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 hasnt improved
Under Five MR
Neonatal MR
DHS 88, 93, 98, 03, 08
<5 year old and Neonatal Mortality
#

o
f

d
e
a
t
h
s

p
e
r

1
0
0
0

l
i
v
e

b
i
r
t
h
s


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)
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 2
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
e
a
t
h
s

p
e
r

1
0
0
0

l
i
v
e

b
i
r
t
h
s


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: 6571
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
R
e
l
a
t
i
v
e

R
i
s
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?
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 3
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 28C
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 babys 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
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 4
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 babys 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;964:1345
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 5
Early Skin-to-Skin Contact
If breathing or crying:
Position prone on the
mothers 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
Properly-Timed Cord Clamping
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.
Properly-Timed Cord Clamping
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
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 6
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
newborns 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
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 7
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 mothers
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
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 8
Counsel on positioning
Newborns neck is not
flexed or twisted
Newborn is facing the
breast
Newborn is close to
mothers body
Newborns whole body is
supported
Support Continued and
Exclusive Breastfeeding
Counsel on
attachment and
suckling
Mouth wide open
Lower lip turned
outwards
Babys chin touching
breast
Suckling is slow,
deep with some
pauses

Support Continued and
Exclusive Breastfeeding
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
Essential Newborn Care - Evidence into
Practice
5/6/2013
Prepared by Team EINC for APDCN Faculty 9
Underarm Hold
Football hold
Baby is held like a
clutch bag
Nose further away
from the breast
Babys trunk is
secure beside
mothers trunk
Breastfeeding after Cesarian Delivery
Side-Lying Position Side-Lying Position
E.O. 51 and its rIRR: The DONTs
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: