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Child health nursing

1. Immediate care at birth

2. 1. Goal and learning outcomes Every newborn receives evidence-based care at birth. Provide routine care immediately after birth including thorough drying, assessment, skin-to-skin contact, delayed cord clamping, support of early exclusive breastfeeding. Give preventive treatments. Assess at birth and manage accordingly. Communicate effectively and give respectful maternal and newborn care.

3. 2. The situation: Newborn needs and rights Meena’s son Aarush has just been born by spontaneous vaginal delivery at term Data from 4 public facilities in Nepal 31,804 spontaneously-breathing newborns observed immediately after childbirth 63% received a medical procedure without consent 25% were “roughly handled” 21% suctioned with no medical need 72% did not have delayed cord clamping 78% not breastfed within first hour after birth 3% kept in skin-to-skin contact Inequitable care for female infants and those born to younger women or women from disadvantaged ethnic groups ©WHO/Dr Helenlouise Taylor

4. 2.1 Meena gives birth In groups of 4 (“mother”, “ midwife ”, “companion” and observer/helper). Use newborn mannequin and any other equipment you use. Receive Aarush and carry out immediate newborn care. What do you do next? Participate in the debriefing. Continue to practise with your peers. There are no complications. Meena gives birth to her son Aarush by normal vaginal delivery at term. Aarush breathes and cries.

5. 2.2 Key points for immediate care at birth You all did things slightly differently. Everyone forgot some steps. This training will enable you to prepare and carry out each step: in the correct order at the correct time in the correct way Ensure safe respectful care for every newborn . Understand WHY you carry out each step. Always use the Action Plan or other job aid to help you remember the steps.

6. 3. Basic needs of all newborns To be protected To breathe normally To be warm To be fed

7. 4. Use job aids for immediate newborn care

8. 5. Key steps for immediate care at birth Observe carefully each step. Use the Action Plan / algorithm noting the timing of each action. Note steps that you missed or did differently. Ask any questions. What was NOT done to the baby? Facilitator demonstration

9. 5.1 Immediate care at birth Immediate care at birth 0:00-2:39 and 6:05 -7:26

10. 5.2 What steps did you observe and at what time? Prepare and check all necessary equipment. Call out time of birth and sex of baby. Deliver the newborn onto the mother’s abdomen. Dry the newborn thoroughly and discard the wet cloth. Assess breathing; if the newborn is not crying, assess need for additional help to breathe. Safely position and leave the newborn warm in skin-to-skin contact. Cover the baby with dry cloth and place hat. Place identification label. Delay umbilical cord clamping for 1–3 minutes. Monitor every 15 minutes. Observe feeding cues and support early initiation of breastfeeding if required. Do not leave mother and baby alone. Give preventative treatment. Birth 30 seconds 1 minute 90 minutes

11. 5.3 Immediate newborn care The newborn is crying. Use your mannequin and show us what you will do. Call out time of birth and sex. Deliver the newborn onto the mother’s abdomen. Dry the newborn thoroughly and discard the wet cloth. Assess breathing; if the newborn is not crying, assess need for additional help to breathe. Safely position and leave the newborn warm in skin-to-skin contact. Cover the baby with dry cloth and place hat. Clamp and cut cord when no longer pulsating (1–3 minutes). Place identification label.

12. 5.4 Which babies will have immediate care with mother? Immediate care of twins (2.44- 4.29) Immediate newborn care SMALL baby Fatima term baby 3.2 kg delivered by forceps. Benjamin term baby 3.0 kg delivered by ventouse . Tatiana born 38 weeks gestation born by caesarian section. Charity and Patience (twins) born by spontaneous vaginal delivery at 37 weeks gestation 2.5 and 2.6 kgs. Leo born at 35 weeks gestation 1.9 kg.

13. 5.5 Assess breathing To “breathe normally” is one of the baby’s immediate and basic “needs”. Oxygen is needed to keep the baby’s brain and other vital organs healthy. While the baby is being dried, the baby’s breathing should be assessed. You will learn how to assess breathing in the “ Basic resuscitation of the newborn” and “Examine the newborn” modules.

