Essential Newborn Care

Dr Rupak Kumar Rana

VCHS
2080
 Learning Objectives
• Definition of ENC
• Components of ENC
• How to provide ENC
• Algorithm of neonatal resuscitation
• Prevention of Hypothermia in neonates
 ENC: Definition
• Majority of babies born healthy and at term
• Care during first hours, days and weeks of life
determine whether they remain healthy
• Basic care to support survival and wellbeing
is called ENC
• It includes immediate care at birth, care
during the first day and up to 28 days
 Neonatal Deaths
Neonatal deaths are a major contributing factor to U5 mortality in
Nepal

Under
five deaths

Neonatal deaths
38% 16%

World Nepal
Source:
PFC 2007 & SRS
 Major causes of U5 mortality
Neonatal
45% Measles Others, 6
4% Diarrhoea, 2
Malaria
1%
Neonatal
Others
8% Tetanus, 4
injuries
2% Congenital
HIV/AIDS anomaly, 4
1% Sepsis, 36
Pneum onia
Diarrhoea
19%
20% Small/Very
Small at birth,
21

Asphyxia, 23

WHO 2008, CHERG (Nov 2006)

Causes of Neonatal Deaths
Nepal: When and why do neonates die ?

Week 1 73.3%
Day U5
Day1 39.5% Child
deaths
2 6.7% Asphyxia
3 10.2% Prematurity
1st day
4 5.6% 20%
5 5.6%
By 3rd
day
25%
6 2.7%

7 3.0%
By 7th
Tetanus
Sepsis / day
37%
pneumonia
Week 2 13.8%
By 28th
Week 3 8.7% day
50%
Week 4 4.2%

0% 10% 20% 30% 40% 50% 60% 70% 80%

 Four basic needs of ALL
newborns
• To breath normally
• To be protected
• To be warm
• To be fed
 Essential Newborn Care
Interventions
• Clean childbirth and cord care
– Prevent newborn infection
• Thermal protection
– Prevent & manage newborn hypo/hyperthermia
• Early and exclusive breastfeeding
– Started within 1 hour after childbirth
• Initiation of breathing and resuscitation
– Early asphyxia identification and management
Universal Precautions & cleanliness
• Wash hands.
• Wear gloves.
• Protect yourself from blood and other
body fluids during deliveries.
• Practice safe sharps disposal.
• Practice safe waste disposal.
• Deal with contaminated laundry.
• Sterilize and clean contaminated
equipment.
 PREPARING FOR BIRTH
WASH YOUR HANDS
ESSENTIAL
• A draught free, warm room - temperature 250C +
• A clean, dry and warm delivery surface
• A radiant heater
• Two clean, warm towels/cloths: to dry, wrap or
cover the newborn baby.
• A folded piece of cloth
• A suction device
• A newborn size self inflating bag, masks
• Laryngoscope
• Oxygen
• Disposables
• Medications
• A CLOCK
 Care of the baby at the time of
birth
(Until around 1 hour after birth)
• Provide routine care at birth for all
newborns

• Identify and manage newborns who may

need special care
 Routine Care
• Call out time of birth
• Place baby on mother’s abdomen
• Dry baby with warm clean sheet
• Wipe mouth and nose with clean cloth
• Assess baby’s breathing while drying
• Clamp cord after 1-3 min, cut with sterile
instrument, put sterile tie
• Put identity label on the baby
 Routine Care
• Examine for malformations/ birth injury
• Initiate breast feeding within 1 hour
• Record baby’s weight
• Give Inj Vit K 1mg IM ( 0.5 mg for preterm)
• Cover baby’s head with cloth.
• Cover mother and baby with warm cloth
APGAR SCORING
 OBJECTIVES
• Overview of Apgar scoring
• Explain the significance and components
of Apgar scoring
 APGAR SCORING
• The Apgar score was devised by Dr. Virginia
Apgar in 1953 and is a commonly quantitative
measure of neonates wellbeing at and around
birth.
• The purpose of the Apgar score is to evaluate
physical condition of the newborn at birth and
the immediate need for resuscitation.
• The newborn is rated at 1minute and 5 minutes
after birth and it gives a total score ranging
from 0 to 10.
• The 1 minute score indicates the degree of central
suppression of the baby and is important for further
management of resuscitation.
• The 5 minute score indicates the baby’s ability to
adapt to extrauterine life and is also a reliable
predictor of the risk of death during the first 28days
of life and the child neurological state and risk of
major disability at the age of 1 year.
• The higher the Apgar score the better the outcome of
the baby.
• The mnemonic for Apgar score is:
• A Appearance (i.e. color)
• P Pulse (i.e. heart rate)
• G Grimace (i.e. response to stimuli)
• A Active (i.e. tone)
• R Respirations
The five indicators used are;
 Heart rate: auscultate or palpate at the
junction of the umbilical cord and skin. This is
the most important assessment. A newborns
heart rate of less than 100 beats per minute
indicates need for immediate resuscitation
 Respiratory effort: second most important
assessment. Complete absence is termed
apnea and a vigorous cry indicates good
respirations.
 The muscle tone: evaluate the degree of
flexion and resistance to straightening of the
extremities. A normal term newborns elbow’s
and hips are flexed, with the knees positioned
up towards the abdomen.
 Reflex irritability: evaluate as the newborn
is dried or by lightly rubbing the soles of the
feet. A cry is a score of a 2 and a grimace is a 1
and no response is 0.
 Skin color: inspect cyanosis and pallor.
Newborns generally have blue extremities and
the body is pink which merits a score of 1. This
condition is termed acrocyanosis and is present
in 85% of normal newborns at a 1 minute after
birth. A completely pink newborn scores 2and
a totally cyanotic, pale newborn score 0.
Newborns with darker skin pigmentation will
not be pink. Their skin color is assessed for
pallor and acrocyanosis and a score is selected
based on assessment.
 0 1 2
Appearance Pale/ Blue Acrocyanosis Pinkish all
over
Pulse Absent Slow, Good, crying
irregular
Grimace No Response Grimace/ Vigorous cry
Flaccid

