIAL NEWBORN CARE PROTOCOL

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TIME-BOUND INTERVENTIONS

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I. Immediate Newborn Care (The First 90 minutes)• TIME BAND: At perineal bulging, with presenting

part visible (2nd stage of labor)• INTERVENTION: Prepare for the delivery• ACTION: • Check temperature of the delivery room

– 25 - 28 C– Free of air drafts

• Notify appropriate staff• Arrange needed supplies in linear fashion• Check resuscitation equipment. • Wash hands with clean water and soap. • Double glove just before delivery.

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A. TIME BAND: Within the 1st 30 secs

• Call out the time of birth• INTERVENTION: Dry and provide warmth.• ACTION:• Use a clean, dry cloth to thoroughly dry the baby

by wiping the eyes, face, head, front and back, arms and legs.

• Remove the wet cloth.• Do a quick check of newborn’s breathing while

drying.

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• During the first 30 seconds:– Do not ventilate unless the baby is floppy/limp

and not breathing.– Do not suction unless the mouth/nose are

blocked with secretions or other material.

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B1. TIME BAND: If after 30 secs of thorough 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 that the newborn has

difficulty breathing and that you will help the baby to breathe.

• Start resuscitation protocol.

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B2. TIME BAND: If after 30 secs of thorough drying, newborn is breathing or crying

• INTERVENTION: Do skin-to-skin contact• ACTION:• If a baby is crying and breathing normally, avoid any

manipulation, such as routine suctioning, that may cause trauma or introduce infection.

• 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 (not wrist).– Skin to skin contact is doable even for cesarean section newborns.

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Notes:

• Do not separate the newborn from mother, as long as the newborn does not exhibit severe chest in-drawing, gasping or apnea and the mother does not need urgent medical stabilization e.g. emergent hysterectomy.

• Do not put the newborn on a cold or wet surface.• Do not wipe off vernix if present.• Do not bathe the newborn earlier than 6 hours of life.• Do not do footprinting.• If the newborn must be separated from his/her mother, put

him/her on a warm surface, in a safe place close to the mother. NOTE: If there is a 2nd baby, manage as multi-fetal pregnancy.

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C.TIME BAND: 1 - 3 minutes

• INTERVENTION: Do delayed or non-immediate cord clamping• ACTION:• Remove the first set of gloves immediately prior to cord

clamping.• After the umbilical pulsations have stopped (typically at 1 to 3

minutes), clamp the cord using a sterile plastic clamp or tie at 2 cm from the newborn’s umbilical base.

• Clamp again at 5 cm from the base• Cut the cord close to the plastic clamp with sterile instrument.• Observe for oozing blood.

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Notes:– Do not milk the cord towards the newborn.– After the 1st clamp, you may “strip” the cord of

blood before applying the 2nd clamp.– Cut the cord close to the plastic clamp so that

there is no need for a 2nd “trim.”– Do not apply any substance onto the cord.

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D.TIME BAND: WITHIN 90 minutes of age

1. INTERVENTION: Provide support for initiation of breastfeeding

• ACTION:• Leave the newborn on mother’s chest in skin-to-skin

contact.• Observe the newborn. Only when 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.

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• Counsel on positioning and attachment. When the baby is ready, advise the mother to:– Make sure the newborn’s neck is not flexed nor twisted.– Make sure the newborn is facing the breast, with the newborn’s nose opposite her nipple and chin touching the breast.– Hold the newborn’s body close to her body.– Support the newborn’s whole body, not just the neck and shoulders.– Wait until her newborn’s mouth is opened wide.– Move her newborn onto her breast, aiming the infant’s lower lip well below the nipple.

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• Look for signs of good attachment and suckling:– Mouth wide open– Lower lip turned outwards– Baby’s chin touching breast– Suckling is slow, deep with some pauses

• If the attachment or suckling is not good, try again and reassess.

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Notes:– 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.

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2. INTERVENTION: Provide additional care for a small baby or twin• Kangaroo Mother Care* - Please refer to slide #115.ACTION:• For a visibly small newborn or a newborn born >1 month early:

– Encourage the mother to keep the small newborn in skin-to-skin contact with her as much as possible.– Provide extra blankets to keep the baby warm– If mother cannot keep the baby skin-to-skin because of complications, wrap the baby in a clean, dry, warm cloth and place in a cot. Cover with a blanket. Use a radiant warmer if room not warm or baby small.– Do not bathe the small baby. Ensure hygiene by wiping with a damp cloth but only after 6 hours. Prepare a very small baby (<1.5 kg) or a baby born >2 months early for referral.

