CHILD HEALTH DIVISION

Ministry of Health and Family Welfare

Government of India

NAVJAAT SHISHU SURAKSHA KARYAKRAM 2020

FLIP CHART

RESUSCITATION AND ESSENTIAL NEWBORN CARE

 INTRODUCTION TO THE REVISED NSSK PACKAGE
Time: 10 minutes
Introduce yourself and ask the participants to introduce themselves and share information about their role & level of health facility.
After the introduction, provide an overview of the two days of the training programme.

EXPLAIN EACH BRIEFLY • Routine care

The facilitator should elaborate regarding teaching methods used, • Initial steps
the skills to be practiced ‘hands on’ and the key aspects that will • Resuscitation using bag and mask
be covered in this training. • Monitoring
• Technique of KMC
TRAINING METHODS • Technique of breastfeeding
• Discussion using flip chart & wall chart
• Skills practice on mannequin, equipment KEY ASPECTS COVERED
• Role plays 1. Preparation for receiving a baby in the LR/OT
• No reading 2. Routine care
3. Resuscitation with bag & mask
4. Observational care for babies who received initial
HANDS ON PRACTICE
steps/Bag and mask ventilation for less than one minute
It is mandatory for each participant to practice
5. When to seek help
• Receiving baby in dry warm linen
6. Admission/Referral/Discharge
• Cord clamping

01
 CHILD HEALTH DIVISION
Ministry of Health and Family Welfare
Government of India

NAVJAAT SHISHU SURAKSHA KARYAKRAM 2020

FLIP CHART

RESUSCITATION AND ESSENTIAL NEWBORN CARE

01
 OBJECTIVES FOR DAY 1
Time: 30 minutes
The facilitator on Day 1 should make the participants understand the revised
algorithm of NSSK. Show participants the algorithm on the wall chart and
inform them that the same will be referred to, during this training. Each
participant should learn to practice how to effectively ventilate using bag
and mask:

1. Ensure you have the resuscitation tray, mannequin and wall chart ready
2. Show front of chart and ask questions written on back of flip chart in bold
3. Always summarize with key messages at the end of the page
02
ALGORITHM FOR NEONATAL RESUSCITATION

Birth
• Note the time of birth
• Place baby prone on mother’s abdomen
Routine care
• Continue skin to skin care
Is the baby breathing/crying Yes • Turn head to one side & wipe secretions, if visible
• Dry baby, discard wet linen
No

GOLDEN MINUTE
• Cover baby and mother together
•  lamp & Cut cord immediately
C • Clamp & Cut cord between 1-3 mins
• Place under radiant warmer • Initiate breastfeeding
• Position head with neck slightly extended • Check Breathing, Colour and Activity
• Clear airway by suctioning mouth then
nose if required
• Dry baby, discard wet linen
• Stimulate by rubbing the back
• Reposition Observational Care with Mother
•  lace the baby prone between the mother’s breasts.
P
• Cover baby and mother together.
Assess Breathing • Initiate breastfeeding.
Breathing well
• Monitor neonate (temperature, heart rate, breathing and colour,
Not Breathing Well
every 15 minutes in first hour and then every
• Initiate bag and mask ventilation using room air. 30 minutes in next one hour).
• Give 5 ventilatory breaths and look for chest rise.
• If no chest rise after 5 breaths, take corrective steps.
• If adequate chest rise, continue for 30 seconds

BEYOND GOLDEN MINUTE

Assess Breathing
Breathing well
Not Breathing Well
• Call for Help*
• Continue bag and mask ventilation
Assess Heart Rate
Yes Assess Breathing
HR ≥ 100/min Breathing well Refer to SNCU
No
• Continue bag and mask ventilation using 100% oxygen (if HR<100bpm).
• If help* available, then intubate, provide chest compression and Not breathing well *Help - A person skilled to provide
medication, as required chest compression, intubation and
medication
Organize referral to SNCU and continue ventilation (if not breathing well)

02
 SKILLED ATTENDANT AT BIRTH MAKES A DIFFERENCE

Time: 15 minutes
Ask the participants Discuss
a) Baby 1 & 2 have just been delivered. Enumerate the differences that How often do you attend births at your health facility?
you observe between baby 1 & baby 2 (Ask each participant to respond)
Baby 1 appears to be crying lustily and is pink in colour
Baby 2 appears not crying, looks blue and limp/flaccid
Ask them to share their experiences from their health facility with respect
You may narrate case studies to describe the situations in which the outcome to care of babies at the time of birth to understand the preparedness and
is a vigorously crying baby or a baby that has not cried immediately after ground realities
birth and is limp
b) What do you think can make a difference?
Presence of a skilled attendant who follows the right steps, performs these
steps correctly and within the critical time period, can lead to establishment
of respiration in an asphyxiated baby

KEY MESSAGES:
1. Most babies cry at birth but 1 in 10 babies needs help to breathe. So, it is important to anticipate problems and be prepared to perform
resuscitation at every delivery.
2. 90% of the babies will not require any support and will benefit from routine care.
3. Presence of a skilled provider can make a difference to a baby’s survival.
4. During this training you will practice the skills required to effectively resuscitate a neonate and provide care after birth.

03
ENUMERATE THE DIFFERENCES IN these two BABIES?

Baby 1 Baby 2
03
 PREPARATION OF THE DELIVERY ROOM

Time: 10 minutes
Ask the participants to explain ‘what do you see on the flip chart’. Ask each participant to enumerate steps towards:

1. Maintaining delivery room temperature 2. Providing privacy to mothers in labour

Explain Discuss
Switch off the fans to avoid direct draught of air over the baby Ask participants to share their experiences from
Close all the doors and windows and draw the curtains their health facility with respect to privacy during child
birth
Switch on the radiant warmer 20 minutes before the delivery and place two baby sheets in
the bassinet before delivery Different participants will give different
Temperature: A well lit room with temperature in the range of 26‐28°C. Use heating/cooling views on privacy
devices depending on local conditions
All the trays with the recommended contents as per MNH Tool kit namely Baby tray,
Medicine tray should be inspected in the labour room/OT prior to delivery

KEY MESSAGES:
1. Ensure privacy and empathetic care to all the pregnant women who are in labour.
2. Keep the Temperature of the delivery room between 26‐28°C with the help of heating/cooling devices depending on the outside ambient temperature.

04
E DELIVERY PREPARATION
ROOM: OF THE DELIVERY ROOM:
PREPARATION OF THE DELIVERY ROOM: WHAT DO YOU SPECIFICALLY
FICALLY NOTE
WHATABOUT
DO YOU OF
PREPARATION PRIVACY
SPECIFICALLY
THE NOTE
DELIVERY AND
ABOUT
ROOM: ROOM
PRIVACY TEMPERATURE?
AND ROOM
NOTE ABOUT room temperature and privacy?
TEMPERATURE?
WHAT DO YOU SPECIFICALLY NOTE ABOUT PRIVACY AND ROOM TEMPERATURE?

1 2 THERMOMETER
°C °F
50 120
40 100
30 80
Switch off fans 20
1. Switch Off Fans 60
1. Switch Off Fans 10
3 40
2. Maintain Room Temperature
00 Temperature
2. Maintain Room
Between 26=280 C 20
Between 26=2810 C
20 0
30 20
40 40

Maintain room temperature

Labour room with curtained cabins between 26-28°c
3. Labour room with curtained cabins 04 2. Maintain Room Temperature
 PREPAREDNESS FOR BIRTH: EQUIPMENT

Time: 15 minutes
Ask the participants to enumerate the items shown in the flip chart

1. Baby tray with two clean, warm towels/ sheets, shoulder roll, Mucous extractor (Dee Lee’s), gloves, cord clamp/tie, cotton
swabs,
Needle (26 gauge) and syringe(1ml), Inj. Vitamin K‐1
2. Clean cord cutting equipment (Scissors/New blade)
3. Wall clock with seconds hand
4. Functional self‐ inflating bag (240 & 500 mL); Infant masks in two sizes: size ‘1’ for normal weight baby
Discuss &
and ‘0’ for small baby
Demonstrate
5. A functional radiant warmer (tell the participants that they will learn about it in greater detail at a later
stage in the training)
6. Oxygen source
7. Stethoscope
8. Suction machine (Electrical/foot operated) (suction pressure 80‐100 mmHg) and Suction catheters 10 F and 12 F
9. A folded piece of cloth to be used as shoulder roll during resuscitation (1/2 to 3/4th” thick)

KEY MESSAGES:
1. Ensure all essential equipment is in place and in working condition before every delivery.
2. Discard mucus extractor and suction catheter after single use and replace with a new one.
3. Disinfect bag and mask, stethoscope, radiant warmer and suction machine after use.

