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Mentors'Manual
Volume: 3
Essential New Born Care
at 24/7 PHCs
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KHPT
Karnataka Health Promotion Trust
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Mentors'Manual
Volume
Essential Newborn Care at 24/7
Primary Health Centers
Sukshema
Maternal, Neonatal ai
SOCHARA
Community Health
Library and Information Centre (CLIC)
Community Health Cell
85/2,1st Main, Maruthi Nagar,
Madiwala, Bengaluru - 560 068.
Tel: 080-25531518
email: clic@sochara.org / chc@sochara.org
www.sochara.org
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Government of Karnataka
Department of Health and Family Welfare
National Health Mission
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PREFACE
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Institutional deliveries in Karnataka have risen over recent years due to the efforts by the state health
directorate which were strongly complemented by various innovations and schemes implemented under
the National Rural Health Mission (NRHM) such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha
Karyakram (JSSK), ASHA support, 108 ambulance services, etc. There has been a reduction in maternal and
newborn mortality rates (MMR, NMR), but not enough to achieve the proposed state targets. With over
80% of pregnant women now delivering in facilities, it is critical that these deliveries are conducted as per
the highest standards for quality of care. To accommodate this rising demand, government had prioritized
upgradation of Primary Health Centres into 24/7 facilities to provide delivery services in rural areas and
reduce the burden on district and larger hospitals enabling them to function more appropriately as first
referral units (FRU) to provide emergency care. To achieve good quality of services provided in public
health facilities it is important that the service providers working at these facilities are proficient in skills
and practices that are appropriate particularly with reference to pregnant women, mothers and new
borns. To facilitate this, the need for dedicated teams to improve and monitor quality is crucial.
As a part of technical assistance to NRHM, Karnataka Health Promotion Trust and its consortium of
partners developed an innovative nurse mentor led quality improvement program after detailed situation
assessment and consultations with governmert. It was pilot tested in Bellary and Gulbarga during 20122013 where trained Nurse Mentors worked with 24/7 primary health centres (PHCs) staff to improve the
quality of delivery and postpartum care. The mentoring programme integrated elements of clinical
mentoring with facility-based quality improvement processes. Another critical component of the
intervention wasthe use of revised case sheets by the staff that helped them in multiple’ways, i.e. as job aid
to adhere to standard practices, as a simple case documentation tool and as a tool to monitor and audit
quality of care. The intervention results showed marked improvements in facility readiness and provider
preparedness to deal with institutional deliveries and associated complications. Subsequently the
program was scaled up in the remaining high priority districts of northern Karnataka and further taken up
both within and outside the country.
•*
As a part of this intervention, several technical products and training material were developed; they consist
of 1) process documentation of the intervention that details the process of planning, implementing and
monitoring the mentoring program, 2) Facilitator/ Trainer and Participant manuals. These materials have
as annexures within them, various tools including the case sheets that were implemented under this
initiative. We sincerely hope that these resources will be found useful by program managers in terms of
gaining an in-depth understanding of the intervention and replicating it in their respective contexts.
I
Smt. Sowjaiiya, i.a.s
Mission Director
National Health mission
Sri.
Dcpi. ofHcalth &
Principal Secretary,
Dept, of Health & Family welfare
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11
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Contents
Contents
Acknowledgments
iv
About the Manual
v
Abbreviations
vii
Glossary of Terminology
x
Chapter 1
Neonatal health situation in northern Karnataka
1
Chapter 2
Classification of a newborn at birth
4
Chapter 3
Care of a normal newborn at birth till first hour of life
9
Chapter 4
Newborn resuscitation including preparation of newborn corner
21
Chapter 5
Breastfeeding
40
Chapter 6
Thermal control and Kangaroo Mother Care (KMC)
55
Chapter 7
Care of the newborn at facility till discharge
65
Chapter 8
Common problems of newborn Newborns and referral
72
Chapter 9
Feeding a low birth weight newborn
85
References
97
Bibliography
98
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Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
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Acknowledgements
The authors appreciate the support provided by numerous individuals over an extended period of time to allow
documentation of this important innovation. Special thanks to Dr B.M. Ramesh, former Project Director of Sukshema
Project, for recognizing the importance of documenting the mentoring programme so others can learn from
this activity and for the guidance provided throughout. Thanks to Anna Schurmann for helping to structure the
project's knowledge management strategy and to Baneen Karachiwala who provided independent observation and
interviews of the first mentor training. The dedication of project staff—including several Bangalore-based technical
leaders, support staff, and district programme specialists who coordinated numerous field visits to several districts—
ensured high-quality observations at primary health centres and insightful interviews with those implementing
the intervention. These staff include Dr Swaroop, Dr Mahantesh, Dr Seema, Dr B. Pavan, Dr Nazia Shekhaji, and
Laxshmi C. We thank the team from St John's Research Institute that included Dr Prem Mony, Maryann Washington,
Dr Annamma Thomas, Dr Swarnarekha Bhat, Dr Suman Rao and other consultants for their support in the trainings
and handholding visits and for sharing their experiences that have informed the process document. We appreciate
the support of clinical consultants from University of Manitoba, Lisa Avery and Maryanne Crockett for their support
during the design of the program. We also acknowledge the efforts of Dr Sudarshan and Dr Nagaraj from Karuna Trust
for their support to the implementation of the program. Appreciation is extended to Arin Kar, Deputy Director of
Monitoring and Evaluation, for providing data support and to H.L Mohan, Director of Community Interventions and
Somshekar Hawaldhar, Deputy Director of the community intervention component for contributing to the discussion
on program coordination. Special appreciation is also due to the nurse mentors for their enthusiastic participation
in interviews and focus groups, and for facilitating the ability to observe their work in action. We thank the many
primary health centre staff and district government officials who met with us to share their candid views about the
mentoring programme. Finally, we thank Stephen Moses, Professor and Head of Community Health Sciences of Dr
James Blanchard, Director, Centre for Global Public Health, University of Manitoba for their valuable reviews and
inputs.
