Newborn Care

This presentation is on newborn care/neonatal care. This presentation is made to take a training session for nurse and paramedic.

1. This Presentation is on Newborn Care Dr. Swarna Das Lecturer Forensic Medicine GMCH Medical Officer CRHCC

2. Objectives Introduction • Definitions • Components of essential newborn care • Elaboration of each component • Recognitions minor physical peculiarities and problems • Discharge and follow up • Key message

3. Introduction Birth- crucial period of transition from in utero dependent life to extra utero independent existence. Effective care reduce neonatal mortality and morbidity.

4. Definitions Neonatal period – First 28 days of life. Perinatal period – 22 weeks of gestation to 7 days after birth. Early Neonate –Birth to first 7 days of life. Late Neonate –After 7 days – 28 days of life. Term – Baby born after 37 completed weeks up-to 42 completed weeks of gestation. Preterm – Baby born before 37 completed weeks of gestation Post.

5. Definitions Continued… LBW - < 2500gm Vlbw - < 750 Micropreemie -<500 SGA - BW < 10th centile AGA - Bw 10th - 90th LGA - Bw > 90th

6. Normal Neonate Birth weight > 2500 g. Gestation > 37 weeks. Birth weight between 10th to 90th percentiles on a standard intrauterine growth chart. No need of resuscitation at birth. Absence of maternal illness or any adverse intrapartum event. No postnatal illness such as respiratory distress, sepsis, hypoglycemia or polycythemia or requiring admission in neonatal unit.

7. Components Of Essential Newborn Care at Birth Preparedness Immediate basic care Prevention of hypothermia Establishment of breast feeding Postnatal care Prevention of infection Detection of danger signs

8. Proper newborn corner -in delivery room (DR) and maternity operation theatre (MOT). Go through maternal history ( any chronic illness, any medications). Anticipate high risk newborn. Trained health personnel should present before delivery. Attending personnel should document the baby details (time of birth, weight, gender and any other relevant information in all cases). Care at Birth Preparedness

9. Newborn Corner

10. 5C-Asepsis Concept of “Clean Chain” Clean hands – wear gloves. Clean surface- clean and sterile towel to dry and cover the baby. Clean cord-cut umbilical cord by a clean & sterile blade/scissor. Clean tie/thread for cord. Do not apply anything to the cord. Universal precaution should be apply in every delivery.

11. N ewborn Care Corner(NBCC) NBCC is a space within the delivery room in any health facility where immediate care is provided to all newborns at birth. This area is MANDATORY for all health facilities where deliveries are conducted. Newborn Stabilization Unit(NBSU) NBSU is a facility within or in close proximity of the maternity ward where sick and low birth weight newborns can be cared for during short periods. All FRUs/CHCs 1 need to have a neonatal stabilization unit, in addition to the new born care corner. Special Newborn Care Unit(SNCU) SNCU is a neonatal unit in the vicinity of the labor room which will provide special care(all care except assisted ventilation and major surgery) for sick newborns. Any facility with more than 3,000 deliveries per year should have an SNCU (most district hospitals and some sub-district hospital would fulfill this criteria).

12. What Care/Protection does a baby need just after birth? A newborn needs care of breathing (Protection from Hypoxemia). Care of temperature (Protection from Hypothermia). Care of feeding (Protection from Hypoglycemia). Care of skin, cord and eye (Protection from Infection and sepsis).

13. How to identity a baby with Birth Asphyxia/Hypoxemia/Inadequate breathing/Respiratory Distress? If a new born is not crying. If a new born is having a breathing rate of < 30 per minute. Noisy Breathing like Grunting. Chest Retraction, nasal flaring and Cyanosis, the baby is said to be in respiratory distress. All neonates can show a periodic breathing pattern defined as apnoea of less than 5 seconds. Apnoea of more than 15 seconds may be seen in preterm babies.

14. How to care for breathing? Crying is the first sign of breathing. If baby is crying, Receive the baby in a dry, clean, warm towel. Put the baby over mother’s abdomen. DRY the baby but don’t wipe off VERNIX. Replace the wet towel and wrap the baby with second clean, dry and warm towel. Cut the cord within 1-3 minutes.

15. Golden 1 Minute Resuscitation Establishing of breathing is the most prior action to take after delivery of baby. If a baby is not crying or not breathing well: Step-1(a): Look for Meconium , if meconium is absent, dry the baby. Drying up by clean cloth stimulates and helps in initiation of breathing. During drying baby gets stimulated to start crying/breathing.