05
 WHAT EQUIPMENTS ARE NEEDED FOR BIRTH PREPARATION?
WHAT EQUIPMENT IS NEEDED
WHAT EQUIPMENTS FOR
ARE NEEDED BIRTH
FOR BIRTH PREPARATION?
PREPARATION?
WHAT EQUIPMENTS ARE NEEDED FOR BIRTH PREPARATION?
WHAT EQUIPMENTS ARE NEEDED FOR BIRTH PREPARATION?

WHAT EQUIPMENTS ARE NEEDED FOR BIRTH PREPARATION?

WHAT EQUIPMENTS ARE NEEDED FOR BIRTH PREPARATION?

05
 INFECTION PREVENTION

Time: 10 minutes
Ask the participants: what steps do you take to prevent infection ?
Discuss with the participants Demonstrate
Cleans Discuss how these cleans can be achieved at
• Clean hands of the attendant conducting the delivery: by strictly following hand washing procedure. Wear sterile gloves for each participant’s work place
vaginal examination or when handling the baby
• Clean surface: ensure that the table, McIntosh, sheet and mattress are clean at facilities, the delivery surface should be cleaned
and then wiped with a 0.5% solution of chlorine after each use. Clean towels/sheets to dry the baby and then wrap the baby
• Clean cord cut; always use a sterile blade or scissors.
• Clean cord tie: use disposable cord clamp or clean autoclaved thread for all babies
• Clean cord care: do not apply anything on the cord, it should be kept clean and dry at all times
• Clean perineum: feces should be wiped away and the perineum washed prior to the birth (mother can shower or bathe)
Basic requirements for hand washing include: Hand washing steps
• 24*7 clean running water supply
• Soap, preferably in a soap dispenser
• Elbow operated taps
 dherence to good housekeeping and asepsis routine:
A
• Cleaning the equipment, floor & walls as per guidelines, ensuring hand washing and use of personal protective gear
Clean equipment:
• Use Disposables and disinfect reusables

KEY MESSAGES:
1. Following 6 CLEANS is the most effective way of preventing infection.
2. Hand washing is critical even when you wear gloves.

06
 INFECTION
INFECTION PREVENTION: WHAT CAN WE DO?PREVENTION: WHAT CAN WE DO?
INFECTION PREVENTION: WHAT CAN WE DO?

06
 ACTIONS AT BIRTH
Time: 20 minutes
Introduce the flowchart for neonatal resuscitation (displayed prominently as a wall chart in the room for each group)
Ask: What steps should be followed?
Picture Actions Explain Demonstrate and Practice
1. Note the exact time of birth Important for records and start of first golden minute Demonstrate steps
2. Place baby prone on mother’s The best way to keep the newborn warm is by providing a. Noting the time of birth
abdomen (Skin to skin contact) skin to skin contact on the mother’s abdomen b. Placing the baby prone on mother’s abdomen
3. Observe: If the baby is breathing Yes: Proceed for routine care c. Observing if the baby is breathing/crying
or crying? No: Proceed for resuscitation d. Deciding care needed
Participants practice in pairs

KEY MESSAGES:
1. Note time of birth 3. Observe if the baby is breathing/crying
2. Place baby prone on mother’s abdomen

07
 WHAT ACTIONS ARE TAKEN AT BIRTH?

Birth ROUTINE CARE

• Note the exact time of birth BABIES
• Is the baby WHO CRY AT
breathing/crying – BIRTH REQUIRE ROU
YES/NO
Birth
WHAT ACTIONS ARE TAKEN AT BIRTH?
• Place the baby prone on mother’s abdomen  Note the exact time of birth
 Receive baby in warm dry clean linen
 Is the baby breathing/crying – YES/NO
 Decide care needed

1 2

Place
1. Place baby
baby prone
prone on on mother’s
mother’s abdomen
Notetime
1. Note time of birth
of birth 2. Receive baby in warm, dry linen
abdomen

07
 ROUTINE CARE FOR BABIES WHO CRY AT BIRTH

Time: 30 minutes
Ask: What steps do you see in the picture?
Discuss with the participants the standard protocol to be followed if baby cries at birth. Proceed for routine care.

Picture Actions Explain Demonstrate

1. Continue skin to skin care, turn
head to one side and wipe secretions,
if visible, dry the baby, discard
wet linen, cover mother and baby
together.
2. Clamp & cut cord between 1‐3
minutes
3. Initiate breastfeeding
4. Keep mother and baby covered and
observe breathing,colour and activity
Advantages: baby remains warm and facilitates the initiation of breastfeeding. Demonstrate on
Turn head to one side and clear visible secretions by wiping the mouth and nose mannequin: Turning
to ensure an open airway. Drying the baby prevents hypothermia. head to one side,
wiping visible
secretions from mouth
Place the cord clamp and cut within 1‐3 minutes using a sterile blade/scissors and nose, drying the
baby and cutting of
Normal term and preterm infants shows significant benefits of delayed cord
the cord.
clamping in improving haemoglobin levels
Demonstrate how to
Early initiation of breastfeeding helps in establishing as well as sustaining cover the mother baby
lactation. dyad together.
Some mothers may need help for early initiation of breastfeeding
Covering the baby and mother together keeps the baby warm
Observing the baby’s breathing,colour and activity helps determine smooth
transition and identifies the need for resuscitation

KEY MESSAGES:
Skin‐to‐skin contact helps to keep the baby warm, establishes breastfeeding and encourages mother‐ child bonding.
08
 Routine care
CARE ROUTINE CARE
• Place baby prone on mother’s abdomen
HO CRY AT BIRTH REQUIRE
BABIES ROUTINE
WHOCARE
CRY AT• BIRTH
Dry the baby REQUIRE ROUTINE CARE
• Turn head to one side

• Discard wet linen

• Cover mother and baby with dry warm sheet

1 2
•
•
Cut cord between 1-3 minutes
Initiate breast feeding Routine Care
• Continue skin to skin care, turn head to one side,
wipe secretions if visible, dry the baby, discard wet
linen
• Cover mother and baby together
Place the baby prone between the mother’s
ATIONAL CARE breast. Cover baby and mother together. • Cut cord between 1-3 minutes
TH MOTHER ? Initiate breastfeeding. • Initiate breastfeeding
Monitor neonate (temperature, heart rate,
breathing and colour every 30 minutes. • Check breathing, colour and activity
Continue skin to skin care, turn head to one
side, wipe secretions if visible, dry the baby
2. Turn head to one side and dry the baby
er’s abdomen Cut cord within 1‐3 minutes

3 4

Keep mother and

4. Cover baby covered
mother and babyand
s Initiate breastfeeding
Initiate breastfeeding observe breathing, colour and activity
08
 BABY WHO DOES NOT CRY