The funding support for development of this manual was provided by Bill and Melinda Gates Foundation.
The following institutionsand individuals have contributed to development of volume 1 of the SUKSHEMA
Facilitator's Manual.
Karnataka Health Promotion Trust (KHPT)
St John's National Academy of Health Sciences (SJNAHS)
University of Manitoba (UoM)
Dr LTroy Cunningham, KHPT
Mrs Janet Bradley, UoM
Dr John Stephen SJNAHS
Ms Maryann Washington, SJNAHS
Dr Sanjiv Lewin SJNAHS
Dr K Karthikeyan, Independent Consultant
Dr Manoharan, Independent Consultant
Dr Savitha Kamalesh, SJNAHS
Ms N Gayathri, SJNAHS
Dr Reynold Washington, KHPT/UoM
Dr Lisa Avery, UoM
Dr B M Ramesh, KHPT/UoM
Mr Arin Kar, KHPT
Mohan H L, KHPT/UoM
Dr Swaroop N, KHPT
Dr Krishnamurthy, KHPT/UoM
Mentors' Manual Volume 3
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About the Manual
The Sukshema project aims at providing technical support to National Rural Health Mission of Karnataka
to improve the maternal, newborn and child health (MNCH) outcomes in Karnataka with a focus on eight
districts of northern Karnataka. As a part of the project, several interventions are implemented at facility,
community and health systems level to improve the availability, accessibility, quality, utilization and
coverage of critical MNCH services. One of the interventions is onsite mentoring to 24/7 PHCs to improve
the quality of delivery and postpartum care with the help of a new cadre of nurse mentors. Being a new
cadre, the project designed a training program and manuals for training this cadre. The nurse mentors are
expected to be proficient in clinical skills related to delivery and postpartum care and also have the right
attitudes and abilities to provide mentorship to the PHC staff. They will be responsible for onsite, on the
job coaching and facilitating change in provider practices that will ensure better quality care for mothers
and newborns. The purpose of this manual is to guide the MNCH mentors of the Sukshema project in how
to assist health care providers at primary health care centers (PHCs) to improve the quality of labour and
delivery, postpartum and newborn care services.This manual is used by participants during initial training
and also as a guide during mentoring activities in the field.
This manual is divided into 3 volumes.
Volume 1 - Volume! has two sections.
Section A - Quality Improvement Principles and Approaches
This section introduces the context of MNCH mentoring intervention in the Sukshema Project, Karnataka,
principles of quality improvement, Sukshema's quality improvement approach and tools, and their use at
various levels, qualities of an MNCH mentor, and mentor responsibilities.
Section B - PHC Systems Strengthening
This section contains technical information related to systems strengthening in PHCs and covers infection
prevention, referral system strengthening and supply chain management.
Volume I appendix include various tools and reporting formats that the MNCH mentors use to plan,
implement and report on their PHC visit activities.
Volume 2 - Skilled Birth Attendance during Labour, Delivery and Postnatal Periods at 24/7 PHCs
This volume contains information related to clinical knowledge and skills required to provide quality care
during labour, delivery and postnatal period at 24/7 primary health centers.The section covers both provision
of routine delivery and postnatal care as well as identification, management and referral of most common
maternal complications during these periods.
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Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Volume 3 - Essential Newborn Care at 24/7 PHCs
This volume contains information related to clinical knowledge and skills required to provide quality care
during the early neonatal period at primary health centers. The section covers both provision of routine
newborn care as well as identification, management and referral of most common newborn complications.
