Essential Newborn Care Protocol

The ENC Protocol: DOH Administrative Order

December 2009

Rationale

➲ RP among 42 countries accounting for 90% of under-five deaths

➲ Reductions in childhood death rates have slowed down Neonatal deaths declined the slowest

➲ 3/4 of under-five deaths occur in the neonatal period

➲ Half of all neonatal deaths occur in first 2 DOL

Rationale

➲ Observational study of minute-by-minute newborn care done in first hour of life in 51 hospitals showed: Only 3% of newborns were dried prior to or with cord

cutting Unnecessary delays and restrictions on immediate

and sustained skin-to-skin contact, early latching on, rooming in and breastfeeding

Almost no newborn benefited from natural transfusion through non-immediate cord clamping

Only 61.3% of newborns was initiated to breastfeeding within the first hour

More than 80% exposed to hypothermia during washing

Virtually all healthy newborns were suctioned unnecessarily

Objectives

➲ In general, this policy aims to ensure the provision of globally accepted evidence-based essential newborn care focusing on the first week of life.

➲ Specifically, it aims to: Guide health workers and medical practitioners in

providing evidence-based essential newborn care Define the roles and responsibilities of the

different DOH offices and other agencies in the implementation of the ENC protocol

Scope of Application

➲ AO applies to whole hierarchy of the DOH and attached agencies

➲ Also applies to: Public and private providers of health care Development partners implementing the MNCHN

strategy All health practitioners involved in maternal and

newborn care

Guiding Principles

➲ Evidence-based interventions➲ Integrated service delivery➲ Human-rights based approach➲ Life-cycle based intervention➲ Multi-sectoral collaboration

Specific Guidelines

➲ Ensure Quality Provision of Time-Bound Interventions:

This is the aspect of newborn care in RP that have not met international standards, and should therefore be re-taught and re-learned by all health care providers

Within the first 30 seconds: Dry and provide warmth to the newborn

After thorough drying: Facilitate bonding between the mother and her newborn

through skin-to-skin contact Up to 3 minutes post-delivery:

Delayed or non-immediate cord clamping Within 90 minutes of age:

Facilitate early initiation to breastfeeding Proper eye care

Specific Guidelines

➲ Non-immediate interventions Vitamin K prophylaxis Hepatitis B and BCG vaccinations Examine newborn, check for birth injuries,

malformations or defects Cord care

➲ Newborn Resuscitation➲ Additional care for small baby or twin

Specific Guidelines

➲ Unnecessary procedures Routine suctioning Early bathing/washing Footprinting Giving sugar water, formula, or other prelacteals

and the use of bottles and pacifiers Application of alcohol, medicine and other

substances on the cord stump and bandaging the cord stump or abdomen

➲ Discharge instructions

Roles and responsibilities LGU:

Adopt and implement the policy Ensure availability of budget support Conduct orientation/trainings for private and

public health workers on maternal and newborn care policies including this protocol

Monitoring and evaluation Development partners:

Support implementation of maternal and newborn care policies and activities

Coordinate and collaborate with DOH and the LGUs in the conduct of maternal and newborn care practices

The Essential Newborn Care Protocol (Unang Yakap)

The ENC Protocol

1. Within the first 30 seconds: Dry and provide warmth to the newborn

2. After thorough drying: Facilitate bonding between the mother and her newborn through skin-to-skin contact

3. Up to 3 minutes post-delivery: Delayed or non-immediate cord clamping

4. Within 90 minutes of age: Facilitate early initiation to breastfeedingProper eye care

Immediate newborn care Time band: at perineal bulging Intervention: prepare for the delivery Action:

Ensure that the delivery area is draft-free and between 25-28⁰C using room thermometer

Wash hands with clean water and soap Double glove just before delivery

Immediate Newborn Care (First 90 minutes) Time band: First 30 seconds (call out time of birth) Intervention: dry and provide warmth Action:

Use 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 baby’s breathing while drying

Note: Do not ventilate unless baby is floppy/limp/not

breathingDo not suction unless the mouth/nose are blocked with secretions or other material

Immediate Newborn Care (First 90 minutes)• Time band: if after first 30 seconds of drying, baby

is limp/floppy/not breathing• Intervention: Re-position, suction and ventilate• Action:

• Clamp and cut cord immediately• Call for help• Transfer to warm, firm surface• Inform parents that baby has difficulty breathing and

you will help the baby to breathe• Start resuscitation protocol

Notes for baby who is floppy/limp/not breathing Health worker not skilled at advanced

resuscitation (or skilled but not equipped with intubation needs): Clear the mouth Start bag/mask ventilation Refer and transport