Time: 30 minutes
Ask: What steps do you take when a baby does not cry at birth?
Picture Actions Explain Demonstrate and Practice
1. Clamp and cut The cord should be clamped and cut immediately to start effective resuscitation
cord immediately
2. Place baby under The baby is placed under pre heated radiant warmer
radiant warmer
3. Position head Place a shoulder roll – rolled cloth 1/2 to 3/4 th inch under the shoulder. Positioning helps in aligning the airway Show a shoulder roll and how to use
with neck slightly in one plane for facilitating air entry it for positioning the baby
extended
4. Clear airway Suctioning should be done only if the mouth or nose is full of secretions. Use 10 F catheter for clear liquor. Demonstrate how to use Dee Lee
Bigger size (12 F) suction catheter is needed to remove meconium. This is because meconium is particulate mucus extractor
and its removal needs wide bore catheters. If using electrical machine, then suction pressure should be kept at
80‐100 mmHg
Remember to always do suction of mouth first and then nose
5. Dry the baby and Drying prevents heat loss and also stimulates the neonate to breathe Demonstrate how to dry a neonate
discard wet linen after birth
6. Stimulate by Stimulate by rubbing back 2‐3 times Demonstrate and practice
rubbing back Reiterate that no other method is to be followed for stimulating the baby stimulation
7. Reposition Check if the above actions have disturbed the position. Reposition and ensure that the neck is slightly extended
8. Assess breathing Breathing well - Provide observational care
Not breathing - Initiate positive pressure ventilation

KEY MESSAGES:
If the newborn does not start breathing despite clearing airway, drying and stimulation, initiate positive pressure ventilation.
09
 WHAT ACTIONS WILL YOU TAKE IF BABY DOES NOT CRY?
Clamp and cut the
cord immediately
1 2
Clear airway if required (mouth before nose)
stiimulate to breathe
4
Place baby under Position head by placing a shoulder
radiant warmer roll beneath the shoulders •  lamp & cut cord immediately
C
• Place baby under radiant warmer
• Position head by placing a
shoulder roll beneath the
shoulders
• Clear airway by suctioning
mouth then nose (if required)
• Dry the baby and discard wet
linen
• Stimulate by rubbing the back
3 • Re‐position
Dry the baby and discard Stimulate by rubbing
wet linen the back Reposition
5 6 7
09
 USING BAG & MASK

Time: 20 minutes
Ask: How should one use bag and mask?
Actions Explain Demonstrate and Practice on
mannequin
Check the Remember to use a clean and functional bag and mask (Checked before delivery) Show how to check the functionality
equipment Check functionality by occluding the patient outlet against the palm and squeezing the bag. Look of bag & mask
for release of pop off valve and listen for hissing sound produced, feel the pressure on the palm and
observe that the bag reinflates on release.
Position the baby Remind that before assessing breathing, the position of the airway is to be ensured Positioning a baby for PPV
Selection of the Position the mask on the face so that it covers the tip of the chin, mouth and nose: (Tip of the chin Choosing the correct size of mask and
correct size mask rests within the rim of the mask and it covers over the mouth till the base of the nose). Begin by how to position it correctly over the
cupping the chin in the mask and then covering the nose. Size 1 mask is used for normal weight baby’s face
babies and size zero is usually used for smaller babies
How to make a The mask is held on the face with the thumb and index finger encircling the rim of the mask in Making a proper seal between the
firm seal between shape of letter “C” while the middle, ring and little fingers bring the chin forward to maintain a mask and face. This is a prerequisite
the mask and patent airway for effective ventilation. The 2 most
face important and difficult steps in
ventilation are:
• Positioning the head properly
• Making a firm seal

KEY MESSAGES:
Appropriate size of face mask & correct position of the baby, are the two essential prerequisites for making a good seal.
10
 If the baby is still not breathing, ventilate with a bag and mask.

ENTILATING WITH A BAG AND MASK

HOW
Recheck the baby’s position and ensure that TO
the neck USEextended.
is slightly BAG & MASK?
Position the mask and check the seal:
- Place the mask on the baby’s face so that it covers the baby’s chin, mouth,
andFitting
nose; Mask Over Face:

Right size and Mask held Mask too Mask too

position of mask too low small large
WHAT ARE THE STEPS FOR POSITIVE PRES
VENTILATION ?

Check functionality

Right Wrong Wrong Wrong

- Form a seal between the mask and the baby’s face;
Place mask covering the chin,
- Squeeze the bag with two fingers only (adult-size bag) or with the whole mouth and nose to make a tight seal
hand (newborn-size bag); Initiate bag and mask ventilation using room air If
10 Give 5 ventilatory breaths and look for chest rise
 STEPS FOR POSITIVE PRESSURE VENTILATION (PPV)

Time: 20 minutes
Ask: This baby did not cry after drying and stimulation. What are the next steps ?

Actions Explain
Give 5 ventilatory breaths to Give 5 ventilatory breaths using enough pressure to
initiate bag & mask ventilation adequately aerate the lungs with room air only. Look
using room air for chest rise. Remember the lungs of the fetus are filled
with fluid, so the first few breaths will often require high
pressure. If the chest does not rise with each inflation,
then the lungs are not being aerated and the heart rate
will not increase
KEY MESSAGES:
While providing five initial breaths, ensure firm seal and enough pressure to achieve chest rise.

11
 WHAT ARE THE STEPS FOR POSITIVE PRESSURE VENTILATION ?
InitiateInitiate
bag andbag
mask
andventilation
mask ventilation
using room
usingair
room a
WHATWHAT
ARE THE
ARE STEPS
THE STEPS
FOR POSITIVE
FOR POSITIVE
PRESSURE
PRESSURE Give 5 ventilatory
Give 5 ventilatory
breathsbreaths
and lookand
forlook
chest
forrise
chest r
VENTILATION
VENTILATION
? • Initiate
? bag and mask ventilation using If no chest
room Ifair
norise
chest
after
rise5 after
breaths
5 breaths
take corrective
take corrective
steps. steps.
• Give 5 ventilatory breaths and look for chest rise
If adequate
If adequate
chest rise,
chest
continue
rise, continue
for 30 seconds
for 30 second
• If no chest rise after 5 breaths, take corrective steps
• If adequate chest rise, continue for 30 seconds

1 1 1 2

Initiate bag and mask ventilation using room air. Give 5 ventilatory
breaths and look for chest rise If no chest rise after 5 breaths take corrective steps

Initiate
Initiate
bag and
bagmask
and mask
ventilation
ventilation
using using
room room
air air If no chest
If no chest
rise a†er
rise5a†er
breaths
5 breaths
take corrective
take corrective
steps steps
11
 NO CHEST RISE AFTER 5 BREATHS: TAKE CORRECTIVE
STEPS
Time: 30 minutes
Ask: What corrective steps are needed if there is no chest rise?

Actions Explain Demonstrate and practice on mannequin

If no chest rise after 5 breaths, 1. Adjust the mask to ensure airtight seal Demonstrate the corrective steps for checking
take corrective steps 1 & 2. 2. Reposition the head to open the adequate chest rise
Give 5 ventilatory breaths again airway
and look for chest rise. If there is3. Suction to remove excessive secretions
still no chest rise, take corrective if required
steps 3 & 4. 4. Increase pressure by squeezing the
bag to get a visible chest rise
If chest rises, then continue with bag and mask ventilation

KEY MESSAGES
4 Actions If no chest rise:
1) Adjust the mask to ensure airtight seal 2) Reposition the head to open the airway
3) Suction to remove excessive secretions, if required 4) Increase pressure by squeezing the bag to get a visible chest rise

12
WHAT CORRECTIVE STEPS ARE TAKEN WHEN THERE IS NO CHEST
RISE AFTER 5 BREATHS?

1 2

Adjust the mask to ensure airtight seal Reposition the head to open the airway

3 4

Increase Pressure by squeezing bag to

Suction to remove excessive secretions
get a visible chest rise
12
 RATE OF POSITIVE PRESSURE VENTILATION (PPV)

Time: 25 minutes
Ask: How is a ventilatory rate of 40‐60/minute maintained?