Though this manual is divided into three volumes for the convenience of readers, each volume has links and
cross references with the others. It is highly recommended that the mentors consult all three volumes when
preparing for a mentoring visit and also have them available for ready reference during a mentoring visit.
In the first volume of the manual we introduce the A.M.M.A approach to quality improvement. A.M.M.A
approach refers to assess (A), manage (M), measure (M) and advocate (A) for continuous quality improvement
and has at its core, the key principles of client and provider rights, self assessment and team building, and
mentoring. This approach can be used at several levels to improve PNC linkages with the community, to
address PNC level problems, to improve individual provider's knowledge and skills and to improve PHC
linkages with the wider health system.
Mentors' Manual Volume 3
Abbreviations
ABO
Blood groups A, B, O
COC
Combined oral contraceptive
A.M.M.A
Assessing and diagnosing,
managing, measuring and
CPD
Cephalopelvic disproportion
CVS
Cardiovascular system
DBF
Direct breast feeding
DDK
Disposable delivery kit
DHO
District health officer
DMPA
Depot medroxyprogesterone
acetate
advocating
AMTSL
Active management of the third
stage of labour
ANC
Antenatal care
ANM
Auxiliary nurse midwife
APH
Antepartum hemorrhage
DNS
Dextrose normal saline
ASHA
Accredited social health activist
DPS
District programme specialist
ART
Antiretroviral therapy
EBM
Expressed breast milk
AWW
Anganwadi worker
ECP
Emergency contraceptive pill
AZT
Zidovudine
EDD
Expected date of delivery
BCC
Behaviour change communication
FEFO
First expired, first out
BEmONC
Basic emergency obstetric and
neonatal care
FHR
Fetal heart rate
FHS
Fetal heart sound
BM
Breast milk
FIFO
First in, first out
BMV
Bag and mask ventilation
FRU
First referral unit
BPL
Below poverty line
FS
Female sterilisation
CBO
Community-based organisation
Gol
Government of India
CCT
Controlled cord traction
H/O
History of
CEmONC
Comprehensive emergency
obstetric and neonatal care
Hb
Haemoglobin
HBV
Hepatitis B virus
CHC
Community health centre
HCP
Health care providers
CBMWTF
Common bio-medical waste
treatment facilities
Hg
Mercury
HBsAg
Hepatitis B surface antigen
Chief medical officer
HCG
Human chorionic gonadotrophin
CMO
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Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
Development
HIV
Human immuno deficiency virus
HLD
High level disinfection
MPHW
Multipurpose health worker
HMIS
Health management information
system
MRP
Manual removal of placenta
MTP
Medical termination of pregnancy
HR
Heart rate
MVA
Manual vacuum aspiration
h2o
Water
NFHS
National Family Health Survey
IM
Intramuscular
NGO
Non-governmental organisation
Inj
Injection
NRHM
National Rural Health Mission
IV
Intravenous
NS
Normal saline
ICTC
Integrated counselling and testing
centre
NSSK
Navjaat Shishu Suraksha
Karyakram
NSV
No-scalpel vasectomy
PEP
Post-exposure prophylaxis
IFA
Iron and folic acid (supplements)
IMNCI
Integrated management of
neonatal and childhood illness
IUCD
Intrauterine contraceptive device
PHC
Primary health centre
IUD
Intrauterine deat
PIH
Pregnancy induced hypertension
IUGR
Intrauterine growth retardation
PIP
Project implementation plan
JSY
Janani Suraksha Yojana
PNC
Postnatal check-up
JHFA
Junior health female assistant
POC
Products of conception
KMC
Kangaroo mother care
PPE
Personal protective equipment
LAM
Lactational amenorrhea method
PPH
Postpartum hemorrhage
LBW
Low birth weight
PPTCT
LHV
Lady health visitor
Prevention of parent-to-child
transmission
LMP
Last menstrual period
PPV
Positive pressure ventilation
MgSO4
Magnesium sulfate
PRI
Panchayati Raj Institution
MM
MNCH mentor
PROM
MMR
Maternal mortality ratio
Premature or pre-labour rupture of
membranes
MNCH
Maternal neonatal and child health
P/A
Per abdomen
MO
Medical officer
P/S
Per speculum
MoHFW
Ministry of Health and Family
Welfare
P/V
Per vaginum
QI
Quality improvement
Ministry of Women and Child
RCH
Reproductive and child health
MoWCD
Mentors' Manual Volume 3
RDK
Rapid diagnostic kit
STI
Sexually transmitted infection
Rh
Rhesus factor
TBA
Traditional birth attendant
RL
Ringer lactate
TT
Tetanus toxoid
RPR
Rapid plasma reagin
UTI
Urinary tract infection
RR
Respiratory rate
VDRL
RTI
Reproductive tract infection
Venereal Disease Research
Laboratory
SBA
Skilled birth attendant
VHND
Village health and nutrition day
SC
Sub-centre
WBC
White blood cell
SDM
Standard days method
WHO
World Health Organization
SN
Staff nurse
3TC
Lamivudine
Units of measurement
At the rate of - to measure speed
KCal
Percent - to compare anything to
100
Kilocalories- to measure energy
produced
Kg
Kilogram - to measure weight
°C
Degree Celsius - for temperature
L
Litre to measure volume
cc
Cubic centimetre - to measure
volume
lb
Pound to measure pressure
mcg
Microgram to measure weight
cm
Centimetre - to measure length
mg
Milligram to measure weight
dl
Decilitre - to measure volume
min
Minute
°F
Degree Fahrenheit - for
temperature
ml
Millilitre to measure volume
gm
Gram - to measure weight
mm
Millimetre to measure length
hrs
Hours - to measure time
mmHg
Millimetre of mercury to measure
BP
IU
International units - to measure
dose
secs
Seconds
U
Units to measure dose
%
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Glossary of Terminology:
Abortion: Termination of pregnancy by the removal or expulsion of a foetus or embryo from the uterus
before 20 weeks of pregnancy
Abscess: A localized collection of pus in any part of the body, with pain and redness.
