ESSENTIAL NEWBORN CARE

PROTOCOL
Warsame, Ahmed
Sebanes, Kimberky Mae
Silao, Emee Joy
 ESSENTIAL NEWBORN CARE PROTOCOL (UNANG
YAKAP)
• Philippines is 1 of the 42 countries that account for 90%
of global under 5 mortality
• Neonatal Mortality accounts for 37% of under 5
mortality which in number translates to more than
40,000 newborns dying in the Philippines per year
• Half of newborns die in the first 2 days of life - Most die
from preventable causes
• Majority of Newborn (NB) deaths are due to:
• Birth asphyxia – 31%
• Complications of prematurity – 30%
• Severe Infections – 19%
• ENC Protocol is a simple, concise, and straightforward
guideline that is backed by solid research evidence. It
emphasizes a core sequence of actions performed step by
step and can be enforced immediately in all health care
settings
 
ENC Protocol

• At the heart of the protocol are 4-time bound interventions:

– Immediate and thorough dying of….
– Skin to skin contact between mother and NB
– Properly timed cord clumping and cutting
– Non-separation of NB and mother for early
breastfeeding
• UNANG YAKAP (first embrace)
Is a campaign to spread the use of ENC Protocol which can prevent at
least half of NB deaths without additional cost to both families and
hospitals
• Organized by time
• Walks the health worker through the process of preparing the delivery
area, standard precautions through ENC practices, beginning at the time
of perineal bulging until 1 week of life

– Immediate NB care (1st 90 mins)

– NB care from 90 min to 6 hrs after birth
– Care prior to discharge
– Care from discharge to 7 days
– Additional care
– Enabling the environment
– Equipment and Supplies maintenance Checklist
– References
– Index
I- Immediate NB care (1st 90 mins)

1st Time band: at perineal bulging, w/ presenting part

visible (2nd stage of labor)

Intervention: prepare for delivery Action:

– Ensure that delivery is draft-free and between 25-28
degC
– Wash hands with clear water and soap
– Double gloves just before delivery

Time Band: w/in 1st 30s after birth

– Call out the time or birth
Intervention: Dry and provide warmth

Action:
– Use a clean, dry cloth to thoroughly dry the baby by
wiping the eyes, face, head,
Front & back, arms and legs
– Remove the wet cloth
– Do a quick check of the NB’s breathing while drying
2nd Time Band: After 30s of thorough drying, NB is
breathing or crying

Intervention: Do skin to skin contact

Action:
– If crying and breathing normally, avoid any manipulation
such as routine suctioning that may cause trauma or
introduce infection
– Place the NB prone on the mother’s abdomen or chest
skin-to-skin
– Cover the NB’s back w/ a blanket and head w/ bonnet
– Place ID band on ankle
– Do not separate NB from mother unless NB or
mother needs immediate medical attention
– Do not NB on a cold or wet surface
– Do not wipe off vernix if present
– Do not bath the NB earlier than 6 hours of life
– Do not do footprinting
– If the NB must be separated from the mother,
put the baby in a warm surface, in a safe place
close to the mother
 3rd Time Band: 1-3 min
Intervention: Do delayed or non-immediate cord clumping

Objectives:
– Reduce the incidence of anemia in the term NB
– Reduce the incidence of Intraventricular hemorrhage in
preterm NB (Hint: Do cord clumping when pulsations stop)
Action:
– Remove the 1stset of gloves immediately prior to cord
clumping. Clumpand cut the cord after cord pulsations have
stopped (typically at 1-3 mins)

Note: Do not milk the cord towards the NB

– Put ties tightly around the cord a 2cm and 5cm from the NB’s
abdomen
– Cut ties with sterile instrument
– Observe for oozing of blood
4th Timeband: w/in 90min of age
Intervention: Provide support for initiation of breastfeeding

Action:
– Leave the NB on mother’s chest in skin-to-skin contact. Observe
the NB. Only when the baby chews feeding cues (opening of
mouth, tounguing, licking, rooting), make verbal suggestion to
the mother to encourage her NB to move towards the breast.
Example: nudging
– Counsel on positioning and attachment. When the baby is ready,
advise the mother to: oMake sure the NB is facing the breast with
the NB’s nose opposite her nipple and chin touching the breast
• Hold the NB’s body close to her body
• Support the Nb’ whole body not just the head and
shoulders oWait until the NB’s mouth is wide open
• Move her NN onto her breast aiming the infants lower lip
well below the nipple
Look for signs of good attachment and suckling:
• Mouth wide open oLower lip turned outwards
• Baby’s chin touching breast
• Suckling is slow, deep w/ some pauses

