KEY PRINCIPLES OF NEWBORN CARE AT

BIRTH

1) PREPARATION FOR DELIVERY

2) DRYING3) ASSESSMENT OF STATE4) CLASSIFICATION , PRECAUTIONS5) CLEAN THE AIRWAYS AS NEEDED6) SKIN TO SKIN CONTACT7) CORD CLAMPING

steps 2-7 are performed 1 minute from birth.

6) EARLY START OF BREAST FEEDING7) PROPHYLACTIC ACTIVITIES8) OBSERVATION OF MOTHER AND

NEWBORN 9) ASSESSMENT , MEASURING,

EXMINATION OF NEWBORN10) PERFORMING ROOMING-IN IN

DAYTIME AND AT NIGHT

PREPARATIONS FOR DELIVERY

ALL DELIVERY EQUIPMENT & SUPPLIES INCLUDING NEWBORN RESUSCITATION EQUIPMENT SHOULD BE READY(E.g.: The bag & mask of resuscitation. A baby needing help to breathe could easily die or suffer brain damage if a bag and mask is not working properly. so make sure all equipment is checked daily well BEFORE you need to use it)

WARM & CLEAN DELIVERY ROOM, ROOM TEM: 250C

WARM BABY CLOTHS,CAP & SOCKS(The temperature inside the mother’s womb is 38 C, once the baby is born it is in a much colder environment and immediately starts to lose heat)

Resuscitation equipment should always be close to where the baby is being born and health workers must know how to use it quickly and correctly. Equipment must be checked Daily and well before a delivery takes place.

DRY & ASSESS:

IMMEDIATELY DRY THE NEWBORN WITH A DRY TOWEL. ASSESS: HEART RATE, BREATHING WHILE DRYING.(to identify who

need resuscitation)(Not all babies cry after delivery, but it doesn’t mean that they have got asphyxia: if baby breathes regularly with frequency of 30-60 per minute but does not cry, it means the baby is not asphyxic. This baby stays on mother’s belly while provided regular care)

SKIN TO SKIN CONTACT: CONTAMINATION BY MOTHER’S MICROFLORA & TO PREVENT HYPOTHERMIA START OF EARLY BREAST FEEDING

CORD CLAMPING: MOST OPTIMAL TIME – END OF 1st MINUTE FROM DELIVERY IF THE NEWBORN IS IN MOTHERS ABDOMEN, THE CORD CLAMPING SHOULD BE

POSTPONED UNTIL THE PULSATION STOPS. EARLY CORD CLAMPING IS PERMITTED ONLY IN URGENT CASES (IF RESUSCITATION

IS NEEDED)

DELAYED CORD CLAMPING results in a shift of blood from the placenta to the infant. Placental transfusion was about 80% at 1 minute and was practically completed at 3 minutes. Placental transfusion associated with delayed cord clamping provides additional iron to the infant's reserves and may reduce the frequency of IRON DEFICIENCY ANEMIA later in infancy.

Delaying cord clamping also favors early contact between mother and baby. In addition, it also reduces splashing of blood, which helps protect the birth attendant in areas where HIV infection is common.

Delaying cord clamping by 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion and less intraventricular haemorrhage.

START OF EARLY BREAST FEEDING: SKIN TO SKIN CONTACT

BABY’S ATTATCHMENT TO BREAST WHEN HE IS READY

(Council mother how to attach her baby to the breast when he is ready)

CHECK THE CORRECTNESS OF ATTATCHMENT & FEEDING

GIVE THE NEWBORN THE OPPURTUNITY TO SUCK FROM BOTH BREAST S LONG AS THEY NEED

ROOMING IN MOTHR & NEWBORN AS LONG AS POSSIBLE

POSTPONE WEIGHING,WASHING etc. UPTO FIRST FEEDING

Put the baby next to the breast with its mouth opposite the nipple and areola.

Let the baby attach to the breast by itself when it is ready.

Do not let a health worker attach the baby. When the baby is attached, check that the

attachment and positioning are correct, and help the mother to correct anything which is not quite right and to help support her baby if needed.

Help the mother and baby into a comfortable position Tell the mother, when her baby begins to show signs

of wanting to feed, to help it into a position where it can easily reach her breast.

This can take up to 1 hour after delivery. The baby will open its mouth and start to move its

head from side to side, it may also begin to dribble.

The baby should have no other foods or drinks apart from colostrum, as these reduce the amounts of protective and growth factors the baby receives from this important first milk.

Colostrum is produced in small amounts. It contains protective factors in a concentrated form which the newborn baby needs to

keep him healthy. It is a natural form of immunization. Let the baby feed for as long as it wants, with no interruption. When it finishes feeding on

one breast let it feed from the other breast. Keep the mother and baby together for as long as it is possible after delivery. Unless there is a good medical reason delay the initial routine birth procedures, such as

weighing until after the first feed. This first time together is very important in helping the mother and baby to get to know

each other and to form a close loving relationship. Maternal procedures can be done with a baby in skin-to-skin contact unless she needs

treatment requiring sedation.

PROPHYLACTIC ACTIVITIES:CONJUNCTIVITIS:

1% SILVER NITRATE / 0.5% ERYTHROMYCIN OINMENT / 1% TETRACYCLINE IS USED PREVENTION OF NEWBORN OPHTHALMIA- 1% TETRACYCLINE 1% TETRACYCLINE IS EFFECTIVE AGAINST Neisseria gonorrhea & Chlamydia trachomatis &

HAVE NO SIDE EFFECTS For effective prevention, the ointment must be applied with in 1 hour after delivery

USE OF VITAMIN-K:

TO PREVENT BLEEDING & HEMORRHAGIC DISEASE

(A single dose (1.0 mg) of intramuscular vitamin K after birth is effective in the prevention of classic HDN. Either intramuscular or oral (1.0 mg) vitamin K prophylaxis improves biochemical indices of coagulation status at 1-7 days)

THERMAL REGULATIONS REQUIRED TO COMFORT THE NEW BORN:

A NEWBORN CANNOT REGULATE HIS TEMPERATURE AND NEED PROTECTION FROM HYPOTHERMIA

PROTECT TH BABY FROM DRAUGHTROOM TEMPERATURE >25IMMEDIATE DRYINGSKIN-SKIN CONTACTEARLY START OF BREAST FEEDINGAPPROPRIATE CLOTHINGROOMING-INWARM TRANSPORTATIONRESUSCITATION IN WARM CONDITIONS

4 WAYS OF LOSING WARMTH IN NEWBORN:

CONVECTION It is heat exchange with the surrounding air. Common problems: temperature in delivery rooms, draughts.

DURING RESUSCITATION: Fan, air conditioner, radiant heater is blocked by those performing resuscitation(Take the baby away from an open door or window).

RADIATION It is losing heat due to the neighboring object, even if the baby is not in direct contact with it. Not covering the baby’s head so that its body heat is able to pass into the surrounding air. Common problems: Cold walls or windows. Changing tables and cradles are incorrectly located.Cold equipment (Put a hat onto the baby’s head)

EVAPORATION

It is heat loss due to evaporation of fluid from the skin.

Common problems: The skin of the babies after birth is wet. Insufficient drying. No clothes and blankets.Not drying the baby after delivery when it is wet. (Dry the baby with a towel)

CONDUCTION

It is losing heat due to the contact with, cold or wet surfaces.

Common problems: Contact with cold, wet linen, weighting on the scale, contact with cold changing table,leaving the baby on a cold surface, particularly metal (as seen in the previous overhead). (Take the baby off the table top, wrap it up and indicate you have put it in a cot temporarily)

HYPOTHERMIA CAN LEAD TO :

REDUCTION OF OXYGEN REDUCTION OF GLUCOSE LEVEL REDUCTION OF SUCKING REFLEX & THUS IT CAUSES RESPIRATORY DISTRESS, HYPOGLYCEIA, ACIDOSIS. WHICH CAN LEAD TO BLEEDING, INFECTIONS, BRAIN INJURY, CONVULSIONS etc.