Amniotic fluid: Fluid present in the uterus during pregnancy which protects the fetal inside
Amnionitis: Infection of the protective lining around the baby (amnion or inner lining);
occurs in PROM
Anaemia: Condition caused by low hemoglobin in blood
ANC: Check up done during pregnancy to determine the condition of the woman and fetus
APGAR: The APGAR score indicates the newborn's well-being. It will be calculated at 1 minute and at
5 minutes after birth. An APGAR score of more than 7 is considered satisfactory. Less than 7 APGAR babies
need referral to a higher centre for further management
APH: Bleeding in pregnancy (before delivery)
Asphyxia: Condition in a newborn due to severely deficient supply of oxygen to the body when the
baby is unable to breathe normally
Atonic: Lack of muscle tone; loose or soft
Assisted deliveries: Vaginal delivery when the baby's delivery has to be assisted/helped out by using
forceps or vacuum extraction applied to the baby's head
Blurred vision: Unclear or hazy vision, associated with high blood pressure, weakness
Breech presentation: When the buttocks of the fetus are in the lower area of the uterus
Chorioamnionitis: Infection of the protective lining around the fetus (amnion or inner lining and
chorion or outer lining); occurs in premature rupture of membranes (PROM)
Clammy skin: When the skin is cool, moist and pale. Sign of emergency such as shock, dehydration
CPD: Size or space of pelvis is narrow and does not allow baby to pass through
CVS: System related to heart and circulatory system
Diastolic blood pressure: Lower reading of blood pressure
Depressed/depression: Sadness, no interest in surroundings; may be seen in postnatal period
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DM PA: Injectable contraceptive whose action lasts for 6 months
ECP: To be taken by a woman within 72 hours of unprotected, unplanned sexual contact to prevent a
pregnancy
Effacement: Thinning of cervix at the time of labour
Endometritis: Infection of uterus; after PROM, repeated per vaginal (PV examination, unsterile
conditions, after abortion/ MTP done in unsterile conditions
Engorgement: Filling up/swelling
Flank pain: Pain in the side of the abdomen below the ribs
Fluctuant: Moving
Floppy: Poor muscle tone, limp
Fetal: Developing unborn baby inside the uterus
Fetal distress: Condition when the fetus is having some problem inside the uterus; detected by
abnormal heart rate (FHR more than 160/min or less than 120/min), or irregular FHR
Fundal height: Height of the uterus which increases with pregnancy and decreases after delivery;
measuring the upper border of the uterus and comparing with the standard in weeks of pregnancy gives
the approximate duration of pregnancy
Gestation: Pregnancy/the period of development of the fetus in the uterus from conception until birth
Gestational age: Age of an embryo or fetus; calculated in weeks
Gravidity/gravid:The number of times the woman has been pregnant
Icterus: Jaundice or yellowish discolouration of sclera (white part of eye) in adult or skin in newborn
Infant: Baby from one month after birth to one year of age
IUGR: Inadequate/ slow growth of a fetus inside the uterus
Jerky movement: Fast movements which are not controlled and that have no purpose. Seen in fits
KMC: Care given to small baby by placing over the chest of mother/parent to provide extra warmth to
the baby
LAM: Used as a traditional temporary method of contraception, when a woman does not have her
monthly periods due to breast feeding
Latent: Developing or present but not visible
LBW: When the baby weight is below 2500gms (standard weight)
Lump: A localised swelling; may be hard or soft
_________ a
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
oa1 n-R
Lochia: Discharge from the vagina from delivery up to a week
Liquor: Same as amniotic fluid
LMP: First day of last menstrual period a woman had before pregnancy, used to calculate EDD
Madilu kit: This is a postnatal kit given to mothers after delivery under a government scheme for
postnatal care of mother and baby
Mastitis: Infection of breast; seen as pain and redness
Meconium: Yellow or green coloured stools passed by the fetal inside uterus or by newborn at birth
MRP: Done by removing the placenta by hand in condition of retained placenta
Murmur: An abnormal sound of the heart
MVA: Method of performing MTP where suction is created by a manual pump to remove contents in
uterus
Misoprostol: Drug used to cause contraction of uterus and thereby prevent or treat postpartum
hemorrhage; available as tablets of 200mcg; not given to women with asthma