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Notes: • Avoid any manipulation, e.g. routine • suctioning that may cause trauma or infection• Place identification band on ankle (not wrist) • Skin to skin contact is doable even for cesarean

section newborns

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Non-Immediate Interventions

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3. INTERVENTION: Do eye careACTION:• Administer erythromycin or tetracycline

ointment or 2.5% povidone-iodine drops to both eyes after newborn has located breast.Do not wash away the eye antimicrobial.

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Newborn Care from 90 minutes to 6 hours after birth

TIME BAND: From 90 Min - 6 Hrs• INTERVENTION: Give Vitamin K prophylaxisACTION:• Wash hands. • Inject a single dose of Vitamin K 1 mg IM.

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INTERVENTION: Inject hepatitis B and BCG vaccinations at birth.

ACTION:• Inject hepatitis B vaccine intramuscularly and

BCG intradermally.• Record.

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INTERVENTION: Examine the babyACTION:• Thoroughly examine the baby.• Weigh the baby and record.

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INTERVENTION: Check for birth injuries, malformations or defects.

ACTION:• Look for possible birth injury:

– Bumps on one or both sides of the head, bruises,swelling on buttocks, abnormal position of legs (after breech presentation) or asymmetrical arm movement, or arm that does not move.

If present:

– Explain to parents that this does not hurt the newborn, is likely to disappear in a week or two and does not need special treatment.– Gently handle the limb that is not moving.– Do not force legs into a different position.

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Look for malformations:– Cleft palate or lip– Club foot– Odd looking, unusual appearance– Open tissue on head, abdomen or back

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If present:– Cover any open tissue with sterile gauze before

referral and keep warm.• Refer for special treatment and/or evaluation if

available.– Help mother to breastfeed. If not successful

teach her alternative feeding methods

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INTERVENTION: Cord careACTION:• Wash hands.

– 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.– Explain to the mother that she should seek care if the umbilicus is red or draining pus.

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– Teach the mother to treat local umbilical infection three times a day.– Wash hands with clean water and soap.– Gently wash off pus and crusts with boiled and cooled water and soap.– Dry the area with clean cloth.– Paint with gentian violet.– Wash hands.– If pus or redness worsens or does not improve in 2 days, refer urgently.

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Notes:– Do not bandage the stump or abdomen.– Do not apply any substances or medicine on the

stump.– Avoid touching the stump unnecessarily.

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• INTERVENTION: Provide additional care for a small baby or twin

• ACTION:• If the newborn is delivered 2 months earlier or

weighs < 1500 g, refer to specialized hospital.• If the newborn is delivered 1-2 months earlier or

weighs 1500 - 2500 g (or visibly small where scale not available provide additional care for small newborns.

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Notes:• – Encourage the mother to keep her small baby in

skin-to-skin contact.• – If mother cannot keep the baby in skin-to-skin

contact because of complications, wrap the baby in a clean, dry, warm cloth and place in a cot.

• Cover with a blanket. Use a radiant warmer if the room is not warm or the baby small.

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

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UNNECESSARY PROCEDURES

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UNNECESSARY PROCEDURES

1. Routine suctioning– No benefit if the amniotic fluid is clear and especially

with newborns who cry or breathe immediately after birth

– Moreover, a dirty bulb can become a source of infection

– Has been associated with cardiac arrhythmia– Indicated only if the mouth/nose is blocked with

secretions or other materials

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UNNECESSARY PROCEDURES

2. Early bathing/washing– Hypothermia which can lead to infection,

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

– Infection – the vernix is a protective barrier to bacteria such as E. coli and Group B Strep; so is maternal bacterial colonization

– No crawling reflex

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UNNECESSARY PROCEDURES

3. Footprinting– Proven to be an inadequate technique for newborn

identification purposes– Better identification techniques such as DNA

genotyping and human leukocyte antigen tests

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UNNECESSARY PROCEDURES

4. Giving sugar water, formula or other prelacteals and the use of bottles or pacifiers– Delayed initiation to breastfeeding has been linked

to a 2.6 fold increase in the chances of newborn deaths due to infection

– If the sugar water, formula or prelacteals are introduced using a bottle, the newborn may develop a learned preference for the bottle leading to nipple confusion and inefficient suckling which can further lead to failure in breastfeeding

