HO 3 Essential Newborn Care 06May2013

Essential Newborn Care - Evidence into

Practice

5/6/2013

Prepared by Team EINC for APDCN Faculty 1

Essential Newborn Care:

From Evidence to Practice

Ma. Lourdes Imperial, MD, FPSNbM

Co-Convener, Essential Intrapartum and Newborn Care

Objectives

By the end of this session, the learner should

• be able to discuss the problem of child mortality focusing on neonatal mortality

• know preventive interventions to address the above

• be able to discuss the immediate newborn care practices that save lives

MILLENNIUM

4 5

0

10

20

30

40

50

60

70

80

1988 1993 1998 2003 2008

• 1988-1998: 40%

• 1998-2008: 20%

• Neonatal mortality hasn’t improved

Under Five MR

Neonatal MR

DHS 88, 93, 98, 03, 08

<5 year old and Neonatal Mortality

# o

f dea

ths

per

1000

live

birt

hs

Source: WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html)

Major Causes of Under Five Deaths Western Pacific Region - 2010

Prematurity 27%

Asphyxia 26%

Infection (Sepsis+Pneumonia) 10%

Congenital Anomalies 9%

Neonatal Tetanus 2%

Diarrhea 2%

Other Conditions

Causes of Neonatal Deaths, 2010

Source: WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html)

http://www.who.int/gho/child_health/en/index.html

http://www.who.int/gho/child_health/en/index.html


Practice

5/6/2013


0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

3 out of 4 newborn deaths occur in the 1st week of life

Day of Life

# o

f d

eath

s p

er 1

000

live

bir

ths

NDHS 2003, special tabulations

Majority of newborns die due to stressful events

or conditions during labor, delivery and the

immediate postpartum period Preventive Interventions

Breastfeeding 13%

Insecticide-treated materials 7%

Complementary Feeding 6%

Zinc 4%

Clean delivery 4%

Hib Vaccine 4%

Water sanitation, hygiene 3%

Antenatal Steroids 3%

Newborn temperature management 2%

Vitamin A 2%

Tetanus Toxoid 2%

Nevirapine and replacement feeding 2%

Antibiotics for premature rupture of membranes 1%

Measles vaccine 1%

Antimalarial intermittent preventive treatment in pregnancy <1%

The Lancet Child Survival Series. Lancet 2003; 362: 65–71

What Can We Do to Save Newborn Lives?

This was considered and handled as a hospital infection control problem

Large NCR Hospital partially

closed for cleanup

25 babies reportedly died due to infection

How much colostrum did the cases receive?

Environmental cultures positive

Delaying Initiation of breastfeeding

increases risk of infection-related death Nepal 2008 N = 22,838 breastfed babies

0

1

2

3

4

5

<1 1-24 24-48 48-72 >72

Re

lati

ve

Ris

k

Hours after Birth

Mullany LC, et al. JNutr, 2008; 138(3):599-603.

Essential

Newborn Care

Protocol was

developed to

address these

issues

What Immediate

Newborn Care

Practices Save Lives?


Practice

5/6/2013


Antenatal Steroids Antenatal Steroids Betamethasone

12 mg IM q 24 hrs x 2 doses May be the preferred drug – less PVL

Dexamethasone 6 mg IM q 12 hrs x 4 doses

Have dexamethasone available in the E-cart

No additional benefit to using higher or more frequent doses

Prednisone, methylprednisolone, cortisol are unreliable

Every Newborn Has Needs

To breathe normally

To be warm

To be protected

To be fed

Providing Warmth:

Check the Environment

Check temperature of the delivery room*

Ideal temp: 25 – 28°C

Check for air drafts

Turn air conditioner off at time of delivery

*non-mercury thermometer

After a baby is born, what should be

the first action performed?

• Clamp and cut the cord A

• Dry the baby B

• Suction the baby’s mouth and nose C

• Do foot printing D

Immediate Thorough Drying Immediate drying: Stimulates Breathing

Prevents hypothermia

Hypothermia can lead to Infection

Coagulation defects

Acidosis

Delayed fetal to newborn circulatory adjustment

Hyaline membrane disease

Brain hemorrhage Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000,

Imperial College Press: London, UK. p. 207-220; TollinM,etal.. Cell Mol Life Sci 2005


Practice

5/6/2013


Immediate Thorough Drying

Dry the newborn thoroughly for at least 30 seconds

Do a quick check of breathing while drying

>95% of newborns breathe normally after birth

Follow an organized sequence

Wipe gently, do not wipe off the vernix

Remove the wet cloth, replace with a dry one

Drying should be the first action,

IMMEDIATELY

for a full 30 seconds unless the infant is both

floppy/limp and apneic

Immediate Thorough Drying

If baby not breathing, STIMULATE by DRYING!

Do not slap, shake or rub the baby

Do not ventilate unless the baby is floppy/limp and not breathing

Do not suction unless the mouth/nose are blocked by secretions

Unnecessary Suctioning

Of the 455 who were already breathing

94.9% suctioned once

84.0% suctioned more than once

Likelihood of UNNECESSARY suctioning

With training in Neonatal Resuscitation – 2.5 times

With training in Pediatric Resuscitation – 2.2 times

Prepared by Team EINC for APDCN Faculty

During drying and stimulation of the baby,

your rapid assessment shows that the baby

is crying.

What is your next action?