Magnesium sulfate: An anti-convulsant drug used for prevent!ng/treating eclampsia/severe
pre eclampsia without causing sedation in mother or baby
Monitoring: Observe and check the progress or quality over a period of time
Nasal flaring: An increase in nostril size due to any difficulty in breathing
Newborn: A recently born baby
Obstetric: Related to pregnancy
Obstructed: Blocked; unable to come out
Oedema: Swelling due to accumulation of water
Outcome: End result
Pallor: Lack of colour especially in the face; seen in anaemia and long standing diseases
Parity/Para: Total number of deliveries and abortions a woman has had till present pregnancy
Pelvis: Cavity formed by joining together of the two hip bones and sacrum; contains, protects, and
supports the intestines, bladder, and internal reproductive organs
Perineum: Area around vagina and the anus in females
PIH: Increased blood pressure (more than 140/90 mmHg) without proteinuria in a woman after 20 weeks
gestation
Preterm: Pregnancy less than 37 completed weeks gestation
Mentors'Manual Volume 3
Pre-referral management: Activities carried out to stabilise the complicated cases before referring
to a higher centre
Presentation: That part of the fetal lying over the pelvic inlet which would be first to come out at
delivery
P/S: Using the speculum to view the vagina and cervix
P/V: Vaginal examination
Prolonged: Long duration/delayed
PROM: Rupture of membranes (bag of waters) before labour has begun; can be before 37weeks premature or before delivery - term or mature
Puerperal: The period immediately after delivery to 42 days
Purulent: Containing pus
Pustule: A small boil over skin filled with pus; a pimple
Retained:To hold in a particular place; not coming out
RPR: A newer blood test to screen routinely for syphilis in pregnant women
RR: Rate of breathing in one minute
Respiratory distress: Condition in which patients are not able to breathe properly and get enough
oxygen
SBA: Person (doctor, nurse, ANM) trained in pregnancy, delivery, postnatal and newborn care
SDM: Used as a traditional temporary method of contraception where a woman tracks the days of her
menstrual cycle and avoids unprotected sexual contact on fertile days of the cycle
Sepsis: Condition where infection from any site spreads throughout the body
Seizures: Convulsions, fits
Spontaneous: Without any effort or natural
Sterilization: A procedure to make free from live bacteria, virus or other microorganisms, used for
cleaning needles and surgical instruments
Stillbirth: Birth of a dead fetus any time after the completion of 20 weeks of gestation.
Syphilis: A sexually transmitted disease which in pregnancy may cause congenital defects in the fetus
Systolic blood pressure: The upper level of blood pressure
Tender/tenderness: Pain felt if touched
Term: State of pregnancy which has completed 37 weeks
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Essential Newborn Care at 24/7 Primary Health Centres
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Transverse: Lying across
Traction: Pulling force
Tubectomy: It is a female sterilization procedure where a part of the fallopian tubes is cut. It is a
permanent method of female sterilization
Umbilicus: A scar where an umbilical cord was attached
Unconsciousness: Person not responding to calls, stimulus
Uterine massage: Gently rubbing the uterus after the delivery of placenta to help the uterus contract
and become hard
Uterine tone: Tightness of uterine muscles
Vasectomy: A surgical procedure performed on males in which the vas deferens (male tubes) are cut. It
is a permanent method of male sterilization
VDRL: Blood test done routinely for syphilis in pregnant women; similar to RPR test
Vertex: Normal presentation of the fetus in which the head lies at the opening of the uterus
Voiding: Emptying the urinary bladder
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Mentors' Manual Volume 3
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1.1
Neonatal Health Situation in Northern
Karnataka
Introduction
Four in ten under-five deaths occur during the first month of life, globally. Every year 4 million neonates
die (in the first four weeks of life) .The current neonatal morality rate 32 per 1000 live births accounts for
two-thirds of infant mortality and 40% of under-five mortality. About 40% of neonatal deaths occur in the
first day of life, almost half within three days and nearly three fourth in the first week of life. There are wide
variations in neonatal mortality based on rural and urban residence and based on socioeconomic status of
communities. India alone contributes to quarter of all neonatal deaths in the world.