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UNNECESSARY PROCEDURES

– A pacifier contributes to nipple confusion if these are used before the newborn is offered the mother’s breast

– This undermines the chances of successful breastfeeding by contributing to a vicious cycle of poor attachment, sore nipples and lactational insufficiency

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UNNECESSARY PROCEDURES

5. Application of alcohol, medicine and other substances on the cord stump and bandaging the cord stump or abdomen

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Care prior to discharge TIME BAND: After the 90 minutes of age, but prior to dischargeINTERVENTION: Support unrestricted, per demand breastfeeding, day

and nightACTION:• Keep the newborn in the room with his/her mother, in her bed or

within easy reach. Do not separate them (rooming-in).• Support exclusive breastfeeding on demand day and night.• Assess breastfeeding in every baby before planning for discharge. Ask

the mother to alert you if with difficulty breastfeeding.• Praise any mother who is breastfeeding and encourage her to

continue exclusively breastfeeding.• Explain that exclusive breastfeeding is the only feeding that protects

her baby against serious illness. Define that exclusive breastfeeding means no other food or water except for breast milk.

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Notes:– Do not discharge if baby is not feeding well.– Do not give sugar water, formula or other prelacteals.– Do not give bottles or pacifiers. INTERVENTION: Ensure warmth of the baby ACTION:• Ensure the room is warm (> 25 C and draft -free).• Explain to the mother that keeping baby warm is important for the baby to

remain healthy.• Keep the baby in skin-to-skin contact with the mother as much as possible.• Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap

for the first few days, especially if baby is small.

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INTERVENTION: Washing and bathing (Hygiene)ACTION:• Wash your hands. • Wipe the face, neck and underarms with a damp cloth

daily.• Wash the buttocks when soiled. Dry thoroughly.• Bathe when necessary, ensuring that the room is warm and

draft-free, using warm water for bathing and thoroughly drying the baby, then dressing and covering after the bath.

• If the baby is small, ensure that the room is warmer when changing, wiping or bathing

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INTERVENTION: SleepingACTION:• Let the baby sleep on his/her back or side.• Keep the baby away from smoke or from people

smoking.• Ensure mother and baby are sleeping under

impregnated bed net if there is malaria in the area.

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INTERVENTION: Look for danger signsACTION:• Look for signs of serious illness :– Fast breathing (>60 breaths per min)– Slow breathing (<30 breaths per min)– Severe chest in-drawing– Grunting– Convulsions– Floppy or stiff– Fever (temperature >38 C)– Temperature <35 C or not rising after re-warming

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– Umbilicus draining pus– More than 10 skin pustules or bullae, or

swelling, or redness, or hardness of skin (sclerema)

– Bleeding from stump or cut – PallorIf any of the above is present, consider possible

serious illness.

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Managing Newborn Problems.– Start resuscitation, if necessary. – Re-warm and keep warm during referral for

additional care.– Give first dose of two IM antibiotics– Stop bleeding.– Give oxygen, if available.

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INTERVENTION: Look for signs of jaundice and local infection

ACTION:Look at the skin. Is it yellow?– Refer urgently, if jaundice present :– on face of <24 hour old newborn– on palms and soles of ≥24 hour old infant– Encourage breastfeeding.– If feeding difficulty, give expressed breast milk by cup.

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Look at the eyes:Are they swollen and draining pus?– If present, consider gonococcal eye infection.– Give single dose of appropriate antibiotic for eye

infection.– Teach mother to treat eyes.– Follow-up in two days. If pus or swelling worsens or

does not improve refer urgently.– Assess and treat mother and her partner for possible

gonorrhea.

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Look at the umbilicus:– What has been applied to the umbilicus? Advise mother

proper cord care .– If there is redness that extends to the skin,consider local

umbilical infection.– Teach mother to treat umbilical infection.– If no improvement in 2 days, or if worse, refer urgently.– If the umbilicus is draining pus then consider possible serious

illness– Give first dose of two IM antibiotics– Refer baby urgently

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Look at the skin, especially around the neck, armpits, inguinal area:

– Are there pustules?– If less than 10 pustules, consider local skininfection: Teach mother to treat skin infection.– Follow-up in 2 days. If pustules worsen or do not

improve in 2 days or more, refer urgently.– If more than 10 pustules, refer for evaluation.

