a presentation on Post Natal Care -.pptx

Post Natal Care -.pptx

1. Post Natal care of Newborn RRTC Resource Material

2. Importance of postnatal period & Postnatal care of newborn in health facility Daily care in postnatal ward by Doctor and Staff Nurses Newborn Examination Common newborn findings, benign skin and mucosal changes Congenital defects and injuries Eye, Skin and Cord care Immunization Schedule for Newborn Discharge of healthy newborn Checklist before discharge– Danger signs & Key messages for mother/caregiver regarding Maintenance of Body Temperature and Immunization Schedule for Infant and Child Key Learning Points Topics

3. Postnatal care (PNC ): create patient centric supportive environment for both mother and newborn as a continuation of the care the woman has received through her pregnancy and labor. Postnatal period – the first six weeks after birth – is critical to the health and survival of a mother and her newborn, most critical being first 48 hours which are generally spent at the health facility. F irst check-up of newborn within first 24 hours of delivery is a must in the post natal ward as part of routine morning rounds and is very important. Review the labor and birth record to identify any risk factors or any events during the birth which may be important in the management of the mother and the baby . Postnatal Environment : warm room with and a temperature of 26-28 ℃ keeping mother and baby together in the same bed right from birth helps in their close bonding Importance of Post natal period It is important to greet the mother appropriately before starting the examination of the baby. Good communication helps to reassure the mother that she & her baby will receive good care.

4. Service provider must d ocument & communicate to mother and other family members time of birth, weight , gender , any other relevant information and initiation of breast feeding. Ensure facility /state specific identification mark for baby. Cord should be kept clean, dry & free of any application (antiseptic etc.). Weigh all the infants after Breast feeding initiation preferably on a digital scale Administer Injection Vitamin K1, 1mg. Postnatal care of newborn in the labour room Mother /family to be counselled on using MCP card specially danger signs

5. Look# Examine Record Must look for any prelacteals used by mother/family. If Yes, what and how Breastfeeding initiated and sustained Any difficulty in feeding Meconium & Urine passed by 48 hours Alertness Cry, activity, reflexes Record any significant labour history Colour of the baby Jaundice , Cyanosis   Referral if required Mother’s Bld gp & Rh , Oxygen start time if cyanosis persists Eyes / umbilicus Umbilicus for any bleeding, redness or pus If treatment started Danger Signs Respiratory rate / minute Body temperature (to use palms to test core and limb temperature) Respiratory rate/ minute Temperature (axillary) Physiological changes/ developmental variations ** Weigh (if not done earlier) weight (naked weight) Look for any visible congenital malformations* and any birth injury and record it COMMON EXAMINATION FINDINGS IN NEWBORN *RBSK annexure

6. Daily care in postnatal ward by Doctor & Staff nurse Activities Observations Cry, activity , reflexes Babies cry when hungry/ in discomfort. Reasons for d iscomfort --- unpleasant sensation of a full bladder before passing urine, painful evacuation of hard stools or mere soiling by urine and stools. Examine and evaluate in detail if persistent crying Adequacy of breast feeding Passes urine at least 6-8 times in a day , no excessive weight loss. Any weight loss >5% in a 24-hour period is abnormal. Maintenance of temperature Keep the baby clean and dry at all times. Maintain room temperature in all weathers During winter : Pre-warm the linen and clothes of the baby before dressing. Cover the baby adequately using cap socks and mittens. During summer : Dress the baby in loose cotton clothes and kept indoors. Exposure of the baby to sunlight during the hot summer months can lead to serious hyperthermia. Jaundice Examine in daylight for the development and severity of jaundice twice a day till admitted. Passage of urine/meconium Meconium/ Urine not passed for 24 hours after birth needs to be evaluated