Neonatal mortality includes early and late neonatal mortality. Neonatal mortality is lower in communities
or states where there are more institutional deliveries. In India nearly 67% of deliveries occur at home with
only 46.6% of these being attended by skilled birth attendants (doctors, nurses, midwives).
1.2 Definitions
Neonatal mortality rate is the number of newborns dying before the completion of 1 month for every 1000
live births.
The perinatal mortality rate is the number of still births (late fetal deaths after 28 weeks of pregnancy) and
plus newborns that die within one week of birth for every 1000 live births and stillbirths.
1.3 Understanding the Neonatal Health Situation in Karnataka
What are the causes of death in newborns?
The commonest causes of neonatal death are birth asphyxia, severe infection such as sepsis, and prematurity
or low birth weight. These three causes account for nearly 80% of all neonatal deaths in India.
Causes of Neonatal Death In India (%)
■ Birth
Aspyxia/trauma
■ LBW/P re maturity
■ Infections
■ Others
Figure 1.1: Causes of neonatal death in India
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Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
When do most newborns die?
Nearly three fourth of neonatal deaths occur in the first week of life, and 40% of deaths occur in first two
days of life. Several reasons could contribute to these, but with effort, measures such as delaying pregnancy
amongst young women (15-19 years); encouraging at least four antenatal visits during pregnancy and
institutional deliveries; and increasing awareness amongst the community and pregnant women about
danger signs and when to seek professional help could go a long way in reducing neonatal mortality. In
addition having facilities for safe childbirth along with essential newborn care such as providing warmth
and newborn resuscitation could reduce these numbers.
The most important period is the first two days (48 hours) of life. Close watch on the newborn could help
identify danger signs early, and this could help in quicker response of nurses to refer the newborn for
higher facility care nearby.
Adolescence and
before pregnancy
Postnatal (neonatal)
Birth
Pregnancy
Child health
V
V
◄------------------ ►
Condition
Window of
opportunity
Days
Weeks
% of neonatal deaths
2
3
5
2
6
3
5
6
Figurel.2: Timing of neonatal deaths
What is the urgency associated with these deaths?
Two important characteristics of these deaths are:
❖ Predicting (or anticipating) the possible risk factors through a good initial assessment of the woman
in labour can alert the PNC staff to be ready for diagnosing early any problem, providing initial
management and referring the newborn as fast as possible to a higher facility
❖ The risk of neonatal deaths is lower when the family is close to facilities where advanced care is available
(sick newborn care unit); and the risk of neonatal deaths are higher when Emergency Neonatal Care
(ENC) facilities are not available.
The average duration from onset until death is short especially in the case of birth asphyxia. Thus it is
important that these conditions are identified as soon as possible and action is taken immediately to
reduce the chance of a newborn dying (Table 1.1).
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Table 1.1: Time to act for common neonatal conditions
Average duration until death if condition very serious
Neonatal Condition
2. Prematurity/LBW
Anytime after 3 days
3. Infection
What does this mean for your district?
See the estimated number of births and neonatal deaths in a 12-month period in each of your districts
(Table 1.2). About one-fifth of these births occur in primary health centres (PHCs).Thus as nurse mentors you
can help to prevent many deaths by maintaining quality of care in the important window of opportunity
period (that means during labour, delivery and early neonatal period).This could include simple actions
such as following infection control guidelines; identifying danger signs such as newborn not crying at birth
(asphyxia), weak newborn whose temperature is low and not feeding (sepsis), starting initial management
and referring such newborns quickly.
Table 1.2: Project Sukshema districts with their population and estimated number
of live-births and neonatal deaths per year
Population (year
2011)
District
Bagaitot'■
Neonatal deaths per
year*
Live-births*
_ _57900
IL
. . ■■■
Bellary
1848941
illlflf
sHoo 113
Bijapur
2134790
1400
50000
Koppal
1370023
900
32100
760
26800
'
Yadgir
\
'I '
1897372 \
1148788
.- • - .
j
43300
1210
Bidar
_
' :
*assuming crude birth rate = 23.4/1000 and neonatal mortality rate =28/1000 in northern Karnataka (year 2011)
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
B
Classification of
a Newborn at Birth
>2
Learning Objectives
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❖ Recall how to classify a newborn newborn by gestational age (history/ ultrasound report or physical
characteristics) or by birth weight .
.;
❖ Demonstrate how to classify newborns by gestational age, weight or physical features.