- If the attachment or suckling is not good, try again and

reassess
- Health workers should not touch the NB unless there is
medical indication
- Do not give sugar and water formulas or other prelactals
- Do not give bottles or pacifiers
- Do not throw away colostrums
 5th Intervention: Do eye care
Action:
• Administer erythromycin or tetracycline ointment
or 2.5% Povidone iodine drops to both eyes after
NB has located the breast
• Do not wash away the antimicrobials
II- NB care from 90 min to 6 hrs after birth

 
1. Intervention: Give Vitamin K prophylaxis Action:
• Wash hands
• Inject a single dose of Vit K 1mg IM. If parents decline IM injection, offer
oral Vit K as 2nd line
2. Inject Hep B vaccine IM and BCG ID Action:
• Inject and record

3. Intervention: Examine the baby. Check for birth injuries, malformations, or

defects Action:
• Weigh the NB and record
• Look for possible birth injury and or malformations
• Refer for special treatment and or evaluation of available
• If the NB has feeding difficulties because of injuries or malformations,
help the mother to breastfeed. If not successful, teach her alternative
feeding method
4. Cord Care
• Wash hands
• Fold diaper below stump. Keep stump loosely
• Cover w/ clean clothes
• If stump is soiled, wash it with clean water and snap.
Dry it thoroughly w/ clean cloth
• Explain to the mother that she should seek care if the
umbilicus is red or draining pus
• Teach the mother to treat local umbilicus 3x a day
• Do not bandage the stump or abdomen
• Do not apply any substances or medicine on the stump
- Avoid touching stump unnecessarily
UNNECESSARY PROCEDURES:
• procedures routinely done in the Phil settings but in fact not
recommended for all neonates
1. Routine suctioning
• no benefit if amniotic fluid is clear and neonate
is breathing normally
• can become a source of infection, can cause
cardiac arrhythmia
 
2. Early Bathing (after 6hrs)
• can cause hypothermia leading to increased
risk of infection, coagulation defects and
brain hemorrhage
• it removes the vernix caseosa w/ch is a
moisture barrier, protective against bacteria
than can cause neonatal sepsis
3. Footprinting
• Proven to be an adequate technique for NB
ID purposes
• Better: genotyping & HLA tests acdg to AAP
and ACOG
4. Giving sugar and water & other prelactals
• Not advised
• Delays initiation of breastfeeding which is
linked to a 2.6x increase in the chances of
NB deaths due to infection

5. Application of alcohol and other medicines and bandaging the cord

stump or abdomen
• Clearing with alcohol can keep the stump
moist wch can result to bacterial growth
• Bandaging prevents aeration à facilitates
delayed drying process
III- Care Prior to discharge
1.Support unrestricted, per demand breastfeeding, day
and night
2.Ensure warmth of the baby
3.Washing and bathing (hygiene)
4.Sleeping (let NB lie on his/her back or side)
5.Look for danger signs
6.Look for signs of
jaundice and local
infections (eyes, DANGER Signs:
• Fast/slow breathing, severe chest in-drawing,
skin, umbilicus) quinting
• Convulsions, floppy or shiff
• Fever >38degC or temp <35degC or not rising
after rewarming
• Umbilicus draining pus, bleeding from stump
• More than 10 skin pustules or bullae or swelling or
redness or hardness of the skin (sclerema)
Discharge Instructions:
1. Advise the mother to return or go to the hospital if
baby has any of the following
- Jaundice of the soles
- Difficulty of feeding
- Convulsions
- Movement only when stimulated
- Fast or slow or difficulty breathing (ex: severe in-
drawing)
- Temp more than or equal to 37.5degC or less
than or equal to 35.5degC

2. Advise mother to bring her NB to the following for

routine check-up:
1.Postnatal visit 1: at 48-72 hours of life
2.Postnatal visit 2: at 7 days of life
3.Immunization visit: 6 weeks of life
IV. Care after Discharge to 7 days

TIME BAND: From discharge to 7 days

ACTION:
Ask the mother exactly what the baby fed on in the past 24
hours before the visit. Ask about water, vitamins, local foods
and liquids, formula and use of bottles and pacifiers. Ask
about stooling and wet diapers.