14. 5.6 How will you ensure the newborn stays warm? Warm environment, no drafts. Place baby naked on the mother’s chest in skin- to-skin contact. Thoroughly dry the baby. Discard wet cloth. Cover the baby and put on a hat. Do not interrupt skin-to-skin contact for at least one hour after birth or until after the first breastfeed. Do not separate for care procedures. These can wait until after the first breastfeed. Delay bathing for 24 hours. Immediate care after birth Continuous skin-to-skin care

15. 5.7 Describe what you see © WHO/ Yoshi Shimizu

16. WHO Immediate Care at Birth 0.0-1.58 5.8 Describe what you see © WHO/Yoshi Shimizu

17. If we do not practise early uninterrupted skin-to-skin contact, what may be the consequences? 5.9 What are the r isks of NO skin-to- skin contact? © WHO/Yoshi Shimizu Risk of infection Unstable temperature Less stable respiratory and cardiac signs More difficulty learning to breastfeed Shorter duration of exclusive breastfeeding More maternal stress More infant stress, more crying Greater pain and distress during procedures

18. 5.10 Which babies should have continuous skin-to-skin care? © Felicity Savage Ensure that ALL newborns have continuous skin-to-skin care. Ensure skin-to-skin contact for mothers who will NOT breastfeed. If the baby is in a special care unit, ensure skin-to-skin contact as soon as possible. Ensure continuous skin-to-skin contact on the postnatal ward.

19. 5.11 How and when do you cut the cord? Wear sterile gloves. If you are the sole health-worker, c hange gloves or remove the outer pair. Clamp and cut the cord after 1–3 minutes, when it has stopped pulsating. Put ties tightly around cord at 2 cm and 5 cm from the baby's abdomen. Cut between ties with a sterile instrument. Observe for oozing blood. If blood oozes, place a second tie between the skin and the first tie. Do NOT apply any substance to the stump. Do NOT bind or bandage the stump. Leave the stump uncovered.

20. The mother and baby should remain in the delivery room from the time of birth until after delivery of the placenta for monitoring. NEVER LEAVE mother and baby alone during first hours after delivery. Monitor together. Zero separation. 5.12 When and what will you monitor? Monitor every 15 minutes. Observe breathing, position and colour . Ensure safe skin-to-skin position: Mother semi-reclined and responsive Baby (face seen, mouth and nose uncovered) Colour is pink.

21. 5.13 Initiation of breastfeeding After an initial resting period, the newborn is showing signs of readiness. All images: © WHO/Yoshi Shimizu

22. 5.14 Aarush crawls to reach Meena’s breast The baby is moving his whole body to reach the nipple and breast. All images: © WHO/Yoshi Shimizu

23. 5.15 Aarush attaches to the breast himself A baby may take 10 – 60 minutes or longer before starting to breastfeed. © Sandra Lang

24. 5.16 Eye care When and how will you carry out eye care for the newborn? Wipe both of the newborn's eyes with a sterile gauze square and discard the wet cloth. Use a separate square for each eye, and wipe from the inner corner to the outer corner. Explain to the mother that eye care is needed to prevent infections. Allow the baby to localize the breast and breastfeed before putting antimicrobial in the eyes (60–90 minutes) while in skin-to-skin contact. WHAT eye treatment is recommended by your Ministry of Health? Avoid touching eye tissue when applying the topical treatment.

25. 5.17 What are the benefits of delayed cord clamping? Maternal Full-term infants such as Aarush Preterm/low birthweight No effect on maternal bleeding or third stage of labour . Decreased incidence of retained placenta. Adequate blood volume and birth iron stores. Increases haematocrit and haemoglobin . Improves haematological status at 2–4 months. Improves iron status up to 6 months. Decreased risk: intraventricular haemorrhage , necrotising enterocolitis and late onset sepsis. Less need for transfusion and surfactant mechanical ventilation. Increased: haematocrit , haemoglobin , blood pressure, cerebral oxygenation, red blood cell flow, haemoglobin at 10 weeks of age. Improved neurodevelopmental outcomes.

26. 5.18 How will you protect all newborns ? Universal precautions and sterile cord care Breastfeeding and skin-to-skin care No separation Giving preventative treatment Delivery room & postnatal ward warm, no drafts Immediate thorough drying Skin-to-skin care. No separation. Newborn rights No discrimination or denial of services or detainment because of lack of payment. Ensuring right to evidence-based treatment, needs and birth registration. No harmful practices. Gentle handling. No verbal abuse. Light and noise control. No unconsented treatment. Zero separation. Skin-to-skin contact and nurturing care. Support for breastfeeding and lactation. Parental access with no limitation. Psychological support for parents, pain management for procedures, a supportive environment, parental support. From hypothermia? From infection?