❖ Demonstrate accurate documentation of gestational age of newborn
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❖ Demonstrate mentoring skills for classification of newborn
, -
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- ---------------------------------------------------------------- ------------------------------------------------------------------- ----------------------------------------------------------------------- - ---------------- -- --------------------------------------------------- -------
2.1 Introduction
Newborns could have different outcomes based on their gestational age. The normal term newborn is
37 completed weeks of pregnancy / gestation. One important task a PHC staff must do before and if not
possible soon after delivery is to calculate the gestational age of the newborn (in weeks). Early identification
of a high risk newborn at birth is important for the survival and long term growth of the newborn. Hence
a PHC staff who conducts a delivery must either anticipate the birth of a high risk newborn or identify one
soon after birth by a quick assessment so that appropriate care can be given.
2.2 Components of Classification of Newborn and its Importance
This can be done by either
Estimating the gestational age by weeks from the history of the LMP or ultrasound
report if available
❖ Preterm newborn :
less than 37 weeks
37-42 weeks
❖ Term newborn
:
❖ Post term newborn:
more than 42 weeks
Checking the weight of the newborn at birth:
Newborns are classified by weight and size
❖ Low birth weight (LBW) less than 2500 gms
❖ Very LBW less than 1500 gms
❖ Extremely LBW less than 1000 gms
Figure 2.1 Preterm newborn
Newborns are classified by size and gestation age
❖ Small for gestational age (SGA)
❖ Appropriate for gestational age (AGA)
❖ Large for gestational age (LGA)
Mentors' Manual Volume 3
IBSlS
This can be assessed by plotting the newborn's weight (in gm) against the gestational age (in weeks) on
the standard chart. If the plot falls between the two
curved lines in the graph the newborn is considered
5000
to be appropriate for gestational age (AGA = 2.S-3.5
LGA
4500
kg). If the plot is below the lower curved line (below
<000
10th percentile) then the newborn is considered to
be small for gestational age (SGA) and above the
1 3500
AGA
upper red line (above 90th percentile), the newborn
3000
is large for gestational age (LGA).
2500
Assessing physical
newborn newborn
features
of a
The posture; examination of physical features of the
ears, breast buds, genitalia, and sole creases could
help in estimating broadly whether the newborn
is term or preterm. This is important especially if
the gestational age cannot be calculated when the
mother is not able to provide a reliable history.
2000
$GA
1500
1000
500
24
»
«
http://en.wikipedia.org/wiki/Small for gestational age
Figure 2.2: Standard chart to plot weight
(gm) and GA (weeks)
2.3 Importance of Components
Classification by gestational age
❖ Smaller and less mature newborns are known to have more problems than a term newborn. Hence
knowledge of this even before a newborn is born or at birth could help a PHC staff to be prepared for
any health problem soon after.
❖ It is best that the PHC staff knows the gestational age of the newborn even before being born by asking
the mother her LMP or her EDD or looking at the Thayi card.
Classification by weight and size
❖ Classification of newborns could help to identify those newborns that have a higher chance of
becoming sick.
♦♦♦ It is important to check the weight of the newborn accurately using the infant weighing scale on the
first day of life. This must be recorded in the case sheet. Based on the weight the newborn can be
classified as low birth weight or small for gestational age. Those newborns whose weight is low or who
is small for gestational age could have a greater chance of developing hypoglycemia, hypothermia and
other long-term problems.
❖ Therefore these newborns must be watched carefully after birth and mothers must be encouraged to
feed them frequently.
Classification by physical features
❖ Sometimes a mother may not know the LMP or there would be no ultrasound report or thayi card. An
abdominal examination might help in estimating gestational age. But this might not be possible if such
a mother comes in to the PHC in active labour.
❖ Then observation of physical characteristics could help to broadly classifying newborns as term or preterm.
5
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
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■
2.4 Requirements for Classification of Newborn
Equipment and supplies
❖ Case sheet to counter check the gestational age based on record of IMP or ultrasound report or
abdominal examination of fundal height
❖ Infant weighing scale to assess the weight of the newborn
❖ Clean cloth
❖ Spirit to clean the tray of the weighing machine
❖ Chart to plot and check if newborn is SGA, AGA or LGA (in under 5 card)
Clinical skills
Check WEIGHT OF NEWBORN
1.
Keep articles ready such as infant weighing machine; clean towel/cloth; cleaning solution - 0.5%
chlorine solution to wipe tray and clean cloth to
wipe the wet tray.
2. Wash hands thoroughly before handling the
newborn.
3.
Explain the procedure to the mother and ensure
that the newborn's weight is checked before the
newborn leaves the labour room.
4.
Place the newborn on the towel. Wait till the
weight stops fluctuating to the nearest 0.01 kg.
Remove the newborn.