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DISCHARGE INSTRUCTIONS

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DISCHARGE INSTRUCTIONS

1. Advise the mother to return or go to the hospital immediately if:– Jaundice of the soles or any of the following are present*– Difficulty of feeding– Convulsions– Movement only when stimulated– Fast or slow or difficult breathing (e.g. severe chest in-

drawing)– Temperature >37.5 C or <35.5 C

*From Lancet 2008, new IMCI algorithm for Young Infant II study

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DISCHARGE INSTRUCTIONS

2. Advise the mother to bring her newborn to the health facility for routine check-up at the following prescribed schedule:– Postnatal visit 1: at 48-72 hours of life– Postnatal visit 2: at 7 days of life– Immunization visit 1: at 6 weeks of life

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DISCHARGE INSTRUCTIONS

3. Advise additional follow-up visits appropriate to problems in the following:– Two days – if with breastfeeding difficulty, Low Birth

Weight in the first week of life, red umbilicus, skin infection, eye infection, thrush or other problems

– Seven days – if Low Birth Weight discharged more than a week of age and not gaining weight adequately

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DISCHARGE INSTRUCTIONS

4. Advise for Newborn Screening

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Care after Discharge to 7 days TIME BAND: From discharge to 7 daysINTERVENTIONS: • Support unrestricted, per demand exclusive

breastfeeding, day and night.• Ensure warmth for the baby.• Look for danger signs (Refer to IMCI)

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Kangaroo Mother Care (KMC) ACTION:• Start kangaroo mother care when:• – The baby is able to breathe on its own (no apneic episodes).• – The baby is free of life-threatening disease or malformations. Notes:• – The ability to coordinate sucking and swallowing is not a pre-requisite to

KMC. Other methods of feeding can be used until the baby can breastfeed.• – KMC can begin after birth, after initial assessment and basic resuscitation,

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

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

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Position the baby for KMC:– Place the baby in upright position between the mother’s breasts, chest to

chest– Position the baby’s hips in a ‘frog-leg’ position with the arms also flexed.– Secure the baby in this position with the support binder– Turn the baby’s head to one side, slightly extended– Tie the cloth firmly

Notes:- KMC should last for as long as possible each day. If the mother needs to

interrupt KMC for a short period, the father, a relative or friend should take over.

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Equipment and Supplies for ENC2-3 pairs of surgical gloves2 clean towels/ blankets1 bonnetcord care set (sterile cord clamps/ forceps or cord ties and scissors)ophthalmic antibioticVitamin K (phytomenadione)Hepatitis B vaccine1 cc syringes with needles 3 cc syringes with needles70% isopropyl alcoholswabsdigital thermometerbaby weighing scaleidentification band

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Others:Clean water and soap/ antisepticLong plastic apronStethoscopeSupport binders for KMCNewborn screen filter cards/ LancetsFeeding cups Self-inflating bag and mask (term and preterm size)Suction tube with mucus trapSuction machine or wall suctionFeeding tubes (Fr 5 and 8)Oxygen sourceRadiant warmer or heat sourceWall clock

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ASSESSMENT

RETURN DEMONSTRATIONQUESTION AND ANSWER

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References

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• Essential Newborn Care Advocacy Video. Retrieved from http://www.wpro.who.int/phl/• videos/ enc/advocacy.htm• Essential Newborn Care at a glance. September 2004. Retrieved from http://siteresources.world

bank. • org/INTPHAAG/Fact%20Sheets/20559137/AAGENCSept04.pdf• Galutira, E. Essential Newborn Care. (PPT document) February 2010.• Healthy Mothers and Healthy Newborns: The Vital Link. Population Reference Bureau and Saving

Newborn Lives. Retrieved from http://www.prb.org/Template.cfm?Section=• PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=7167 • Narayanan I., Rose, M., Cordero, D., Faillace, S. and Sanghvi, V. The Components of Essential

Newborn Care. (PDF document) . June 2004. Retrieved from http://www.basics.org/ documents/pdf/components_of_ENC_paper.pdf

• Newborns: reducing mortality. Retrieved from http://www.who.int/topics/infant_newborn/en/• Saving Newborn Lives: Newborn Health. April 2010. Retrieved from http://www.savethe• children.org/programs/health/saving-newborn-lives/snl-newborn-health.html• Silvestre, M.A. Essential Newborn Care: The DOH/WHO Protocol. (PDF document). March 2010.• State of the Worlds’ Newborns. Saving Newborn Lives initiative, Save theChildren,2001. Retrieved

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