27. 5.19 Meena delivers her son Aarush In groups of 4 (“mother”, “ doctor ”, “companion” and observer/helper). Use newborn mannequin and any other equipment you use. Receive Aarush and carry out immediate newborn care. What do you do next? Participate in the debriefing. Continue to practise with your peers. Meena delivers her son Aarush by normal vaginal delivery at term. There are no complications. Aarush breathes and cries . Repeat simulation Providing essential care at birth Continuous skin-to-skin care

28. 5.20 Maria delivers her son Enzo in a humanitarian emergency In groups of 4 (“mother”, “ midwife”, “companion” and observer/helper). Use newborn mannequin, a clean delivery kit and any other equipment you use. Receive Enzo and carry out immediate newborn care. What do you do next? Participate in the debriefing. Continue to practise with your peers. Maria and her sister are in an emergency tent. There are no delivery beds. She delivers Enzo on a clean plastic sheet on the floor by normal vaginal delivery at term. There are no complications. Enzo breathes and cries . Providing essential care at birth Continuous skin-to-skin care

29. 6. What needs to be in place to ensure quality immediate newborn care? See handout: Requirements for newborns by level of care

30. 6.1 Summary In this module, you have l earned and demonstrated: Immediate care at birth in the correct sequence and timing. How to give preventive treatments, assess and manage the newborn. Respectful communication and support for the mother. Apply what you have learned throughout the course and whenever attending a birth. Continue to practise .

31. 7. Why is routine suctioning NOT recommended? Find the recommendations on pages 26–27.

32. 7.1 Recommendation and reasons In neonates born through clear amniotic fluid who start breathing on their own after birth, suctioning of the mouth and nose should NOT be performed. Harms of suctioning for normal healthy newborns Lower oxygen saturation levels in normal healthy neonates Lower Apgar scores in normal healthy neonates. Review the evidence: Guidelines on basic newborn resuscitation. WHO, 2012.

33. 7.2 Why it is important to delay umbilical cord clamping? Find the recommendations and guideline See page 160 See pages 7 – 9

34. 7.3 Recommendation and reasons Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes. Benefits of delaying umbilical cord clamping Lowers the risk of iron deficiency Lowers the risk of necrotizing enterocolitis and intraventricular haemorrhage and reduces the need for blood transfusion of preterm newborns Prevent postpartum haemorrhage in mothers. Review the evidence: WHO recommendations Intrapartum care for a positive childbirth experience. 2018. Guideline: delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes. WHO, 2014.

35. 7.4 Do we recommend skin-to-skin contact and early initiation of breastfeeding during COVID-19 pandemic? Find the guidance on pages 55 – 57.

36. 7.5 Recommendation and reasons Mothers with suspected or confirmed COVID-19 should be encouraged to initiate and continue breastfeeding. Benefits outweigh harms Breastfeeding and skin-to-skin contact protect against child illness and death, especially against infectious diseases. Children who are not breastfed are at higher risk from infectious diseases and lifelong ill-health from some non-communicable diseases. Deaths of infants separated from mothers and not breastfed would be at least 60 * times greater than possible deaths due to COVID-19. Review the evidence: Living guidance: COVID-19 Clinical management. WHO, 2021.

37. 8. Clinical practice 60–90 minutes

38. 9. Improving the quality of care for mothers and newborns in health facilities Identify a problem Analyse the problem Develop and test changes 4. Sustain improvement   4 simple steps: (POCQI) QUALITY IMPROVEMENT TEMPLATE Modules/Sessions: Step 1: Identify a set of specific problems, prioritize which problem to tackle first, form a team, and write an “aim” statement. Problem Identified ……………………………………………………………………… ……………………………………………………………….. Team Aim Statement ……………………………………………………………………… …………………………………………………………………………………….. Who Needs to be Involved ……………………………………………………………………… ………………………………………………………………….. Step 2: Analyse the problem, measure and document quality of care. Analyses/Measures ……………………………………………………………………… ………………………………………………………………….. Step 3: Develop and test changes that can improve the quality of care. Possible Changes ……………………………………………………………………… ………………………………………………………………….. Actions – When Who ……………………………………………………………………… ………………………………………………………………….. Step 4: Sustain Improvement.

39. 9.1 References WHO WPRO first embrace videos Also see: WHO recommendations - Intrapartum care for a positive childbirth experience. WHO, 2018. WHO Safe Childbirth Checklist. Breastfeeding in the First Hours Immediate care after birth Attaching Your Baby at the Breast