PRESENTED BY: SAVITA

M.SC NURSING

The first hour after birth has a major

influence on the survival, future death, and

well being of a newly born infant. The health

workers have an important role at this time.

The care they give during this period is

critical in helping to prevent complications

and ensuring intact survival.

Most babies are born healthy and at term. The care they receive during the first hours, days, and weeks of life can determine whether they remain healthy. Although some babies may require special attention (for example, those who are sick or premature), all babies need basic care to help ensure their survival and wellbeing.

This basic care is called essential newborn care (ENC) and includes:

Immediate care at birth

Care during the first day

Care up to 28 days

PREPARE THE BIRTH ROOM:

Clean:

Warm.

Light:

Private:

Keep Records:

Immunization cards

Mother’s records of antenatal care, labor, and delivery

Every birth should be recorded. This includes stillbirths and babies who die in the early newborn period, whether at home or in a facility.

Collect the Equipment, Supplies, and Medicines:

Warmth

Normal breathing

Mother’s milk

Protection from infection

1. CALL OUT THE TIME OF BIRTH:2. RECEIVE THE BABY ON TO A WARM, CLEAN AND DRY TOWEL

OR CLOTH ON A WARM DRY SURFACE:3. CLAMP AND CUT THE UMBILICAL CORD:4. IMMEDIATELY DRY THE BABY WITH A WARM, CLEAN TOWEL

OR PIECE OF CLOTH:5. WIPE EYES6. ASSESS THE BABY’S BREATHING WHILE DRYINGWIPE BOTH

THE EYES WITH STERILE GAUZE7. LEAVE THE BABY BETWEEN MOTHER’S BREASTS FOR SKIN-TO-

SKIN CARE8. PLACE AN IDENTITY LABEL ON BABY.9. COVER THE BABY’S HEAD WITH A CAP.COVER MOTHER AND

BABY WITH WARM CLOTH10. ENCOURAGE MOTHER TO INITIATE EXCLUSIVE

BREASTFEEDING:

AT DELIVERY

Ensure the delivery room is warm (250), with

no draughts.

Dry the baby immediately, remove the wet

cloth.

Wrap the baby with clean dry cloth.

Keep the baby close to the mother (ideally

skin to skin)

Postpone bathing/sponging for 24hours.

Keep the baby clothed and wrapped with the head covered

Minimize bathing especially in cool weather or for small babies

Keep the baby close to the mother

Use KMC for stable LBW babies and for re warming stable bigger babies

Show mother how to avoid hypothermia, how to recognize it, and how to re warm a cold baby. The mother should aim to ensure that the baby’s feet are warm to touch.

All babies must be assessed for need of

resuscitation at birth

At least 1 person skilled in providing

resuscitation must be present

Ventilation must start within 1 minute of

birth

First golden minute

Note the timeReceive baby in dry, warm linen

Is baby crying/

breathing

Routine care• Dry baby on mother’s abdomen• Provide warmth (skin to skincare)• Assure open airway if needed• Cut cord in 1-2 min• Ongoing evaluation of neonate

•Cut cord immediately and placeunder radiant warmer• Provide initial steps (Dry,position, clear airway, tactileStimulus)

Gasping/Apnea or HR<100

Initiate PPV using air/O2

Labored breathing/Cy

anosis

Insure open airway, O2, Monitoring, Consider

shifting to SCNU

YES

Birth

30 sec

60 sec

Assessment

A

Evluation

B

Yes

No

No

Yes

Yes

Initiate PPV using air/O2

Heart Rate after 5infl ations: <100 bpm?

Baby breathing well andheart rate>100 bpm

Look for Chest Rise; if Not• Reduce leaks• Ensure open airway• Consider increasing pressure

If Heart rate < 60 bpm and chest rising• Continue PPV, add 100% oxygen• Start chest compressions: 3:1

Baby breathing well andheart rate>100 bpm

Post-resuscitation

care

PPV <1 min

Observational care

Evaluation

C

Yes

No

Yes

No

If HR not detectable or <60bpmGive Adrenaline

Dry the baby thoroughly under the radiant warmer and remove wet linen.