Actions Explain Demonstrate and practice

If chest rise is To continue ventilation, about 40‐60 breaths Ventilate calling out loudly
adequate, then per min must be delivered. One may call out squeeze- 2‐3 and observing
continue ventilation loud as squeeze- 2‐3 , squeeze- 2‐3, to help for adequate chest rise
for 30 seconds oneself to deliver at the rate of one breath per
Let each participant practice
second
ventilation on a mannequin
Reassess breathing: If breathing well, provide observational care Take the participants to the
with the mother. If not breathing well, call for help and continue wall chart and explain the
bag and mask ventilation next steps

KEY MESSAGES
If there is adequate chest rise continue PPV for 30 seconds. Rate of ventilation should be 40‐60 breaths per minute.

13
 POSITIVE PRESSURE VENTILATION SHOULD BE GIVEN AT WHAT RATE?

Breathe..................... Two..................... Three..................... Breathe..................... Two....................... Three.......................

(squeeze) (release)..........................) (squeeze) (release)............................)

ute should be maintained.

A ventilatory rate of 40‐60/minute should be maintained

13
 ACTIONS TO BE TAKEN IF NOT BREATHING WELL
AFTER VENTILATING FOR 30 SECONDS
Time: 20 minutes
Ask: What should be done if the baby does not start to breathe after 30 seconds of effective bag and mask ventilation?
Assess Actions Demonstrate
Not • Continue bag and mask ventilation How to assess:
breathing • Call for help Breathing
well Heart Rate
Assess • Quickly count heart rate with a stethoscope for 6 seconds. Multiply with 10 to get the
Heart rate HR per minute Also show how to ventilate
(HR) • Continue bag and mask ventilation with 100 percent oxygen. using oxygen
• If HR is less than 100/minute and baby is not breathing well then continue bag and mask ventilation by connecting to oxygen
with an oxygen source(5‐10 L /minute) attached to the oxygen inlet of the self‐inflating bag and a source and attaching
reservoir to the air inlet reservoir
• If help is available, then provide intubation, chest compression and medication as required
• If HR is >=100 beats per minute and the baby is breathing well, refer the baby to SNCU .

KEY MESSAGES
Stop resuscitation if there are no signs of life (no breathing, no heart sounds and no activity) after 20 minutes
of effective ventilation.
14
 Continue bag and mask ventilation with
ED IF BABY IS NOT ACTIONS ARE REQUIRED IF BABY IS NOT BREATHING
WHAT oxygen.
R VENTILATING FOR If help available, then provide chest
WELL EVEN AFTER VENTILATING FOR 30 SECONDS?
compressions, intubation and
S medication.

• Continue bag and mask ventilation

• Assess Heart rate, if heart rate is less than 100 beats per min, continue PPV with 100% oxygen and call for
help. If help is available, then provide intubation, chest compression and medication as required.
• If Heart rate is more than 100 beats per min and baby is breathing well, refer to SNCU.

Assess heart rate and breathing. Continue Bag and Continue bag and mask ventilation
mask ventilation. if heart rate is less than 100 beats
per minute and not breathing well. Call for help. with 100% oxygen.

14
 OBSERVATIONAL CARE WITH MOTHER

Time: 30 minutes
Ask: What care is needed once baby establishes breathing after bag and mask ventilation?

Actions Explain
Place the baby prone between the Observational care is provided to the baby without separating from the mother. All babies who start breathing after
mother’s breast initial steps and have received PPV for less than 1 minute are shifted for observational care with mother and kept in
Cover baby and mother together skin to skin contact and monitored
Initiate breastfeeding Initiate breastfeeding within one hour of birth. The baby is most active after birth and hence breastfeeding should be
initiated as soon as possible within one hour after birth. Baby may initiate breast crawl, open his/her mouth, move the
head from side to side and also begin to salivate. These signs indicate that the baby is ready to breastfeed. Some mothers
and babies may need support at this stage. Reiterate that early initiation is a must for sustaining exclusive breastfeeding
Monitor neonate Monitor temperature, heart rate, breathing and colour, every 15 minutes in first hour and then every 30 minutes in next
one hour. Assessing heart rate , breathing and temperature recording will be discussed later. In case the baby’s lips and
tongue look blue, refer the baby to a higher centre
It is important that the provider who is attending the newborn, informs the parents about the baby’s condition and progress.
Maintain records of actions taken if the baby did not cry immediately after birth

KEY MESSAGES
Continue skin‐to‐skin contact after initial steps of resuscitation and if PPV is required for less than 1 minute.
Monitor the baby’s temperature, heart rate, breathing, colour and look for danger signs, every 15 minutes in first hour and then every 30 minutes in
next one hour. Breastfeeds to be initiated within 1 hour.

15
 HOW TO PROVIDE OBSERVATIONAL CARE breast. Cover
W WHILE KEEPING BABY WITH MOTHER ? Initiate breas
Monitor neon
breathing and

HOW TO PROVIDE OBSERVATIONAL CARE WHILE

KEEPING BABY WITH MOTHER ?

Place the baby prone between the mother’s

HOW TO PROVIDE OBSERVATIONAL CARE
• Place the
HOWbaby prone between
TO PROVIDE the mother’s
OBSERVATIONAL breast.
CARE breast. Cover
Place
Cover
baby baby
and mother
the baby
and mother together
together.
prone between the mother’s
breast. Cover baby and mother together.
W WHILE KEEPING
• Initiate BABY WITH MOTHER ?
breastfeeding
Initiate breastfeeding.
W WHILE KEEPING BABY WITH MOTHER ? Initiate breastfeeding.
Monitor neonate (temperature, heart rate,
• M
 onitor neonate (temperature, heart rate, breathing and colour, every 15 minutes in
Monitor neonate (temperature, heart rate,
breathing and colour every 30 minutes.
breathing and colour every 30 minutes.
first hour and then every 30 minutes in next one hour)
Initiat
Place the baby prone between the mother’s
breast. Cover baby and mother together.

Monito

Initiate breastfeeding
Place the baby prone between the mother’s
Place the baby prone between the mother’s breast. Initiate
Initiate breastfeeding
breastfeeding Monitor every 15 minutes in first
breast. Cover baby and mother together.
by prone betweenCover baby and mother together.
the mother’s hour and then every 30 minutes in
r baby and mother together. next one hour
15
DAY 2
DAY 2
ALGORITHM FOR NEONATAL RESUSCITATION
Time: 20 Minutes

Birth
• Note the time of birth
• Place baby prone on mother’s abdomen
Routine care
• Continue skin to skin care
Is the baby breathing/crying Yes • Turn head to one side & wipe secretions, if visible
• Dry baby, discard wet linen
No

GOLDEN MINUTE
• Cover baby and mother together
•  lamp & Cut cord immediately
C • Clamp & Cut cord between 1-3 mins
• Place under radiant warmer • Initiate breastfeeding
• Position head with neck slightly extended • Check Breathing, Colour and Activity
• Clear airway by suctioning mouth then
nose if required
• Dry baby, discard wet linen
• Stimulate by rubbing the back
• Reposition Observational Care with Mother
•  lace the baby prone between the mother’s breasts.
P
• Cover baby and mother together.
Assess Breathing • Initiate breastfeeding.
Breathing well
• Monitor neonate (temperature, heart rate, breathing and colour,
Not Breathing Well
every 15 minutes in first hour and then every
• Initiate bag and mask ventilation using room air. 30 minutes in next one hour).
• Give 5 ventilatory breaths and look for chest rise.
• If no chest rise after 5 breaths, take corrective steps.
• If adequate chest rise, continue for 30 seconds

BEYOND GOLDEN MINUTE

Assess Breathing
Breathing well
Not Breathing Well
• Call for Help*
• Continue bag and mask ventilation
Assess Heart Rate
Yes Assess Breathing
HR ≥ 100/min Breathing well Refer to SNCU
No
• Continue bag and mask ventilation using 100% oxygen (if HR<100bpm).
• If help* available, then intubate, provide chest compression and Not breathing well *Help - A person skilled to provide
medication, as required chest compression, intubation and
medication
Organize referral to SNCU and continue ventilation (if not breathing well)