16. Golden 1 Minute Step-1(b): If meconium is present, Gentle suction is done to remove mucus and amniotic fluid from mouth and nose with the help of manual mucus sucker. If baby is not crying now: Step-2: Cut the cord, Place on flat, firm, warm surface, Provide warmth, Position the baby with neck slightly extended (helps in drainage of secretion), Suction of mouth and then nose, Stimulate and reposition. Step 1 to 2 should happen in 30 seconds.

17. Golden 1 Minute Continued…. If baby doesn’t cry after step-2, go to step-3. Step-3: It should happen in next 30 seconds and resuscitation becomes necessary to prevent hypoxemia, brain damage and death if natural breathing fails to establish. Resuscitation requires more active measures. Repeat suction. Reposition the baby. Apply bag and mask ventilation for 30 seconds. If breathing doesn’t start Call for help Continue bag & mask ventilation. Add Oxygen

18. Newborn Resuscitation

19. Immediate Care at Birth Establish- airway, breathing, circulation, temperature Receive baby in pre-warm linen Clamp cord by sterile Gender identification by mother Take anthropometry, wipe baby and transfer to another prewarm linen Foot print on paper, identification tag to baby Vitamin K, immunization Clothing of baby and put under radiant warmer/ rooming in with mother

20. Timing and Method of Umbilical Cord Cutting and Clamping Should be clamped after birth at 1- 3mins (FBNC) . Tie cord with a clean thread, rubber band or a sterile cord clamp , clamp should be applied 2-3 cm away from the base, stump should be away from genitalia. The stump should be free of any application (antiseptic etc.).

21. Apgar Score Apgar score should be recorded at 1 and 5 min. Apgar score has a limited value for initiating stabilization and prediction of subsequent outcomes. However it does predict mortality on short term and help defining the need for nursery admission.

22. Identification Each infant must have an identity band with mother’s name, hospital regn.no ., gender and date & time of birth, birth wt. of infant. If footprints of baby is taken, quality of print should be good and hygiene to be maintained. The footprints should always be taken on the mothers case record also.

23. Identification of Sick Neonates Babies with Birthweight < 1800 g. Babies with major congenital malformations. Babies with asphyxia (Needing post-resuscitation care). Babies with breathing difficulty.

24. Cleaning The Baby All infants should be cleaned at birth with a clean, sterile cloth to remove blood clots and/or meconium on the body. NO attempt to remove vernix from the body by any means, as it can result in trauma to skin.

25. Weight Recording All infants should be weighed at least within one hour of birth on a scale with at least 5 gm sensitivity. The weighing scale must be periodically calibrated. Single-use paper towel or a sterile cloth towel should be placed on the weighing scale beneath the infant.

26. Vitamin “K”, Immunization Vitamin K should be administered IM on the antero -lateral aspect of the thigh using a 26 gauze needle (1/2inch) and 1ml syringe. Dose to be used is 0.5 mg for babies weighing less than 1000 g and 1.0 mg for those weighing above a 1000 gm at birth . Birth dose of BCG, OPV, hepB

27. Prevention of Hypothermia Provision of warmth to prevent hypothermia is one of the cardinal principles of newborn care. Can lead to- Hypoglycemia, bleeding diathesis Pulmonary hemorrhage, acidosis, apnea. Respiratory failure, shock Even death.

28. Method of Heat Loss

29. Measurement of Temperature Axillary temp. routinely recommended. safe, hygienic and ease for early detection of hypothermia. The core– peripheral temp. difference of more than 3.5º suggests sepsis Rectal temp Recorded in mod. to severe hypothermia. Measures core temp. Carries risk of perforation.

30. Tepm . Maintenance-Concept of “Warm Chain ” “Warm chain” is a set of ten interlinked procedures carried out at birth and later, which will minimize hypothermia in all newborns. Warm delivery room (26-28 deg celsius ) Warm resuscitation. Immediate drying Skin-to-skin contact between baby and the mother. Breastfeeding. Bathing and weighing postponed. Appropriate clothing and bedding. Mother and baby together. Warm transportation. Training/awareness-raising of healthcare provider.

31. Prevention of Hypothermia-in DR The delivery room should be warm (at least 26-28⁰c) and free from draft of air. Warmer on for at least 20 mins . Infant should be received in a pre-warmed sterile linen sheet. Dried thoroughly including the head and face areas. Wet linen should not be allowed to remain in contact with infant. Infant should be placed in skin-to-skin (STS) contact with mother immediately after birth (on abdomen )

32. Initiation of Breastfeeding When to start Should be initiated at the earliest possible time irrespective of mode of delivery. With-in half an hour in normal delivery, within 1 hour in cesarean section. Position of mother Any position in which mother is comfortable.