• Suction the baby’s mouth and nose A

• Clamp and cut the cord B

• Do skin-to-skin contact C

• Do early latching on D

Skin-to-Skin Contact General perception is purely for mother-baby

bonding

Other benefits:

B – breastfeeding success

L – lymphoid tissue system stimulation

E – exposure to maternal skin flora

S – sugar (protection from hypoglycemia)

T - thermoregulation

Moore E, et al. Cochrane Rev. 2007 Jul 18;(3). Anderson GC, et al. Cochrane Rev 2003;(2).

Brandtzaeg P. Ann N Y AcadSci 2002;964:13–45

http://upload.wikimedia.org/wikipedia/commons/thumb/6/67/Stop.svg/500px-Stop.svg.png


Practice

5/6/2013


Early Skin-to-Skin Contact If breathing or crying: Position prone on the

mother’s abdomen or chest

Cover the newborn

Dry linen for back

Bonnet for head

Temperature Check Room: 25-28 °C

Baby: 36.5 – 37.5 °C

When should the cord be

clamped after birth?

• When the cord pulsations stop A

• Between 1 and 3 minutes B • Not less than 1 minute in terms

and preterms not needing PPV C

• All of the above are appropriate D

Properly-Timed Cord Clamping

• No significant impact on

incidence of Post-Partum

Hemorrhage

• Prevents anemia in both term and preterm

babies

• Prevents bleeding n the brain in premature

babies


When preparing for delivery, don 2 pairs of gloves after thorough handwashing

Remove the first set of gloves

Palpate the umbilical cord

Wait 1-3 minutes or until cord pulsations have stopped.


Clamp again at 5 cm from the base

•Cut the cord close to the plastic clamp

•Clamp cord using a sterile plastic clamp or tie at 2 cm from the umbilical base

2 cm 3 cm


Practice

5/6/2013


Care of the Cord

• Do not milk the cord towards the baby

• Observe for the oozing of blood. If blood oozes, place a second tie between the skin and the clamp

• DRY cord care is recommended • Do not apply any substance onto the cord

• Do not use a binder or “bigkis”

Bathing the Baby in the First

6 Hours is Protective.

TRUE FALSE

Washing

Vernix

protective barrier to E.coli and Group B Strep

Early washing

Hinders crawling reflex

Can lead to hypothermia

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

Prepared by Team EINC for APDCN Faculty

What is the approximate capacity of a

newborn’s stomach?

A

B C

D

How long after birth is a

newborn ready to breastfeed?

•immediately A

•5-9 minutes B

•10-19 minutes C

•20-60 minutes D

Non-separation of Newborn from

Mother for Early Breastfeeding

Weighing, bathing, eye care, examinations, injections should be done after the first full breastfeed is completed

Postpone bathing until at least 6 hours


Practice

5/6/2013


Non-separation of

Newborn from

Mother

Never leave the mother and baby unattended

Monitor mother and baby q15 minutes in the first 1-2 hrs. Assess breathing and warmth.

Breathing: listen for grunting, look for chest in-drawing and fast breathing

Warmth: check to see if feet are cold to touch if no thermometer

Early and

Appropriate

Breastfeeding

Initiation

Leave the newborn between the mother’s breasts in continuous skin-to-skin contact

The baby may want to rest for 20-30 mins and even up to 120 minutes before showing signs of readiness to feed

Early and Appropriate

Breastfeeding Initiation

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

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

Help the mother and baby into a comfortable position

Observe the newborn

Once the newborn shows feeding cues, ask the mother to encourage her newborn to move toward the breast

Early and Appropriate

Breastfeeding Initiation

Breastfeeding Cues • eye movement under closed lids

• alertness, movements of arms and legs

• tossing, turning or wiggling

• mouthing, licking, tonguing movements

• rooting

• changes in facial expression

• squeaking noises or light fussing

!

Crying is a late sign of hunger

After delivery, mother is moved onto a stretcher with her baby and transported to Recovery Room, mother-baby ward or private room

Breastfeeding support is continued

Support Continued and

Exclusive Breastfeeding


Practice

5/6/2013


Counsel on positioning

Newborn’s neck is not flexed or twisted

Newborn is facing the breast

Newborn is close to mother’s body

Newborn’s whole body is supported



Counsel on attachment and suckling Mouth wide open Lower lip turned

outwards Baby’s chin touching

breast Suckling is slow,

deep with some pauses



Proper Breastfeeding Hold

Look for a quiet place

Find a most relaxed position for mother

Provide adequate back support

Support feet

Do not hunch shoulders

Do not “scissor” the breast

Cradle Hold

Cross Cradle Hold Cradle vs. Cross Cradle Hold


Practice

5/6/2013


Underarm Hold

Football hold

Baby is held like a

clutch bag

Nose further away

from the breast

Baby’s trunk is

secure beside

mother’s trunk

Breastfeeding after Cesarian Delivery

Side-Lying Position Side-Lying Position

E.O. 51 and its rIRR: The DON’Ts

Gifts of any sort Samples or products covered under the Milk Code Posters, other promotional materials or direct

promotions of products covered under the code within your Health Facility, Community, Barangays, Events, etc.

Sponsorships without permission from FDA Endorsements of products covered by the Milk Code

DO NOT REQUEST or ACCEPT from Milk Companies or their representatives:

Documents

HO 3 Essential Newborn Care 06May2013