17
ALGORITHM FOR NEONATAL RESUSCITATION

Birth
• Note the time of birth
• Place baby prone on mother’s abdomen
Routine care
• Continue skin to skin care
Is the baby breathing/crying Yes • Turn head to one side & wipe secretions, if visible
• Dry baby, discard wet linen
No

GOLDEN MINUTE
• Cover baby and mother together
•  lamp & Cut cord immediately
C • Clamp & Cut cord between 1-3 mins
• Place under radiant warmer • Initiate breastfeeding
• Position head with neck slightly extended • Check Breathing, Colour and Activity
• Clear airway by suctioning mouth then
nose if required
• Dry baby, discard wet linen
• Stimulate by rubbing the back
• Reposition Observational Care with Mother
•  lace the baby prone between the mother’s breasts.
P
• Cover baby and mother together.
Assess Breathing • Initiate breastfeeding.
Breathing well
• Monitor neonate (temperature, heart rate, breathing and colour,
Not Breathing Well
every 15 minutes in first hour and then every
• Initiate bag and mask ventilation using room air. 30 minutes in next one hour).
• Give 5 ventilatory breaths and look for chest rise.
• If no chest rise after 5 breaths, take corrective steps.
• If adequate chest rise, continue for 30 seconds

BEYOND GOLDEN MINUTE

Assess Breathing
Breathing well
Not Breathing Well
• Call for Help*
• Continue bag and mask ventilation
Assess Heart Rate
Yes Assess Breathing
HR ≥ 100/min Breathing well Refer to SNCU
No
• Continue bag and mask ventilation using 100% oxygen (if HR<100bpm).
• If help* available, then intubate, provide chest compression and Not breathing well *Help - A person skilled to provide
medication, as required chest compression, intubation and
medication
Organize referral to SNCU and continue ventilation (if not breathing well)

17
 CARE AFTER FIRST HOUR OF BIRTH
Time: 15 minutes
Ask: What care should be provided after initiation of breastfeeding?
Actions Explain Demonstrate
Weigh the baby Weigh the baby once the breastfeeding is initiated. Always look for zero error and then place the baby Show how to check for zero error and
on the pan/scale and record the weight ensuring that baby does not get hypothermic in the process how to record the weight correctly
Give Injection Give 1mg of Injection Vitamin K1, IM to all babies weighing 1000gm and above and 0.5mg to babies Show the Vitamin K1 vial. Enquire
Vitamin K1 weighing less than 1000 gm. This should be documented on the discharge slip and referral note. The whether they have used it earlier or not
prophylaxis injection should be given after 1 hour of skin to skin contact
Provide Cord Care Observe for oozing from the cord stump. Keep the cord clean and dry. Leave the cord stump
uncovered, do not bind or bandage stump. The cord stump should be about 5 cms long, a longer cord
will come in contact with the genitalia and may be soiled and become infected.

Infection prevention • Wash hands after changing diaper/nappy and before feeding the baby. Use washed and
after birth clean linen
• Exclusive breastfeeding
Vaccination at birth Details are given in the section below

KEY MESSAGES
1. Weighing and Vitamin K administration should be done and recorded.
2. Hand washing is the most cost effective measure for infection prevention.
3. Do not apply anything on the cord stump and keep it dry.
4. Above mentioned actions should be performed after one hour of Skin to Skin care.

18
 WHAT CARE SHOULD BE PROVIDED AFTER FIRST HOUR OF BIRTH?
a.
a. Hand Hand Washing
a. Washing
Hand Washing b. breast b.feeding
breast feeding
feeding
b. breast

1 2 3

Place the baby prone between the mother’s

HOW TO PROVIDE OBSERVATIONAL CARE breast. Cover baby and mother together.
WWHATWHILE KEEPING
CARE SHOULD BABY WITH
BE PROVIDED MOTHER
IN 1ST ?
HOUR AFTER BIRTH?Initiate breastfeeding.
Monitor neonate (temperature, heart rate,
Weigh the baby breathing and
Inj. Vitamin K colour every 30 minutes. Cord Care
1. Infection prevention
2. Weigh the baby 3. Inj. Vitamin K 4. Cord Care
4. Cord Care
4. Infection prevention
2. Weigh the baby
2. Weigh the baby
3. Inj. Vitamin K
3. Inj. Vitamin K 4. Cord Care

1 2 3 5

4 5 6

a. Hand Washing b. Breastfeeding Vaccination at Birth

a. Hand Washing b. breastbreastfeeding
Initiate feeding
he baby prone between the mother’s 18
Cover baby and mother together.
 MONITORING BREATHING AND TEMPERATURE IN A
NEWBORN
Time: 20 minutes
Ask: How is temperature and breathing monitored?

Actions Explain Demonstrate and practice

Breathing Babies breathe faster as their lungs are small and hence for adequate exchange of gases they need to respire at a higher Participants practice counting
rate respiratory rate assisted by a facilitator
Normal rate is 40‐60 breaths/min. Look for abnormalities in breathing like: on a mannequin (The facilitator should
a. Fast breathing >60 breaths/min. mimic the periodic respiratory pattern
b. No breathing (apnoea) or gasping of a neonate on the manikin with a bag
c. Breathing difficulty – severe chest in-drawing and mask and ask the participants to
Do’s while counting Respiratory rate: count the respiratory rate for a minute)
Breaths must be counted for one minute to decide if the breathing is fast. The baby must be quiet and calm when you look
at his breathing. Use the seconds hand or a digital watch while counting the movement of the infant’s chest/abdomen
Any compromise of the baby’s airway/lung capacity because of improper position, blockage by secretions, meconium and/
or infection may lead to increase in respiratory rate and chest in-drawing
Temperature Baby’s temperature can be assessed with reasonable precision by human touch (back of the hand). The warm and pink Demonstrate touch method of
feet of the baby indicate that the baby is in thermal comfort, but when feet are cold and abdomen is warm, it indicates temperature assessment and use of a
that the baby is in cold stress. In hypothermia, both feet and abdomen are cold to touch. All babies must have their digital thermometer
temperature measured using a digital thermometer and it must be recorded.

KEY MESSAGES
1. A baby breathing at the rate of 40 - 60 breaths per minute indicates that the baby’s breathing is normal
2. The warm and pink feet of the baby on tactile assessment, indicate that the baby is in thermal comfort. The baby’s temperature should normally be
between 36.5 and 37.40C when measured with digital thermometer

19
HOW TO MONITOR BREATHING AND TEMPERATURE IN A NEWBORN ?

HOW TO
HOW TO MONITOR
MONITOR BREATHING
BREATHING AND
AND TEMPERATURE
TEMPERATUREIN
INAANEWBORN
NEWBORN??

1 2 3 4

Monitor temperature (Tactile assessment‐ Monitor temperature (Tactile assessment‐ Recording Temperature with
Monitor Breathing
Abdomen)
Monitor temperature (tactile
Monitor temperature (tactile
assessment‐)
assessment‐)
Periphery)
Monitor temperature (Tactile
Monitor temperature (Tactile
a digital thermometer
assessment‐Periphery)
assessment‐Periphery)

19
 Visible birth defect

Time: 15 minutes
Ask: What do you see in this chart? What are the important malformations which require detection at birth and immediate referral? What malformations do you commonly see?