HYPOTHERMIA OF NEWBORN:

WHEN TEMPERATURE GOES BELOW NORMAL RANGE, TAKE PRECAUTIONS TO WARM THE BODY.

APPROPRIATE MEASURE SHOULD BE TAKEN TO PREVENT SEVERE HYPOTHERMIA

INITIAL ASSESSMENT

BASED ON APGAR (ACTIVITY PULSE GRIMACE APPEARANCE RESPIRATION) SCOREAt the end of 1 and 5 minutes; if at the end of 1 and 5 minutes the baby’s score is less than 6, the baby needs to be re-assessed at 15 and 20 minutes until we get 7 points and more. The APGAR SCORE is not the indication for resuscitation, as resuscitation is to be started immediately after the birth of the baby.

BreathingCheck whether the baby is breathing. If so, evaluate the rate, depth and symmetry of breathing together with any evidence of an abnormal breathing pattern such as gasping or grunting.

Heart rateThis is best assessed by listening to the apex beat with a stethoscope. Feeling the pulse in the base of the umbilical cord is often effective but can be misleading, cord pulsation is only reliable if found to be more than 100 beats per minute (bpm). For babies requiring resuscitation and/or continued respiratory support, a modern pulse oximeter can give an accurate heart rate.

ColourColour is a poor means of judging oxygenation, which is better assessed using pulse oximetry if possible. A healthy baby is born blue but starts to become pink within 30 s of the onset of effective breathing. Peripheral cyanosis is common and does not, by itself, indicate hypoxemia. Persistent pallor despite ventilation may indicate significant acidosis or rarely hypovolaemia. Although colour is a poor method of judging oxygenation, it should not be ignored: if a baby appears blue check oxygenation with a pulse oximeter.

ToneA very floppy baby is likely to be unconscious and will need ventilatory support.

Tactile stimulationDrying the baby usually produces enough stimulation to induce effective breathing. Avoid more vigorous methods of stimulation. If the baby fails to establish spontaneous and effective breaths following a brief period of stimulation, further support will be required.

Classification according to initial assessment

.On the basis of the initial assessment, the baby can be placed into one of three groups:

• Vigorous breathing or crying• Good tone• Heart rate higher than 100 min−1

•This baby requires no intervention other than drying, wrapping in a warm towel and, where appropriate, handing to the mother. The baby will remain warm through skin-to-skin contact with mother under a cover, and may be put to the breast at this stage.

• Breathing inadequately or apnoeic• Normal or reduced tone• Heart rate less than 100 min−1

•Dry and wrap. This baby may improve with mask inflation but if this does not increase the heart rate adequately, may also require chest compressions.

• Breathing inadequately or apnoeic• Floppy• Low or undetectable heart rate• Often pale suggesting poor perfusion

RESUSCITATION:

Airway

Place the baby on his or her back with the head in a neutral position .A 2 cm thickness of the blanket or towel placed under the baby's shoulder may be helpful in maintaining proper head position. In floppy babies application of jaw thrust or the use of an appropriately sized oro-pharyngeal airway may be helpful in opening the airway.

Suction is needed only if the airway is obstructed. Obstruction may be caused by particulate meconium but can also be caused by blood clots, thick tenacious mucus or vernix even in deliveries where meconium staining is not present. However, aggressive pharyngeal suction can delay the onset of spontaneous breathing and cause laryngeal spasm and vagal bradycardia. The presence of thick meconium in a non-vigorous baby is the only indication for considering immediate suction of the oropharynx. If suction is attempted this is best done under direct vision. Connect a 12–14 FG suction catheter, or a Yankauer sucker, to a suction source not exceeding minus 100 mm Hg.

Breathing

After initial steps at birth, if breathing efforts are absent or inadequate, lung aerationis the priority. In term babies, begin resuscitation with air. The primary measure of adequate initial lung inflation is a prompt improvement in heart rate; assess chest wall movement if heart rate does not improve.