Place the baby on its back Position the head so that it is slightly extended (to open the airway) Place a folded piece of cloth under the baby's shoulders to help maintain this position (the folded cloth should not be too thick or thin-this may cause over extension or flexion which will close the airway) Suction first the mouth and than the nose(Remember 'M' comes before 'N') Do this by gently introducing a suction tube 5 cms into the baby's mouth until the '5 cms' mark is at the baby's lips Use suction while withdrawing the tube Next introduce the suction tube upto 3 cmsinto each nostril

Use suction while withdrawing the tube Repeat suction if there is lot of mucus, amnioitic fluid or meconium but not more than two times or for a duration exceeding 20 seconds

In case of meconium and baby if non vigorous (any of the following if abnormal, i.e. heart rate > 100, good breathing, good tone)

After inserting a laryngoscope, use a 12 FG or 14 FG suction catheter to clear the

mouth and posterior pharynx so that glottis can be visualized Insert an endotracheal tube into the trachea and attach a suction source to the endotracheal tube through a special aspirator device. Apply suction for several seconds when the tube is in trachea and continue suction while withdrawing In case bradycardia is encountered the resuscitation should take priority over suction of trachea . During the initial skin to skin contact position after birth, the baby should be kept between the mother’s breasts; this would ensure early initiation of breastfeeding. Initially, the baby might want to rest and would be asleep. This rest period may vary from a few minutes to 30 or 40 minutes before the baby shows signs of wanting to breastfeed. After this period, the baby will usually open his/her mouth and start to move the head from side to side; he may also begin to dribble. These signs indicate that the baby is ready to breastfeed. The mother should be helped in feeding the baby once the baby shows these signs. Both the mother and the baby should be in a comfortable position. The baby should be put next to the mother’s breasts with his mouth opposite the nipple and areola. The baby should attach to the breast by itself when it is ready. When the baby is attached, attachment and positioning should be checked. The mother should be helped to correct anything which is not quite right.

Clean delivery (WHO’s six cleans)

Clean attendant’s hands (washed with soap)

Clean delivery surface

Clean cord cutting instrument (i.e. razor, blade)

Clean string to tie cord

Clean cloth to wrap the baby

Clean cloth to wrap mother

After delivery:

All care givers should wash hands before handling the baby

Feed only breast milk

Keep the cord clean and dry; do not apply anything

Use a clean cloth as a diaper/napkin

Wash your hands after changing diaper/napkin. Keep the baby clothed and wrapped with the head covered.

Clamp and cut cord with a sterile instrument.

Tie the cord between 2 to 3 cms from the base and cut the remaining cord.

Observe for oozing blood.

DO NOT apply any substance to stump.

DO NOT bind or bandage stump.

Leave stump uncovered.

Umbilical cord is important portal of entry for pathogenic organism.

Instruct mother not to apply anything on cord and keep it dry.

Umbilical stump must be inspected after 2-4 hours of clamping.

Bleeding may occur at this time due to shrinkage of cord and loosening of ligature

DO’S:

Clean eye immediately after birth with swabs

soaked in sterile water using separate swabs

for each eye. Clean from medial to lateral

side.

Give prophylactic eye drops within one hour

of birth as per hospital policy.

DON’TS:

Do not apply anything else (e.g. kajal) in the

eyes.

Breathing

Temperature or warmth

Color

The health personnel should monitor these three parameters every 15 min in the first hour after birth of the baby:

PARAMETER

WHAT TO LOOK FOR?

Breathing

Listen for grunting; look for chest in-drawing and fast breathing.

Warmth

Check to see if baby’s feet are cold to touch (by using your hands)

Color

Evaluate the color of the trunk and extremities.

A cold baby:

Is less active

Does not breastfeed well

Has a weak cry

Has respiratory distress

KMC is a special way of caring for the LBW babies. It improves their health and well being by promoting effective thermal control, breastfeeding, infection prevention and bonding.