7. Daily monitoring Weight Most healthy term babies lose weight during the first 2 to 3 days of life and weight remains stationary during next 1-2 days and is generally regained by the end of the week Weight loss can be up to 5-10% of the birth weight. Average daily weight gain is 20-30gm/day Vomiting Regurgitation/spiting out soon after feeds is often due to faulty feeding technique and aerophagy . Counsel mothers regarding feeding and burping. Investigate if the vomiting is persistent, projectile, bile stained or is associated with abdominal distension/tenderness. Stools Transitional stools (Day 3/4 of life) are often semi-loose and greenish-yellow with increased frequency and settles within 24 to 48 hours; need reassurance. Breast fed babies pass stools while being fed or soon after a feed for a couple of weeks. Reassure if weight pattern is satisfactory and not be confused with diarrhea. Some breastfed babies pass stools infrequently (once every few days) then it is not constipation. Preterm babies loose 2-3% weight daily up to maximum of 10-15%. Preterm takes 10-14 days of age to regain birth weight

8. Examine the umbilicus - Umbilical stump should be inspected after 2 to 4 hours of birth as bleeding may occur at this time due to shrinkage of cord and loosening of the ligature. If knot is loose, tie again Look for any discharge or infection and keep cord clean and dry till complete healing takes place . Do not apply any medication on the cord and leave it open as it usually falls after 4 to 10 days. If there is umbilical redness or there is pus discharge and OR pustules manage as local bacterial infection administer A dd Oral Amoxicillin 50mg/ kg twice a day for 5 days as syrup/ drops & Follow up in 2 days Examine the eyes for discharge/ redness /swollen eyelids . Refer the baby to the pediatrician. EYE ,SKIN & CORD Care Continued…

9. Examine from head to toe to clinically screen for any life threatening congenital anomalies, malformations and birth injuries# [(# cephalohematoma, brachial plexus injury, facial paralysis, fracture & dislocation of hip )] Give special attention to identify and document the anal opening. Ensure to record in case sheet. Some of the birth defects to be reported as per RBSK Operational Guidelines are: 1. Neural Tube Defect 2. Down’s Syndrome 3. Cleft Lip & Palate 4. Talipes (club foot) 5. Developmental Dysplasia of Hip 6. Congenital Cataract 7. Congenital Deafness 8. Congenital Heart Disease [Pulse oximetry in all 4 limbs after 24 hrs. If difference in Rt & Lt >3, then refer] DO NOT routinely pass catheter in the stomach, nostrils and the rectum and do STOMACH WASH Look for & Record Congenital defects & injuries

10. Annexure 3

11. Mothers observe their babies very carefully and are often worried by minor physical peculiarities, which may be of no consequence and do not warrant any therapy. Link for case sheet of normal baby

12. Condition Description Action: Reassure Mother Mastitis N eonatorum Engorgement of breasts in term babies of both sexes on the third or fourth day and may last for days or even weeks. No local massage, fomentation and expression of milk. V aginal bleeding   Mild bleeding seen 3/5 days after birth for two to four days. Additional vitamin K is unnecessar y. Mucoid vaginal secretions T hin , grayish , mucoid , vagina l secretion Shoul d no t b e mistake n for purulent discharge. T ongue Tie   Fibrous frenulum with a notch at the tip of the tongue. Does not interfere with sucking or later speech development. Non-retractable prepuce   Normally nonretractable in all male newborn babies, The urethral opening is often pinpoint and is visualized with difficulty. Do not forcibly retract the foreskin. Hymenal tags Seen a t th e margi n o f hyme n in tw o -third of female babies Umbilical hernia   Manifest after the age of 2 weeks or late r. Most disappear spontaneously by one or two years of age . Annexure 1