For the first five inflation breaths maintain the initial inflation pressure for 2–3 s. This will help lung expansion. Most babies needing resuscitation at birth will respond with a rapid increase in heart rate within 30 s of lung inflation. If the heart rate increases but the baby is not breathing adequately, ventilate at a rate of about 30 breaths min−1 allowing approximately 1 s for each inflation, until there is adequate spontaneous breathing.

Adequate passive ventilation is usually indicated by either a rapidly increasing heart rate or a heart rate that is maintained faster than 100 min−1. If the baby does not respond in this way the most likely cause is inadequate airway control or inadequate ventilation. Look for passive chest movement in time with inflation efforts; if these are present then lung aeration has been achieved. If these are absent then airway control and lung aeration has not been confirmed. Without adequate lung aeration, chest compressions will be ineffective; therefore, confirm lung aeration before progressing to circulatory support.

Some practitioners will ensure airway control by tracheal intubation, but this requires training and experience. If this skill is not available and the heart rate is decreasing, re-evaluate the airway position and deliver inflation breaths while summoning a colleague with intubation skills.Continue ventilatory support until the baby has established normal regular breathing.

Circulatory support

Circulatory support with chest compressions is effective only if the lungs have first been successfully inflated. Give chest compressions if the heart rate is less than 60 min−1 despite adequate ventilation.

The most effective technique for providing chest compressions is to place the two thumbs side by side over the lower third of the sternum just below an imaginary line joining the nipples, with the fingers encircling the torso and supporting the back .(An alternative way to find the correct position of the thumbs is to identify the xiphi-sternum and then to place the thumbs on the sternum one finger's breadth above this point.) The sternum is compressed to a depth of approximately one-third of the anterior–posterior diameter of the chest allowing the chest wall to return to its relaxed position between compressions.

Use a ratio of three compressions to one ventilation, aiming to achieve approximately 120 events per minute, i.e. approximately 90 compressions and 30 ventilations.

Check the heart rate after about 30 s and every 30 s thereafter.

Discontinue chest compressions when the spontaneous heart rate is faster than 60 min−1.

Drugs

Drugs are rarely indicated in resuscitation of the newly born infant. Bradycardia in the newborn infant is usually caused by inadequate lung inflation or profound hypoxia, and establishing adequate ventilation is the most important step to correct it. However, if the heart rate remains less than 60 min−1 despite adequate ventilation and chest compressions, it is reasonable to consider the use of drugs. These are best given via an umbilical venous catheter

Stopping resuscitation

Local and national committees will determine the indications for stopping resuscitation. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min, it is then appropriate to consider stopping resuscitation. The decision to continue resuscitation efforts when the heart rate has been undetectable for longer than 10 min is often complex and may be influenced by issues such as the presumed aetiology, the gestation of the baby, the potential reversibility of the situation, and the parents’ previous expressed feelings about acceptable risk of morbidity.In cases where the heart rate is less than 60 min−1 at birth and does not improve after 10 or 15 min of continuous and apparently adequate resuscitative efforts, the choice is much less clear. In this situation there is insufficient evidence about outcome to enable firm guidance on whether to withhold or to continue resuscitation.

Communication with the parents

It is important that the team caring for the newborn baby informs the parents of the baby's progress. At delivery, adhere to the routine local plan and, if possible, hand the baby to the mother at the earliest opportunity. If resuscitation is required inform the parents of the procedures undertaken and why they were required.Decisions to discontinue resuscitation should ideally involve senior paediatric staff. Whenever possible, the decision to attempt resuscitation of an extremely preterm baby should be taken in close consultation with the parents and senior paediatric and obstetric staff. Where a difficulty has been foreseen, for example in the case of severe congenital malformation, discuss the options and prognosis with the parents, midwives, obstetricians and birth attendants before delivery. Record carefully all discussions and decisions in the mother's notes prior to delivery and in the baby's records after birth.