The 2 components of KMC are:

Skin to skin contact:

Early continuous and prolonged skin to skin contact between the mother and her baby. The infant is placed on her mother’s chest between the breasts.

Exclusive breast feeding:

The baby on KMC is breastfed exclusively. Skin to skin contact promotes lactation and thus facilitates exclusive breast feeding.

The 2 requisites of KMC are:

Support the mother in hospital and at home

Post discharge follow up

BREASTFEEDING:

THERMAL CONTROL

EARLY DISCHARGE

LESS MORBIDITY

OTHER EFFECTS: KMC helps both infants and parents. Mothers are less stressed during kangaroo care as compared with a baby kept in incubator. They report a stronger bonding with the baby, increased confidence and a deep satisfaction that they were able to do something special for their babies. Fathers felt more relaxed, comfortable and better bonded while providing kangaroo care.

BIRTH WEIGHT>1800gm: these babies are generally stable at birth. Therefore, in most of them KMC can be initiated soon after birth.

BIRTH WEIGHT 1200-1799gm: many babies of this group have significant problems in neonatal period. It might take a few days before KMC can be initiated. If such a baby is born in a place where neonatal care services are inadequate, baby should be transferred to a proper facility after initial stabilization and appropriate management. One of the best ways of transporting small babies is by keeping them in continuous skin to skin contact with the mother/family member.

BIRTH WEIGHT<1200gm: these babies develop serious prematurity related morbidities often starting soon after birth. It may take days to weeks before baby’s condition allows initiation of KMC.

WILLINGNESS

GENERAL HEALTH AND NUTRITION: the mother should be free from serious illness to be able to provide KMC. She should receive adequate diet as recommended by her physician.

HYGIENE: the mother should maintain good hygiene-daily bath/sponge, change of clothes, hand washing and short and clean finger nails.

SUPPORTIVE FAMILY: apart from supporting the mother, family members should also be encouraged to provide KMC when mother wishes to take rest. Mother would need family’s cooperation to deal with the daily household chores while the baby is requiring KMC.

SUPPORTIVE COMMUNITY: community awareness about the benefits should be created.

CLOTHING:

KMC can be provided using any front open, light dress as per the local culture.

Baby’s clothing: baby is dressed with cap, socks, nappy and front open sleeveless shirt or ‘jhabala’.

Baby should be placed between the mother’s breasts in an upright position.

Head should be turned to one side and in a slightly extended position, it will keeps the airway open allows eye to eye contact between the mother and her baby.

Hips should be flexed and abducted in a ‘frog’ position; the arms should be flexed.

Baby’s abdomen should be at the level of the mother’s epigastrium. Mother’s breathing stimulates the baby thus reducing the occurrence of apnea.

Support the baby’s bottom with a sling/binder.

KMC can be started as soon as the baby is stable.

Skin to skin contact should start gradually in the nursery with a smooth transition from conventional care to continuous KMC.

Sessions that last less than one hour should be avoided because frequent handling may be stressful for the baby.

The length of skin to skin contacts should be gradually increased up to 24 hrs a day, interrupted only for changing diapers.

When the baby does not require intensive care, she should be transferred to the postnatal ward where KMC should be continued.

BENEFITS OF THE BABY:

Complete food, species specific

Easily digested and well absorbed

Protects against infection

Promotes emotional bonding

Better brain growth

BENEFITS TO FAMILY AND SOCIETY

Saves money

Promotes family planning

Decreases need for hospitalization

Contributes to child survival

BENEFITS TO MOTHER

Helps in involution of uterus

Delays pregnancy

Lowers risk of breast and ovarian cancer

Decreases mother’s work load

Mother’s position

Help the mother get into a comfortable

position. If she desires, use pillows or folded

blankets under her head if she is lying down

or under her arm if she is sitting.

On her back. The mother may wish for her

head and shoulders to be supported.

Side-lying. If the mother had a cesarean

delivery, this position may be most

comfortable for her.

Sitting up.

Baby’s position

The mother should hold the baby close with

both the head and the body turned to face

the breast.