13. P eeling ski n Dry skin with peeling and exaggerated transverse sole creases seen in post term & some term babies Milia Y ellow – white spots on the nose or face in practically all babies and disappear spontaneousl y T o xi c erythem a/ Erythem a Neonatorum An erythematous rash of unknown cause with a central pallor appearing on the 2 nd / 3 rd day in term neonates & d isappear s spontaneousl y afte r tw o t o thre e day s withou t an y specifi c treatment . Stork bites (Salmo n patche s / naevu s simplex Discrete , pinkish-gra y , sparse , capillary hemangiomata commonly seen at the nape of neck, upper eyelids, forehead and root of the nose which disappears after a few months. Mongolia n blu e spots Irregula r blu e area s o f ski n pigmentatio n ofte n present over the sacral area and buttocks, though extremities and rest of the trunk , disappear by the age of six months. Sub-conjunctival haemorrhage Semiluna r arc s o f sub- conjuctiva l hemorrhag e are a commo n ly seen. G ets reabsorbed after a few days without leaving any pigmentation. Epstein P earls Whit e spots , usuall y on e o n eithe r sid e o f th e media n raph e o f th e har d palate/ prepuce & have no significance. Suckin g callosities Button like ,cornified plaques over the centre of upper lip, has no significance. Normal phenomena in newborn Annexure 1

14. Discharge once the following criteria are fulfilled: Newborn is free from any illness including significant jaundice and is immunized. Adequacy of breastfeeding is established, indicated by: P assage of urine at 6 to 8 times/24 hrs, Onset of transitional stools, Baby sleeping well for 2-3 h after feeding. Mother confident to take care of her newborn and mother is oriented on use of MCP Card and home visits by ASHA and next follow up visit has been planned and scheduled. Home visits six in number on 3rd day, 7th day, 14th 21st, 28thand 42ndday of post natal period (in case of institutional delivery) and seven visits on 1st , 3rd, 7th, 14th, 21st, 28th and 42nd day of postnatal period (in case of home delivery) by ASHA/ANM Checklist before discharge for healthy newborn

15. Advice at discharge [to mother/caregiver] Maintenance of body temp Nursing mother baby together and covering head and feet Breastfeeding Demand, even during night. During each feed, one breast should be completely emptied before the baby is put to the other breast. No need for additional water or other fluids except under medical supervision. Skin care/bathing Always take special precautions during bathing to prevent draught and chilling. Sponge the baby if not possible to bathe. No bathing for 48 hours. Care of the umbilical stump Do not apply anything on the cord and leave it open, cord usually falls after 4 to 10 days. Care of the eyes Routine application of antiseptic ointment or drops is not recommended. Persistent epiphora (watering ): massage either side of the nose adjacent to the medial canthus) 5 to 8 times daily, while feeding. Immunization Give BCG, zero dose of oral polio vaccine and Hepatitis B vaccine as early as possible. Inform mother about next due date and document in MCP Card bathing special attention should be paid to the head, face, skin flexures, cord and napkin area. Dry properly with a soft cloth When to seek help and where to go in case the baby shows any signs of illness.

16. Annexure 2

17. Immunization Schedule for New-born Vaccine When to give Dose Route Site BCG At birth/as early as possible till one year of age 0.1ml (0.05ml until 1 mth ) Intra-dermal Left Upper Arm Hepatitis B – birth dose At birth/as early as possible within 24 hours 0.5 ml Intra-muscular Antero-lateral side of mid-thigh OPV-0 At birth/as early as possible within the first 15 days 2 drops Oral Oral Source-National Immunization Schedule Wait at least 4 weeks (one month) after previous dose of Pentavalent & OPV before giving next dose. If child comes after gap of more than 4 weeks for its next dose of Penta & OPV, give next dose of series . Do NOT repeat previous dose, as there is no maximum interval between doses. Two live injectable vaccines can be administered simultaneously at different sites, otherwise at a minimum interval of 28 days. Vaccines not be started after 1 Year Age ; BCG, Hep B, Pentavalent, PCV & RVV

18. Give these 4 Key Messages to the Care-giver What vaccine was given and what disease it prevents (e.g. BCG for preventing TB) What minor adverse-events could occur and how to deal with them. When and where to come for the next visit. To keep the vaccination card safe and to bring it along for the next visit Vaccinate even if the child is suffering from diarrhea, mild fever or malnutrition. DO NOT vaccinate only when a sick child requires hospitalization.