Actions Explain Discuss

Demonstrate the RBSK 1. Look at the first vertical column which deals with common defects of the head and spine collectively known as Discuss the most common
visible birth defects neural tube defects, e.g.- Hydrocephalus, and Meningomyelocele malformations as under:
chart. Familiarize 2. Now, look at the second column which depicts malformations related to the face e.g.- Cleft lip and Cleft palate 1. Neural tube defect
the participants 3. Now, focus on the third column showing malformations of the abdomen and anus e.g.-Imperforate anus, and a. Meningomyelocele
b. Hydrocephalous
with the different Omphalocele 2. Cleft Palate and lip
organ systems which 4. Coming to the subsequent columns which deal with Genitalia and the Urinary tract malformations. Some of the 3. a. Imperforate anus
can have common common malformations include Bladder exstrophy and any abnormality of genitalia such as Hypospadias and b. Omphalocele
malformations. Undescended testis 4. a. Bladder Extropy
5. Look at the last column that deals with malformations of extremities such as Polydactyly, Syndactyly and b. Hypospadias
5. Congenital talipes equino varus
Congenital talipes equino varus
(Club foot)
6. Others: Some important birth defects are not visible externally, for example, Tracheoesophageal fistulae (TEF), 6. Tracheoesophageal fistulae –
Congenital heart defect etc Frothy baby who chokes on first
feed.
Discuss the importance Explain to participants that DEIC is a facility at the district level which aims at early detection of defects or DEIC caters to children from birth
and benefits of timely developmental delays and early intervention to minimize disabilities among children till 18 years for selected health
referral to a higher Explain that early referral to a higher centre for surgery is lifesaving in malformations such as Imperforate anus, conditions under RBSK such as
center. Discuss the role Omphalocele, TEF etc Defects at birth, Deficiencies, Diseases
of the District Early and Developmental delays including
Intervention Centre Disabilities. It provides referral
(DEIC). support, management and follow up
services.

20
 EXAMINATION OF THE NEWBORN
FROM HEAD TO TOE FOR COMMON BIRTH DEFECTS
GENERAL OBSERVATION : If present, refer
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Colour of skin: a) Pale b) Blue c) Yellow
Wash your hands, before touching the baby

1 HEAD AND SPINE 2 EYES, EARS, MOUTH AND LIPS 3 ABDOMEN 4 GENITALIA 5 URINARY TRACT 6 LIMBS (UPPER & LOWER)
1. Size too large > 38 cms (full term) AND ANUS 1. Ambiguous genitalia 1. Bladder – not covered
2. Size too small < 32 cms (full term) 2. Vaginal opening absent 1. Absence of a whole or part of upper limb
EYES 2. Wrinkled abdominal wall
3. Absence of skull cap ABDOMEN 3. Urethral opening away from 2. Absence of a whole or part of lower limb
1. Eyelid – swelling 2. Eyelid – droopy 3. Urinary stream – check if
4. Swelling or protruding of the brain 1. Scaphoid (sunken and the tip of the penis – look
3. Gap in eyelid 4. Eyeball – absent male child 3. Fused digits
5. Abnormal swelling of the spine concave) with respiratory where the urine comes out
5. Eyeball – small 6. Inside the eye – corneal clouding distress: X-ray chest 4. Absence of digits or split hand/foot
* 7. Inside the eye – opacity of lens/white reflex 2. Distended: X-ray abdomen * * 5. Extra digits
3. Wall defect- gap with 6. Club foot
herniation of the gut

*
1
1 BLADDER EXSTROPHY
AMBIGUOUS GENITALIA Q 56.4 Q 64.0-64.1
1 HAEMANGIOMA
2 3
PTOSIS COLOBOMA OF EYELID
D 18.01 Q 10.0 Q10.3 1
1 DIAPHRAGMATIC HERNIA Q 79.0
HYDROCEPHALOUS Q03 1 2
* * * LIMB REDUCTION DEFECT LIMB REDUCTION DEFECT
UPPER Q71 LOWER Q72

2
2 PRUNE BELLY Q 79.4
7 2 VAGINAL AGENESIS Q 52.0
4 5 6
INTESTINAL OBSTRUCTION Q 41-42
ANOPHTHALMOS MICROTHALMOS CONGENITAL CATARACT Q12.0 CONGENITAL
Q11.1
ONE EYE OR BOTH EYES
Q11.2 GLAUCOMA
Q15.0 * *
2
MICROCEPHALY Q02 3 4
EAR SYNDACTYLY Q 70 ECTRODACTYLY Q 72.7

1. Absent 2. Abnormal shape

3
3 GASTROSCHISIS Q 79.3 POSTERIOR URETHRAL VALVE Q 64.20
3
* HYPOSPADIAS Q 54 Distended bladder even after passing urine.

3 7 CHROMOSOMAL - DOWN SYNDROME

ANENCEPHALY Q00
3 1. Face: Upward slanting eyes, fold on the inner corner of the eye
1 2 2 OMPHALOCELE Q 79.2 4
ANOTIA MICROTIA II MICROTIA III POLYDACTYLY Q 69
Q 16.0 Q 17.2 Q 17.2
(epicanthal), flat nose, small ear, small mouth, excess skin at the
nape of neck
ANUS
2. Palm: Single crease
MOUTH 1. Absent/imperforate/
abnormally positioned 3. Foot: Increased gap between 1st and 2nd toe
4 1. Cleft (split) lip 2. Cleft (split) palate 3. Cleft (split) lip and palate
ENCEPHALOCELE Q01 *

5 1
SPINA BIFIDA WITH
MENINGOMYELOCOELE Q05
2 3
CLEFT LIP Q 36 CLEFT PALATE Q 35
1
IMPERFORATE ANUS/ANORECTAL
1 2 3 5
ATRESIA AND STENOSIS WITH OR
CLEFT LIP & PALATE Q37 WITHOUT FISTULA Q42.0-Q42.3 DOWN SYNDROME Q90 CLUB FOOT-TALIPES EQUINOVARUS Q 66.0

* Need urgent referral  If any of the above identified, record findings in RCH register and RBSK birth defect recording format along with MCTS details.

POSTER TEMPLATE FOR VISIBLE BIRTH DEFECTS

20
 Newborn Case Sheet
Time: 10 Minutes
Ask: Does every baby have a separate registration number and admission ticket?
What are the parameters that you look for during examination of neonate in the postnatal ward?
Actions Explain
Read each heading of the Newborn Case Sheet and discuss each: Explain each heading of the Newborn Case Sheet
Maternal Details Explain the relevance of maternal blood group: If mother is O/ Rh Negative, watch for icterus
Resuscitation details Explain
• No resuscitation – Routine care
• Neoantes requiring Initial steps, Bag and Mask ventilation for less than 1 min- Observational care
• Referral if BMV given for 1 minute or longer
Immunization Explain that three vaccines are administered at birth to protect against Tuberculosis, Polio and Hepatitis B
Vitamin K Given to prevent bleeding
Alertness/Sensorium Alert- normal
Lethargic- Difficult to awaken. This is a sign of sickness and may require referral
Urine passed Generally, babies pass urine in first 48 hours of life. If not – refer
Meconium passed Generally, babies pass meconium in first 24 hours of life. If not - refer
Vitals
Temperature Normal – 36.5-37.50C
Assessment method:
Touch method: Periphery and trunk
Record axillary temperature
If Hypothermic– Provide warmth
Warm room, KMC, Clothe the baby
Respiration Normal respiratory rate – 40-60/min, no breathing difficulty
If rate >60/min or breathing difficulty- refer
Umbilical site Keep dry, No application. Look for redness, discharge- If present- refer
Icterus Normal finding. If icterus appears within first 24 hours or stains palms and soles – refer
Feeding Emphasize exclusive breastfeeding. Assist breastfeeding
Solve problems related to breastfeeding
Discourage top feeds and prelacteal feeds

21
 Newborn Case Sheet

Name: B/O.......................................................................................................... Assessment of the newborn:

Father’s Name............................................... Age............................................. General Condition Findings (Tick most relevant finding)
Alertness/Sensorium Normal/Drowsy/Comatose
Sex: ................................................................
Activity and cry Good/Weak/Poor
Date and Time of birth: ................................................................................... Urine passed Yes/No
Term/Preterm/Post term ................................................................................. Meconium passed Yes/No
Vitals
Birth Weight: ........................grams Temperature 0
C
Head circumference (HC)=...................cm Respiration Rate- /min, Breathing difficulty (Yes/No)
General Examination
Length=..........................cm
Umbilical cord site Clean and dry/Erythema/Discharge/Bleeding
Maternal History as per records : Icterus Yes/No
Gravida: .......................................... Para: .......................................... Feeding Assessment
Breastfeeding Initiated Yes/No
Maternal Blood Group ..........................................
Frequency of breastfeeds – 8-10 Yes/No
Presentation: Vertex/ Breech/Transverse (Tick one) times/day
Liqour: Clear/ meconium stained (Tick one) Prelacteal feeds Yes/No

Delivery mode: ________ Top feeds Yes/No

Resuscitation details: None/ Initial steps/ Bag and Mask ventilation/ Any difficulty in breastfeeding Yes/No
Advanced resuscitation (Tick one) Any other issues Yes/No
Immunization details: BCG/OPV/Hepatitis B (Tick, if received) If yes, mention details
Final outcome – Discharge/Left against medical advice/Referral/Expired
Vitamin K at birth: Received/ Not received (Tick one)

21
 BREASTFEEDING

Time: 25 minutes
Ask: How do you assess if the baby is breastfeeding well?

Positioning (Four steps of Attachment (Four steps of Frequency of Discuss common problems and
positioning) attachment) feeds their management
1. Baby’s body is well supported. 1. Baby’s mouth is wide open Mother should feed Sore nipples: Ensure proper
2. The head, neck and the body 2. Lower lip is turned outwards her baby at least 8‐10 attachment and application of
of the baby are kept in the 3. Baby’s chin touches mother’s times during the day hind milk
same plane breast and night Breast engorgement: Warm
Discuss 3. Entire body of the baby faces 4. Majority of areola is inside the fomentation, expression of milk,
breastfeeding the mother baby’s mouth ensure proper attachment
4. Baby’s abdomen touches Mother can even feed
mother’s abdomen Breast Abscess is painful swelling
in lying down position
and redness of breast. Mother
may have fever. She needs to be
referred for further management
after giving a dose of paracetamol
Demonstrate Demonstrate positioning on mannequin

KEY MESSAGES
1. Correct position and attachment is important for establishing breastfeeding.
2. Mother should continue to feed even during night.
3. Provide support to the mother for common breastfeeding problems.

22
WHAT ARE THE STEPS FOR EFFECTIVE BREASTFEEDING?
WHAT ARE THE STEPS FOR EFFECTIVE BREAST FEEDING ?

22
 KANGAROO MOTHER CARE (KMC)

Time: 15 minutes
Ask: What is Kangaroo Mother care (KMC)? How is it provided & what are its benefits? Discuss

Which babies should be provided KMC: All low birth weight (LBW) newborns(<2500 grams) should be provided KMC. KMC can be initiated as early as possible for all stable
LBW babies.
When to stop KMC: When the weight is around 2,500 grams and the infant starts wriggling to show discomfort or pulls out and cries, it is time to wean the infant from KMC.

Benefits of KMC :
• Temperature maintenance with a reduced risk of
hypothermia
• Increased breastfeeding rates
• Less morbidity such as apnoea and infections
• Better weight gain
• Early discharge from the health facility
• Less stress (for both baby and mother)
• Better mother infant bonding
Explain
Demonstrate
Additional benefits of KMC:
KMC satisfies all five senses of the infant. The infant feels the 1. Discuss clothing, position and duration
mother’s warmth through skin‐to‐skin contact (touch), listens to 2. D
 emonstrate KMC on mother and
her voice and heartbeat (hearing), sucks breast milk (taste), has eye LBW baby
contact with her (vision) and smells her odour (smell) Conduct a role play on counselling for KMC:
KMC has been found to be effective in improving exclusive Advice a mother regarding KMC for a baby
breastfeeding rates, weight gain, fostering greater maternal and weighing 1,900 grams, who cried soon
family involvement and above all, it is free of cost after birth, is taking feeds well and is being
discharged after 72 hours

KEY MESSAGES
Early, continuous and prolonged skin‐to‐skin contact between the mother and baby along with exclusive breastfeeding are the components of KMC.
The infant is placed on mother’s chest between the breasts. Begin KMC as soon as possible in all low birth weight babies.

23
 HOW DO YOU PROVIDE KANGAROO MOTHER CARE
HOW DO YOU PROVIDE KANGAROO MOTHER CARE

Clothes for Baby

Head turned
Baby between to one side
mother’s breasts

Frog-leg
Support baby’s
captions to be placed for all the pictures position
bottom

Mother providing KMC KMC Position

KMC Position
Cap, Jhabala, Diaper and Socks

23
 IMMUNIZATION
Time: 20 minutes
Ask: Enumerate the vaccines to be given at birth
Ans: (BCG, OPV & Hepatitis B)
Discuss the route of administration of the vaccines and demonstrate site of administration on a mannequin: Intramuscular injection, and Intradermal injection.
Vaccine Route Site Dose/Technique Precaution Reaction Comments
BCG Intradermal Left upper arm 0.05 ml with insulin syringe. This vaccine should be Takes place after 3 weeks Ensure all vaccines are
The vaccine is injected in a used within 4 hours of in the form of redness and administered before
dose of 0.05 ml. A small bleb opening the vial and nodule formation. Sometimes discharge, however if not
is formed on injecting the adding the provided this nodule may rupture and done before discharge, they
vaccine intradermally diluent and should be some liquid may come out. should be administered
protected from sunlight Very rarely an abscess may at the first available
form, for which the baby may opportunity (Hepatitis
need referral B within 24 hours, OPV
within 15 days and BCG
OPV Oral Two drops Check VVM, do not use if None
within the first year)
the VVM is in stages 3 & 4
Hepatitis B Intramuscularly Anterolateral aspect 0.5 ml None
of the thigh Use a 26 gauge needle with
one ml syringe

KEY MESSAGES
1. Give BCG, OPV, Hepatitis B vaccines within 24 hours or ensure they are given prior to discharge.
2. Record the vaccinations given at the time of birth in the discharge slip and in the MCP card.
3. Explain to parents the information in the MCP card.
4. Do not use vaccine with VVM in the stages 3 & 4.

24
 WHICH VACCINATIONS ARE GIVEN AT BIRTH?

WHICH VACCINES AREAREGIVEN

WHICH VACCINATIONS AT BIRTH?
GIVEN AT BIRTH?

WHICH VACCINATIONS ARE GIVEN AT BIR

1 2

OPV Oral BCG‐Intra Dermal

OPV Oral BCG‐Intra Dermal BCG‐Intra Dermal OPV Oral

3 4
OPV Oral BCG‐Intra Dermal

Hepatitis B Intramuscular Record in MCP card

Hepatitis B Intramuscular 24 Record in MCP card
 DISCHARGE PLANNING AND FOLLOW UP PLAN

Time: 30 minutes
Ask: When should you discharge a baby? What messages will you give to parents/caregivers at discharge?

Discharge planning Discharge advice Explain

Checklist before discharge
a. Infant is free from illness and significant
jaundice. (A referral is warranted if jaundice
appears within first 24 hours and if palms and
soles appear yellow)
b. Has received the three vaccines namely
BCG, OPV and Hepatitis B
c. Breastfeeding is established if baby feeds 8-10
times during day and night, passes urine 6-8
times in 24 hours and sleeps well after feeds
d. Mother is free from any significant illness
Advise the mother to;
a. Keep the baby warm
b. Exclusively breastfeed her baby
c. Play & communicate with the baby
d. Wash hands, keep cord clean and dry
e. Watch for signs of sickness
f. When to come for follow up:
Baby appears sick, difficulty in feeding
lethargic, breathing is fast or difficult,
yellow palms and soles or cold to touch/fever
How to give discharge advice to mothers in
simple language? Do a role play where a scene of
discharge counselling by the health care provider
to the mother of a low birth weight baby is
enacted. Emphasis should be on the messages that
the mother needs to know and the skills required
for counselling
Familiarize mother with the MCP card

KEY MESSAGES
1.  lways check before discharge that baby is free from illness, significant jaundice and has received the three vaccines namely BCG, OPV, Hepatitis B
A
2. Mother is confident of taking care of the baby and is free from any significant illness.
3. Make sure baby is breastfeeding adequately (8‐10 times) during day and night.
4. Breastfeeding is considered adequate if the baby passes urine 6-8 times in 24 hours and sleeps for 2‐3 hours after the feeds.