33. Concept of Golden Hour

34. Kangaroo Mother Care (KMC) Technique used in LBW babies wherein the neonate is held, skin-to-skin, with mother or any other adult caretaker. Should be given to all these babies whenever and wherever possible for maximum duration of time (and at least 1 hour). KMC helps in Better thermal protection of neonates Increasing milk production Increasing the exclusive breastfeeding rates. Reducing respiratory tract and nosocomial infections. Improving weight of the baby. Improving emotional bonding. Reducing hospital stay.

35. KMC

36. When to Start KMC- The Baby The baby must be able to breathe on its own. The baby must be free of life-threatening disease or malformations. The ability to coordinate sucking and swallowing is not essential, other methods of feeding can be used until the baby can breastfeed. Kangaroo mother care can begin at birth, after initial assessment and any basic resuscitation.

37. Rooming In No indication for separating a normal infant from the mother for routine observation in nursery, irrespective of mode of delivery. During initial couple of hours after birth, infants are awake & very active (utilized for bonding and initiation of breastfeeding).

38. Clinical Screening for Malformation Inspect the cut end of the cord for number of vessels - Two umbilical arteries and one umbilical vein. Examine for esophageal patency. Rule out anal artesian by inspecting the anal opening at the normal site. Examine oral cavity to exclude cleft palate. Examine the back for any swelling or anomaly.

39. POSTNATAL CARE

40. Care in Post Natal Wards Baby should be observed in the post natal Ward at least twice daily. Following should be taken care of: Maintenance of temperature. Exclusive breast feeding. Cord care. Eye care. Weight. Evaluation for jaundice. Passage of urine & stool. Common developmental & physiological variations Danger signs. Counseling of the mother &family .

41. Exclusive Breastfeeding Mother should be advised to: On demand feeding both during day and night for atleast 15- 20 mins . One breast to be completely emptied during each feed before baby is put to the other breast. Do not give any pre-lacteal feeds like ghutti , tea, sugar water, jaggery , honey etc.

42. Colostrums Highly concentrated milk. Produced during first 2-3 days. Anti infective properties Must be fed to the baby

43. Correct Positioning Wash hands. Be comfortable. Relax your shoulders. Head and body in straight line. Whole body supported. Nose to nipple. Tummy to tummy. Support your breast and thumb is on top and fingers are below the breast.

44. Attachment to breast. Effective Suckling.

45. Signs of Good & Poor Attachment

46. Cord Care Umbilical stump should be kept dry and devoid of any application. Bleeding may occur due to shrinkage of cord and loosening of the ligature. The nappy should be folded well below the umbilical stump. Umbilical discharge/ redness/sepsis

47. Eye Care Eyes of the infant must be cleaned with a sterile swab soaked in normal saline or sterile water. Clean from inner to outer canthus and use a separate swab for each eye.

48. Oil Application Oil application is a low cost traditional practice well ingrained in Indian culture. Prevent heat loss in preterm baby. However, a paucity of data still exists as to what oil should be used for this purpose .

49. Bathing Routine bathing in the hospital should be avoided in view of risks of cross infection and hypothermia. The infant can be sponged, as required. Infant can be bathed at home once discharged from the hospital.

50. Bathing Continued… Traditional practices like kajal , surma , putting oil in ears, giving prelacteal feeds like honey, sugar water should be discouraged. No use of any powder, baby cream. Healthy newborns should be made to sleep on their back

51. Weight Record Healthy term babies lose weight during the first 2 to 3 days of life (up to 5 to 10 % of the BW) Weight remains stationary during next 1-2 days and birth weight is regained by the end of first week. Delayed feeding and unsatisfactory feeding schedule-excessive weight loss. Pre terms experience 2-3% weight loss daily up to a maximum of 10-15%. Any weight loss >5% in a 24-hour period is abnormal. Preterm newborn should regain birth weight by 10-14 days of age. The average daily weight gain in term babies is around 20-30 g/ day.

52. Vomiting Many normal babies regurgitate or spit out some amount of milk regurgitation or vomiting. Seen soon after feeds. Due to faulty technique of feeding and aerophagy . Proper advice regarding feeding and burping, must be imparted to all mothers. If the vomiting is persistent, projectile, or bile stained, the baby should be further investigated.

53. Stool Pattern

54. Excessive Cry Babies cry when they are hungry or in discomfort. Discomfort due to sensation of a full bladder before passing urine, painful evacuation of hard stools or mere soiling by urine and stools. Persistent crying needs examination and detailed evaluation for inflammatory conditions and other causes .