Activity Limp Some flexion Active motion

of extremities

Respiration Absent Less than 30 Greater than

30
• A score of 8 to 10 indicates that the neonate is in
good condition and requires only nasopharyngeal
suctioning and perhaps some oxygen near the face.
• A score of 4 to 7 indicates the need for stimulation
and a score under 4 indicate the need for
resuscitation.
• The midwife should normally expect a score of about
9 in a normal term newborn due to acrocyanosis
caused by poor peripheral circulation. However
some Newborn can give a score of 10
 Resuscitation
• 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
 Resuscitation Flow Diagram
Note the time
Birth Receive baby in dry,
warm linen
Routine care
• Dry baby on mother’s abdomen Assess
• Provide warmth (skin to skincare) ment
Is baby crying/ YES • Assure open airway if needed
breathing • Cut cord in 1-2 min
• Ongoing evaluation of neonate
No
•Cut cord immediately and place
under radiant warmer
• Provide initial steps (Dry, Yes
position, clear airway, tactile A
Stimulus)

No Labored
30 sec Gasping/Apnea or HR<100 breathing/Cyanosis Evluation

Yes
Yes
Insure open airway, O2,
Initiate PPV Monitoring, Consider B
60 sec using air/O2 shifting to SCNU
 Initiate PPV
using air/O2

No Baby breathing well and

Heart Rate after 5
infl ations: <100 bpm? heart rate>100 bpm Evaluation

Yes
Look for Chest Rise; if Not Yes Observational
PPV <1 min
• Reduce leaks care
• Ensure open airway
• Consider increasing pressure
No

If Heart rate < 60 bpm and chest rising Post-

• Continue PPV, add 100% oxygen Baby breathing well resuscitation
and
• Start chest compressions: 3:1 care
heart rate>100 bpm

C
If HR not detectable or <60bpm
Give Adrenaline
Where do babies go from delivery
room?
A) Refer if:
• Birth weight <1500 gms, <34 weeks
• Major congenital malformation
• Severe birth injury
• Respiratory distress
• PPV >1 minutes or needing chest
compression or drugs
B) Observational care:

• Birth weight 1500-1800 gm

• Babies needing IPPV <1 minutes and vigorous

 Immediate cord care
• 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.
Newborn can lose heat in four ways
 Keeping a newborn baby warm
after delivery
Method of heat loss Prevention