25
 HOW DO YOU PLAN FOR DISCHARGE AND FOLLOW UP

Examination before Discharge Discharge Counselling

hropometry before Discharge

thropometry before Discharge Discharge Counselling
Discharge Counselling
25
 Discharge SLIP

Time: 10 minutes
Ask: Should every baby receive a discharge Slip? What are the important aspects that should be covered in discharge advice in your opinion

Actions Explain
Read each heading of the Discharge Slip Explain each heading of the discharge slip
Discharge advice: Discuss in detail discharge advice

a. Exclusive breast feeding i. Counsel the mother regarding importance of exclusive breastfeeding in the
first 6 months.
b. Supplements ii. Bottle feeding and top feeding should be discouraged.
c. Immunization i. Vitamin D3 400 IU should be continued for 1 year
d. General measures i. As advised in MCP card
i. Advice mother to maintain temperature with appropriate clothing and by
keeping the baby dry
ii Follow hand hygiene

26
 DISCHARGE SLIP

Baby of . ................................................Father’s name. ...................................................... Investigations: Mother’s Blood Group ..............................

If performed
Gender ................................................ Baby Reg. No .......................................................
a. Random Blood Sugar
b. Serum bilirubin
Mother Reg. No..................................
c. Baby blood group
Address ................................................................................................................................. d. Any other
Birth Immunization and Vitamin K prophylaxis: (Mark/Encircle, if received)
Ph no ................................. Date of admission ................................................................. BCG
OPV
Date of discharge ................................................................................................................. Hepatitis B
Injection Vitamin K at birth
Date of birth ........................................................................................................................
Final diagnosis – Single or Twin/ Term or Preterm/Male or Female/ Birth weight......................
Time of birth ....................................................................................................................... / Complications if any..................

Birth weight .......................................................................................................................

Final Outcome- Discharge/Referred to higher center
Visible birth defects: Cleft lip/Cleft Palate/Club foot/Meningomyelocele/ Indication of Referral- ………………………………………
Hydrocephalous/Others Discharge Advice
• Exclusive breastfeeding for 6 months
Resuscitation details: Cried immediately/Initial Steps/Bag and Mask Ventilation/ • Vit D3 1 ml OD x 1 yr
Advanced Resuscitation • No bottle feeding/ top feeding
• Maintain Temperature
• Maintain good hygiene
• Danger signs explained
• Immunization as per schedule
• Review after 6 weeks Signature..................................

26
 NEONATAL TRANSPORT

Time: 30 minutes
Ask: What are the indications for referring a newborn and how is safe transfer ensured.
Discuss and demonstrate the activities related with neonatal transport

Indications for Referral
1. A
 ll babies who require PPV
for more than 1 minute during
resuscitation
2. All LBW babies < 1800 gms
3. Feeding difficulty
4. 
Respiratory rate more than 60
per min (at least on two counts)/
apnoea/severe chest indrawing
5. 
Any baby having temperature less
than 35.5ºC
6. Fever >37.5ºC
7. Lethargy
8. Abnormal movements
Components of Safe Transfer Group Discussion & Demonstrate
• Communication with parents & referral unit Discuss current modes and process of neonatal transport.
• Stabilization prior to transport as under: Explain that under Janani Shishu Suraksha Karyakram (JSSK) and
• Maintenance of “warm chain” by placing National Ambulance Services, free referral transport is available
baby in KMC with the mother/any other
available method like transport incubator
• Maintenance of airway and oxygenation.
If need be, continue bag and mask
ventilation
• In case the newborn is accepting feeds,
then continue breastfeeding

KEY MESSAGES
Ensure pre referral management of the babies and provide all the relevant information on referral note. Communicate to the attendants the
need for referral.

27
HOW DO YOUHOW
TRANSPORT
DO YOU TRANSPORTA NEONATE
A NEONATE ? ?
HOW DO YOU TRANSPORT A NEONATE ?

27
 RADIANT WARMER: FAMILIARIZING WITH
THE MACHINE
Time: 30 minutes
Demonstrate radiant warmer: parts and functioning
Sr. No Parts of warmer Functions of the part Demonstrate/Explain
1. Bassinet For placing the neonate Cleaning of the bassinet, mattress & sheet
2. Mode selector Select manual or servo mode Setting up of manual mode & servo mode. How different modes
help in different settings
3. Quartz/ceramic rod Provides radiant heat Explain the need of using the principle of one radiant warmer for one baby
4. Temperature selection panel Select the desired skin temperature Show the different buttons and how to use them for setting temperature
5. Temperature selection knobs Select a desired set temperature Discuss the range of normal temperature and alarm setting
6. Temperature display Displays temperature as set or measured Demonstrate how to set the temperature
7. Skin probe When attached to the baby’s skin, Importance of probe secured in place
displays skin temperature
8. Control panel Has a collection of display and control features/knobs Explain the data on the display panel
9. Heater output display Indicates how much is the heater output Explain the significance of heater output - Low output signifies better
temperature maintenance by the baby
10. Alarms Alarm setting for low and high temperature The functioning and trouble shooting

KEY MESSAGES
1. Check temperature manually at least once per shift.
2. Always respond to alarms promptly and take corrective measures.

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ARE YOU FAMILIAR WITH THE WORKING OF RADIANT WARMER?

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 BAG & MASK–PARTS AND FUNCTION

Time: 30 minutes
Demonstrate assembling of bag and mask and checking functionality of a self‐inflating bag
Explain Demonstrate
EQUIPMENT SIZE Volume ranging from 240 to 500 ml
PARTS
Appropriate sized mask should cover Demonstrate how to choose the correct
Mask – 0 for preterm and 1 for term
the tip of the chin, the mouth, and the nose but not the eyes sized mask
Bag & Mask Body of bag Made of autoclavable material
Two inlets ‐ wider for air and the other for
Oxygen tubing attached at oxygen inlet & reservoir to air inlet.
oxygen.
Pop‐off valve‐ situated on It is a pressure release valve, which opens if excessive pressure is Ask the participants to self check the
top of the bag generated, to prevent lung injury and resulting air leak pop off valve
Patient outlet ‐ Mask is attached at the anterior end of the bag known as patient outlet
Disassemble all parts, wash thoroughly with warm water and soap. Autoclave or soak in glutaraldehyde 2% for 30 minutes for disinfection and for 6 hours for
CLEANING sterilization. After removing from glutaraldehyde rinse with clean water, dry with sterile cloth and then reassemble. Clean mask with spirit between patient use.
Disinfect daily and sterilize weekly
CHECKING Form a seal between the mask and the palm. Deliver a test breath against the palm & feel the pressure on the palm. Squeeze the bag for the pop off valve to open
FUNCTIONALITY and make a sound as the air escapes, check that the bag re‐inflates quickly when you release after squeezing the bag

KEY MESSAGES
Cleaning and checking the functionality of bag and mask must be included as a daily routine.

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 BAG & MASK: PARTS
BAG & MASK: WHAT AREAND FUNCTIONS
IT’S PARTS AND FUNCTIONS ?
Time: 30 minutes
BAG & MASK: WHAT ARE IT’S PARTS AND FUNCTIONS ?
Time: 30 minutes Time: 30 minutes

Pop-off Valve
Oxygen inlet

Body of Bag Air inlet

Mask

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