Advise the mother to:

– Keep the newborn in the room with her, in her bed or
within easy reach
– Exclusively breastfeed on demand day and night (≥8 times
in 24 hours except in the fi rst day of life when newborn
sleeps a lot).
INTERVENTION: Ensure warmth for your baby

ACTION: Explain to the mother that babies need an

additiolnal layer of clothing compared to older children or
adults. Keep the room or part of the room warm, especially in
a cold climate .During the day, dress up or wrap the baby. At
night, let the baby sleep with the mother or within easy
reach to facilitate breastfeeding

Notes:
– Do not put the baby on any cold or wet
surface.
– Do not swaddle/wrap too tightly.
– Do not leave the baby in direct sunlight.
Ensure additional warmth for the small
baby
INTERVENTION: Look for danger signs

ACTION:
Look for signs of “very severe disease”
– Yellow skin to the soles
– History or difficulty feeding
– History of convulsions
– Movement only when stimulated
– Respiratory rate >60 per minute
– Severe chest in-drawing
– Temperature > 38.0oC (per local expert opinion)
– Temperature <35.5oC

Refer baby urgently to hospital !!!

AREA OF CONCERN: Feeding Support
ACTION:
Give special support for breastfeeding:
 Encourage the mother to breastfeed every 2-3 hours.
 Assess breastfeeding daily: positioning, attachment, suckling,
duration and frequency of feeds, and baby satisfaction with the
feed.
 Weigh baby daily.
 When mother and newborn are separated, or if the baby is not
sucking effectively, use alternative feeding methods

Explain KMC to the mother:

 continuous skin-to-skin contact
 positioning her baby
 attaching her baby for breastfeeding
 expressing her milk
 caring for her baby
 continuing her daily activities
 preparing a ‘support binder’4
K4
K9
Position the baby for KMC:

 Place the baby in upright

position between the
mother’s breasts, chest to
chest
 Position the baby’s hips in a
‘frog-leg’ position with the
arms also flexed.
 Secure the baby in this
position with the support
binder
 urn the baby’s head to one
side, slightly extended
 Tie the cloth firmly

Notes:
- KMC should last for as long as possible each
day. If
the mother needs to interrupt KMC for a short
period,
Dealing with Feeding Problems

AREA OF CONCERN: Mother-Infant Separation

ACTION:
When mother and newborn are separated, or if the baby is not
suckling effectively use alternative feeding methods:

Teach the mother hand expression of milk. Do not do it for her.

 Teach her how to wash her hands thoroughly
 Sit or stand comfortably and hold a clean container below her
breasts
 Press slightly inward towards the breast between her finger and
thumb.
 Express one side until milk flow slows. Then express the other side.
 Continue alternating sides for at least 20-30 minutes.
Breastfeeding Positions
1. Cradle Hold

•the most popular way to hold baby

•baby's head is supported by the crook of right
elbow as he nurses from the right breast.
•if baby is heavy, your left arm may be under your right
arm for extra support
•if you are trying to encourage let down reflex, or trying to
empty plugged ducts, left hand can massage the right
breast as the baby is nursing.
•the key here is that right arm will support the baby when
you are feeding from the right breast.
2 Cross Cradle Hold (Crossover Hold)

•especially useful for young infants who do not know yet how to
breastfeed
•when feeding on the right breast, the weight of the baby will be
supported
by the left arm.
• left hand will hold the baby's head and guide it towards the right
breast.
•called cross cradle because left arm is used to hold the baby
while he nurses on the right breast and the right arm to hold
the baby
while nursing on the left breast
3 Underarm Hold, Clutch Hold ( formerly: Football Hold)

•hold requires that you hold your baby like a football.

•to feed on the right breast, you will clasp baby's torso under your
right armpit.
•his legs will not be visible since they will extend behind you.
•use your right hand to position Baby's head to your right breast.
•to feed from the left breast, hold Baby's torso under your left
armpit
and use your left hand to position Baby's head onto your left
breast.
4 Side lying position

• Mother is lying on the lateral position

• Left lateral: if feeding baby on the left breast; right lateral if feeding
baby on the right breast
• Baby’s whole body should be straight, facing mother, and lies close to
the mother’s body
• Mother’s free arm/hand(contralateral) supports the baby, the other
arm/hand, usually resting on a pillow , supports mother’s head.
 BABY’S POSITION
The baby’s body needs to be:
1. in line with ear, shoulder and hip in a
straight line, so that neck is neither
twisted nor bent forward or far back:
2. close to the mother’s body so the baby
is brought to the breast rather than the
breast taken to the baby.
3. supported at the head, shoulders and if newborn,
the whole body supported:
4. facing the breast with the baby’s nose to the
nipple as she or he comes to the breast.
Note: Health worker who assesses the mother/
baby’s position in bf must be in a comfortable
position herself.