Health worker with advanced skills at resuscitation: Intubate the baby and ventilate Refer and transport as necessary

Immediate Newborn Care (First 90 minutes)• Time band: if after 30 seconds of drying the baby

is breathing or crying• Intervention: Do skin-to-skin contact• Action:

• Avoid any manipulation (such as routine suctioning) that may cause trauma or introduce infection

Place baby prone in skin-to-skin contact on mother’s abdomen

Cover baby’s back with a blanket and head with a bonnet

Place identification band on ankle

Notes for the baby who is breathing/crying Do not separate the baby from the mother as

long as the baby does not exhibit severe chest in-drawing, gasping or apnea and the mother does not need urgent medical stabilization (e.g. hysterectomy)

Do not put the baby on a cold or wet surface Do not wipe off the vernix Do not bathe the baby earlier than 6 hours of

life Do not do footprinting

Within first 90 minutes of life Time band: 1-3 minutes Intervention: delayed or non-immediate cord

clamping Action:

Remove first set of gloves immediately prior to cord clamping

Clamp and cut the cord after cord pulsations have stopped Put ties around the cord at 2cm and 5cm from the

baby’s abdomen Cut between ties using sterile instrument Observe for oozing of blood

Note:Do not milk the cord towards the newbornAfter cord clamping, ensure 10IU oxytocin IM is

given to the mother

Within first 90 minutes of life Time band: within 90 minutes of age Intervention: Provide support for initiation of

breastfeeding Action:

Remove the first set of gloves immediately prior to cord clamping

Leave the baby on mother’s chest in SSC Observe the baby. Only when the newborn shows

feeding cues (opening of mouth, tounging, licking, rooting), make verbal suggestions to the mother to nudge her baby to move to the breast

Counsel on positioning and attachment: when the bay is ready, advise the mother to: Make sure the baby’s neck is not flexed or twisted Make sure the baby is facing the breast, with the

baby’s nose opposite her nipple and chin touching the breast

Hold newborn’s body close to her body Support the baby’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

Summary of interventions after drying the baby and placing baby in SSC Do delayed or non-immediate cord clamping

Remove 1st set of gloves immediately prior to cord clamping

Place ties around 2cm and 5cm from baby’s abdomen Oxytocin 10 IU IM to mother after cord clamping

Provide support for initiation of breastfeeding Provide additional care for a small baby or twin

(KMC) Prepare very small baby (<1.5kg) or a baby born >2

months early for referral Do eye care

Administer erythromycin/tetracycline/2.5% povidone-iodine after baby has located the breast

After first 90 minutes Does the baby have signs of illness? Is the baby visibly small?

Keep baby in SSC; cover with extra blankets; prepare for referral if <1.5kg

After 90 minutes of age (after baby has detached from breast): Examine baby Weigh baby Inject Vit. K, Hepa B and BCG

Room in and continue exclusive per demand breastfeeding

After first 90 minutes Time band: 90 minutes – 6 hours Intervention: Vit. K prophylaxis, Hepa B andf

BCG Action:

Wash hands Inject Vit. K 1mg IM Inject Hepa B and BCG

After first 90 minutes Intervention: examine the baby Action:

Thoroughly examine the baby Weigh the baby and record

After first 90 minutes Intervention: check for birth injuries, malformations or

defects Bumps on one or both sides of the head, bruises, swellling

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 baby, is

likely to disappear in 1-2 weeks and does not need special treatment

Gently handle the limb that is not moving Do not force legs into a different position

Look for malformations: cleft palate or lip, club foot, odd looking or unusual appearance, open tissue on head, abdomen or back Cover open tissue with sterile gauze before referral Refer for special treatment

After first 90 minutes Intervention: cord care

Wash hands Put nothing on the stump Fold diaper below the stump. Keep cord stump

loosely covered with clean clothes If stump is soiled, wash with clean water and soap,

then dry thoroughly with clean cloth Explain to mother she should seek care if

umbilicus is red or draining pus Teach the mother how to treat local umbilical

infection 3x a day

Home cord care Mother should wash hands with clean water

and soap before handling the baby 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 to hospital

Schedule of routine visits Postnatal visit 1: at 48-72 hours of life Postnatal visit 2: 7 days of life Immunization visit 1: at 6 weeks of life Schedule additional follow-up visits depending

on baby’s problems: After 2 days: if with breastfeeding difficulty, LBW

in 1st week of life, red umbilicus, skin infection, eye infection, thrush or other problems

After 7 days: if LBW discharged >1 week of age and gaining weight adequately