Evaporation: Wet baby Immediately after birth dry

baby with a clean, warm,
dry cloth
Conduction: Cold surface Put the baby on the
e.g weighing scale etc. mother’s abdomen or on
a warm surface
Convection: Cold draught Provide a warm, draught
free room for delivery at
≥25oC
Radiation: Cold metallic Keep the room warm
surroundings
Kangaroo mother care
 KMC
• Skin to skin contact, any family member can do
• Not less than 1 hour at a time
• useful for LBW
• Provide warmth, promote BF,
• Protects from infection
• Emotional bonding
• Physiological stability, reduces apnea
• Multimodal stimulation
 Warm chain
• Warm delivery room
• Immediate drying
• Skin to skin contact at birth
• Breastfeeding
• Bathing and weighing postponed
• Appropriate clothing
• Mother and baby together
• Warm transportation
 Breastfeeding
• Help mother to initiate breastfeeding within
first hour of birth
• Help mother at first feed
• Ensure
- Good position
- Good attachment
- Effective suckling
CARE OF NEWBORN IN POSTNATAL WARD
 Postnatal environment
• Kept warm with no draughts from open
doors or windows. Temperature of 25 C
required.
• Mother and her baby kept together in same
bed (rooming-in)
• Helps to form bonding, can respond quickly
when her baby wants to feed, reduces
breastfeeding difficulties
 Ask the mother
• Do you or baby have any problems?
• Has infant passed stools, urine?
• Have you started breast feeding infant?
• Is there any difficulty in feeding infant?
• Do you have any pain while breast
feeding?
• Have you given any other foods or drinks
to infant? If yes, what and how?
 Examine the baby
• Count breaths in one minute
• Look for severe chest indrawing
• Look and listen for grunting
• Look at umbilicus. Is it red or draining pus?
• Look for skin pustules. Are there 10 or more
pustules or a big boil?
 Examine the baby
• Measure axillary temperature (if not
possible, feel for fever or low body
temperature)
• See if young infant is lethargic
• Look for jaundice. Are the face, abdomen or
soles yellow?
• Look for malformations
 Assess Breastfeeding
If infant has not fed in previous hour, ask mother
to put her infant to breast. Observe the
breastfeed for 4 minutes.
• Is the infant able to attach?
To check attachment, look for:
- Chin touching breast
- Mouth wide open
- Lower lip turned outward
- More areola above than below the mouth
 Assess Breastfeeding (contd)
• If not well attached, help mother to position so
that baby attaches well.
• Is the infant suckling effectively (that is, slow
deep sucks, sometimes pausing)?
• If not sucking well, then look for:
- ulcers or white patches in mouth (thrush)
• If there is difficulty or pain while feeding, then
look for
- Engorged breasts or breast abcess
- Flat or inverted, or sore nipples
 Look for Normal Phenomena
• milia, epstein pearls, mongolian spots,
enlarged breasts, capillary nevi etc.
• Transitional stools
• Vaginal white discharge/bleeding in female
babies
• Red rashes on skin on 2-3 days of life.
• Weight loss of 6-8% (10-12% in preterms) in
first few days of life
 Cord Care
• 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
 Skin and Eye Care
• Babies are not bathed routinely in hospital to
prevent complications like hypothermia and
infection,
• May be sponged with lukewarm water.
• No routine eye care is required
 Counsel the mother
• Keep baby warm
• Breastfeed frequently and exclusively
• Advise mother to wash hands with soap and
water after using toilet and after cleaning
bottom of baby.
• Advise mother regarding danger signs and
care seeking.
 Immunization
• The baby should receive
-BCG
-OPV-0
-Hepatitis B (HB-1) - if included in immunization
schedule
 Follow-up
• Schedule postnatal visit within first week on
day 3 and day 7 of delivery. Also visit on day
14, 21 and 28 if baby is LBW.
• Assess for growth and development and signs
of illnesses
• Health education of parents done
• Assessed at least once every month for 3
months and subsequently 3 monthly till 1 year.
 SUMMARY
• Basic care to support survival & wellbeing is ENC
• Ventilation must be initiated within 1st min of life
• Help to initiate breast feeding within 1st hr of birth
• Identify and refer neonates requiring special care
• Take all precautions to prevent infection,
hypothermia and counsel mother for the same
• Counsel mother for Danger signs, immunization &
follow-up
 Questions
Q. 1-Which of the following is the most common
cause of neonatal death in India:
• (A) Birth asphyxia
• (B) Sepsis
• (C) Low birth weight
• (D) Congenital anomaly
Q2. After birth, how long it can take to achieve
an oxygen saturation of 90% in normal term
newborn
• (A) 1 minute
• (B) 2 minutes
• (C) 5 minutes
• (D) 10 minutes
Q3. As per neonatal resuscitation program India,
need for resuscitation at birth is decided by
assessing following risk factor/s at birth-
• (A) Gestational maturity
• (B) Breathing
• (C) Muscle tone
• (D) All of the above
Q4. All of the following statements are true
about kangaroo mother care except

• (A)Especially useful for low birth weight

babies
• (B) Risk of apnea is increased
• (C) Decreased risk of infection
• (D) Can be practiced by other family members
Q5. Most consistent clinical finding of early
onset neonatal sepsis is?
• (A) Apnea
• (B)Tachypnea
• (C) Fever
• (D) Seizure
Q6. Presence of all of the following features
suggest good attachment of infant to mother’s
breast except:
A.Mouth widely open
B.Lower lip curled out
C.Chin touches the breast
D.Lower areola visible more than upper
 Answer
• Q1: B
• Q2: D
• Q3: B
• Q4: B
• Q5: B
• Q6: D
THANK YOU