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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)
Phil.ENCC
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
Phil.ENCC
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
Phil. ENCC 12
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
Phil. ENCC 17
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
Phil. ENCC
58
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.
Phil. ENCC
59
• 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