19. Danger Signs : Baby is unable to cry Difficult breathing (severe chest in-drawing or Nasal flaring or grunting) Fast Breathing ( RR ≥ 60 bpm) Not breastfeeding or feeding poorly Develops a fever / feels cold to touch Convulsions/ Lethargic or unconscious Yellow palms and soles ( Jaundice) Inability to pass urine and stool/ Blood in stool Advise the mother to return immediately if the neonate has any of the above danger signs

20. Sign/symptoms Assessment Action Activity Movements are less than normal/ abnormal movement He/she needs to be referred to the Pediatrician cry poor or persistent shrill cry Alertness Not alert and/ Lethargic/unconscious/ Difficult to be awakened by stimulation Respiratory rate- breaths per minute Normal respiratory rate is 40-60/m. Repeat the count, if first count is 60 or more If the count is again 60 breaths or more, the neonate has 'fast breathing RR >than 60/m – categorize as Fast breathers (possible sign of respiratory distress. Respiratory Distress Mild chest indrawing -normal in a neonate because the chest wall is very soft. Severe chest indrawing -(lower chest wall goes in when the infant breathes in) is a sign of pneumonia and is serious in a neonate. Nasal flaring is widening of the nostrils when the neonate breathes in. Grunting is the soft, short sounds a young infant makes when breathing out, when an infant is having trouble breathing. Presence of severe chest in-drawing &/or nasal flaring &/or grunt indicate severe respiratory distress Danger signs contd Severity of Hypothermia Axillary temperature Assessment by feeling Initial Action Mild 36.0  C to < 36.5  C Cold feet, Warm abdomen Skin to skin contact(KMC) Clothe baby adequately covering head & extremities Ask the mother to Breast feed   Fever > 37.5°C (>100 F) Body is warm Remove excess clothing Assess Breast feeding Change environment (take baby to cooler place) Screen for sepsis  

21. Rani delivered a 2kg baby 24 hours ago with no danger signs. The baby is feeding well on breast. Her mother complains that her baby feels cold to touch. Physical examination findings- baby is alert, temperature is 34.6℃, Respiratory rate 50 breaths per minute, no in-drawing of chest, extremities and abdomen are cold. Case Study Questions Answers 1 What will you include in your initial assessment of baby Rani? Greet the mother appropriately before starting the examination of the baby to reassure the mother that she & her baby will receive good care. Baby Rani and her mother should be kept in a room with temperature between 26-28℃ Rapid initial assessment --to determine the degree of illness- temperature, respiratory rate, breathing pattern, colour , level of consciousness and assessment of baby’s temperature by touch 2 What will you examine to help you make a diagnosis? Temperature Examination of extremities and abdomen by touch 3 Any laboratory tests will you include in your assessment of baby Rani? None at this stage 4 Based on findings what is your diagnosis? Baby Rani’s symptoms and signs (temperature 34.6℃ with cold extremities and abdomen are consistent with Moderate Hypothermia) 5 How will you manage this baby? Remove wet clothes, and cover the baby with adequate clothing (3-4 layers) Put the clothed baby under Radiant warmer Breast feed the baby and Perform Skin to skin contact(KMC) Advise: delayed bathing and continue KMC as baby is stable Maintain room temperature 26-28℃ (away from windows, no draught; etc.) Explain danger signs Teach temperature assessment (BY TOUCH)

22. Immunization Schedule for Child Vaccine When to give Dose Route Site DPT booster-1 16-24 months (DPT can be given up to 7 yrs of age) 0.5 ml Intra-muscular Antero-lateral side of mid-thigh Measles / MR 2nd dose 16-24 months 0.5 ml Sub-cutaneous Right upper Arm OPV Booster 16-24 months 2 drops Oral Oral JE -Booster 16-24 months 0.5 ml Sub-cutaneous Left Upper Arm Vitamin A (2 nd to 9 th dose) 16 months with MR 2 nd , Then, one dose every 6 mths up to 5 yrs of age. 2 ml (2 lakh IU) Oral Oral DPT Booster-2 5-6 years 0.5 ml. Intra-muscular Upper Arm TT/Td 10 yrs and 16 yrs 0.5 ml. Intra-muscular Upper Arm Source-National Immunization Schedule