The baby is facing the breast with the baby’s

nose opposite the nipple.

The baby’s whole body is fully supported. If

the baby is lower than the mother’s breast,

put the baby on a pillow or folded blanket so

the baby and the breast are at the same

level.

Ways to help the baby attach to the breast:

The mother should hold her breast in a “C-hold” (thumb on top and other fingers below the breast) with her fingers away from the nipple.

Touch the baby’s lips with the nipple.

Wait for the mouth to open wide.

Move the baby onto the breast with baby’s lower lip below the nipple. Do not move only the baby’s head but support the back of the neck and move the whole body.

Look to see how the baby is attached.

Make sure that breast tissue does not block the baby’s nose while she is sucking.

The mother should not lean over the baby. She should bring the baby to her breast, not move her breast to the baby.

LOOK FOR SIGNS OF GOOD ATTACHMENT:

More areola is visible above the baby’s mouth

than below it.

Baby’s mouth is wide open

Baby’s lower lip is turned outwards

Baby’s chin is touching the breast

CAUSES OF POOR ATTACHMENT:

Use of feeding bottles

Inexperienced mother

Lack of skilled support

Inverted nipples

POOR ATTACHMENT LEADS TO:

Pain or damage to nipple or sore nipple.

Breast milk not to removed effectively thus causing breast engorgement

Poor milk supply hence baby is not satisfied after feeding

Breast produces less milk resulting in a frustrated baby and refusal to suck. This leads to poor weight gain.

ASSESS IF THE INFANT IS SUCKING AND SWALLOWING EFFECTIVELY;

Effective sucking: infant takes several slow deep sucks followed by swallowing, and then pauses.

Ineffective sucking: Infant suckles for a short time but tries out and is unable to continue for long enough.

ASSESSING THE ADEQUACY OF

BRESTFEEDING:

Breastfeeding is considered adequate if the

baby:

Passes urine 6-8 times in 24 hours.

Goes to sleep for 2-3 hrs after the feeds.

Gains weight @ 10-15gm/kg/day.

Crosses birth weight by 2 weeks.

Assess the Baby

Assess every 30 minutes to 1 hour for at least 6 hours or until the newborn is stable and stays warm and pink. Check the baby during the first day for the following:

Breathing: The normal baby breathes 30-60 times a minute with no gasping, grunting, or indrawing of the chest.

Warmth: Check if the baby is warm:Use a thermometer to take an axillary

temperature or Feel the baby’s abdomen or back with your hand and compare his temperature to that of a well person.

Color: Check that the tongue, lips, and mucous membranes (inside the mouth) are pink.

Bleeding: Check the cord for bleeding. As the cord dries, the tie may become loose. If the tie is loose, put on gloves and tie the cord again tightly. Assessment of the baby on the first day also includes a complete history and physical.

On the day of birth, give vitamin K, 1 mg IM. Give the first immunizations according to your country’s immunization schedule and protocols. Recommended newborn immunizations include:

BCG

Polio

Hepatitis B

These can all be given on the day of birth or as soon as possible. See Appendix A for Infant Immunization Schedule and a list of websites for up-to-date information. Make sure the birth is recorded and a birth certificate is prepared. Record all findings and treatments, and record all stillbirths and early newborn deaths.

Take a History

A healthy mother is very important for optimal growth development and birth of the infant. The care a woman receives in pregnancy, labor, and birth will affect the health of the newborn. Therefore be sure to check the mother’s records (if available). It is important to collect information on the mother’s and baby’s history to know if the baby needs special attention and to help determine what care to give the newborn

Do a Physical Examination

The purpose of the physical exam is to find out if the baby is healthy and if the baby has any health needs or problems. Wait until the baby is able to keep a normal body temperature (the baby feels warm or has an

axillary temperature of 36-37 °C (96.8-98.6 °F) before doing a newborn examination. You can wait up to 6 hours. Before starting the exam, prepare the following equipment:

Thermometer

Watch or clock with a second hand

Thank you