55. Danger Signs in Newborn

56. Evaluation of Jaundice All infants must be examined for the development and severity of jaundice twice a day for first few days of life. Visual assessment in daylight.

57. Clinical Criteria to Assess Jaundice

58. Development Variations and Physiological Conditions Mastitis Neonatorum . Peeling skin. Milia . Mongolian spots. Epstein pearls. Sub- conjunctival hemorrhage. Erythema toxicum . Sucking callosities. Tongue tie. Non retractable prepuce. Hymenal tags. Umblical hernia

59. Mongolian Spots Blue to blue-black macules occur anywhere on the body, mostly on the back and buttocks. Caused by the deposition of melanin. Usually disappear within 6 months – 2 years

60. Erythema Toxicum Erythematous rash with a central pallor. Begins on face and spreads down to the trunk and extremities in about 24 hours. Differentiated from pustules which need treatment. Disappears spontaneously after two to three days. The exact cause is not known. Usually develop 2 – 3 days after birth. Spares palms and soles. Lesions seem to migrate by disappearing within Hrs and then reappearing elsewhere.

61. Milia Multiple 1- to 2-mm yellowish white cystic lesions. Affect 40% of newborns. Found most commonly over the cheeks, forehead, nose, and nasolabial folds due to blocked sebaceous glands. Resolve spontaneously

62. Epstein Pearls These are white spots, usually one on either side of the median raphe of the hard palate. Similar lesions may be seen on the prepuce. They are of no significance

63. Normal Peeling Dry skin with peeling and exaggerated transverse sole creases is seen in all postterm and some term babies. Usually occurs after 24-36 hours. Will resolve spontaneously and does not need any creams, oil, ointment or lotions. Excessive peeling is seen in pathological conditions like placental dysfunction,congenital syphilis and candidiasis SSSS.

64. Sucking Callosites Button like, cornified plaques over centre of upper lip. No significance. Friction of repeated sucking. Resolves spontaneously

65. Staphylococcal Pustulosis Usually at 3-5 days. Discrete pustules with erythematous base. Diaper area, periumbilical , neck, lateral aspect of chest. More than 10 pustules is a danger sign. T/t- betadine cleaning. Systemic antibiotics  Screen for sepsis

66. Subconjunctival Hemorrhage Newborns often have small, bilateral hemorrhages, presumably from the pressure of uterine contractions. Normal finding. The blood gets reabsorbed after a few days without leaving any pigmentation.

67. Natal Teeth Erupted teeth at birth. Usually lower incisors. ( Neonatal teeth: Erupt during 1st month). Removed- when it affects normal breast feeding or when the teeth are Loose (risk of aspiration)

68. Breast Engorgement Bilateral fullness of breasts in both sexes. Overlying skin shows no signs of redness, warmth or tenderness. The condition resolves spontaneously in days to weeks. No intervention is required.

69. Vaginal Bleeding Menstrual like vaginal bleeding may due hormonal withdrawal. Occur in about ¼ female babies after 3-5 days of birth. The bleeding is mild and lasts for 2-4 days. Additional vit k is not needed. Mucoid vaginal secreations Most female babies have thin grayish white.

70. Umbilical Hernia Tongue Tie Sacral Dimple

71. Non retractable prepuce: • normally non retractable in all male newborn should not be diagnosed – phimosis . No forcibly retracting the foreskin. Hymenal tags : Mucosal tags at the margin of hymen seen in 2/3rd of female infants

72. When Should Normal Newborn be Discharged Ideally infant should be discharged after 72-96 hours once all the following criteria are fulfilled: Infant is free from any illness including significant jaundice. The infant has been immunized. Adequacy of breastfeeding has been established. This must be assessed in all infants and the same would be indicated by passage of urine at 6 to 8 times/24 hr, onset of transitional stools, baby sleeping well for 2-3 h after feeding.

73. When Should Normal Newborn be Discharged Continued… Every infant should have a routine formal examination before discharge Examination performed with infant naked and in optimum light in presence of mother using a checklist . Mother should be provided ample opportunity to ask questions and clarify her doubts. Measure weight at discharge

74. Advice on Discharge Exclusive breast feeding. Immunization. Follow up. Danger signs Difficulty in feeding. Convulsions. Lethargy. Fast breathing. Severe chest indrawing . Temp >37.50C and < 35.50 C

75. Follow Up Each baby should be followed in well baby clinic for assessment of growth and development,early diagnosis and management of illnesses and health education of the parents. It is preferable that every baby is seen and assessed by a health worker at each immunisation visit. The developmental assessment should be organised both in community and the facility

76. Any questions?

77. All those things concludes my presentation. Thank You all for patience hearing…