5. Cover the newborn immediately and hand over
to mother or rewarm by asking the mother to
provide kangaroo mother care (KMC) or keep
under radiant warmer if needed
Figure 2.3: Weighing a newborn
6.
Record the weight in the newborn's case sheet.
7.
Refer a newborn with birth weight "less than 1800 gms" for further management
Classify by GESTATIONAL AGE USING LMP
1. Ask the mother for the date of her LMP or look in the Thayi card or case sheet for the same
2. Calculate the gestational age in weeks
3. Make inference of gestational age as follows:
a.
Preterm : less than 37 weeks
b.
Term : 37 -42 weeks
c.
Post term : more than 42 weeks
Check GESTATIONAL AGE BY PHYSICAL FEATURES
i.
Use the chart given in Table 2.1 to classify the newborn as preterm or term. This is based on physical
features. It is a quick way to decide the approximate age of the newborn especially when the
gestational age is not known.
*________________________
Mentors' Manual Volume 3
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Table 2.1: Guide to determine age of newborn, when gestational age is not known
Physical features
Term newborn
Preterm newborn
Flexed
Semi flexed
Incurvature complete, cartilage thick
and thus easily recoilable
Incurvature incomplete, not easily
recoilable
Areola and nipple well defined and seen
Barely visible areola and nipple
1. Posture
r T5-'
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2. Ear examination
3. Breast buds
■
4. Genitalia - female
Labia majora covers labia minora
Labia majora does not cover the labia
minora
A;
5. Genitalia - male
Testes descended, scrotal rugae present
Scrotal rugae absent, increased chance
of undescended testes
6. Sole creases
Present
Absent
HHHH
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Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
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2.5 Key Messages - Do's and Don'ts
........................................... .................................................... '■■■>:................... :i-r*..... ..............................................
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... ........................................................................ '................................. "
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..... ..................................... ........................................
DO be prepared. Make sure all necessary equipment and supplies are available and
functional in the newborn corner. Being prepared makes it easy to complete the taskfester.
_—
—————— ; J..;-.!?.
———-———-4
DO place the newborn immediately on the mother's chest/abdomen and dry with
a warm cloth. This encourages skin-tb-skin contact keeps the newborn warm ahd)
promotes bonding.
,
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""
DO know that the normal birth weight of newborns is 2500-3500 gms (2.5 3.5 Kgs)
and gestational age is 37 completed weeks of gestation. If the newborn is less than
2500 gms (2.5 kgs) or less than 37 weeks gestation there is more chance of newborni
complications.
Do's
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DO remember that a newborn that has a weight less than 2500 gms (2.5 kgs) is
classified as low birth weight. A newborn newborn who is between 1800 gms (1.8
kgs) and 2500 gms (2.5 kgs) can be managed in the PHC
....
--------------- —_______—l-------,—J---------- !—_____-------------;— -------__—:-------------------
•
DO refer those newborns below 1800 gms (1.8 kgs) to a higher center for further
management. Such newborns might have complications of breathing, hypoglycemia
or a higher chance of infection. They will need to be watched carefully and would:
need specialized care in a neonatal unit.
DO remember that gestational age below or above 37 weeks indicate either
preterm or post term respectively. If gestational age is not known, certain physical
characteristics can Indicate prematurity,
■
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:------- ——’-------------- --------------- -—
-—
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----------- :------------ - --------- ——---------------- —--------------- —
p—
Do remember that a newborn can lose up to 10% of its birth weight in the first week
oflife - this is normal. But weight loss of more than 10% in the first week is a flag sign
that something might be wrong.
_ _________ ,
____
1
:
................... . .....................
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DO NOT delay in assessing the gestational age and weight of the newborn once he/
she is stable. It is best checked before the newborn and mother are shifted out of the
labour room.
Donis
DO NOT expose the newborn to open air for too long when checking the weight or
making observations of physical characteristics to estimate the gestational age. This
could lead to hypothermia in the newborn.
DO NOT delay referral ofa newborn that is less than 1.8 kgs. This newborn can either
be SGA or preterm and would require more intensive care.
n____
Mentors' Manual Volume 3
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13
Care of a Normal Newborn at Birth
till First Hour of Life
Learning Objectives
By the end of this chapter you will be able to
■t
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❖ Recall the steps of routine care in the first hour of birth
❖ Demonstrate how to assess and provide routine care in the first hour of birth
.H ifa ?i
❖ Demonstrate accurate documentation of immediate care of the newborn such as drying and H
wrapping the newborn; providing skin-to-skin contact; using radiant warmer; cleaning umbilical !
.
.
.
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.
.
.
.
.
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.
.....
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cord and eyes; checking temperature by touch and the thermometer; administering Vitamin K; 1
assisting a mother to initiate breast feeds
❖ Demonstrate mentoring skills for provision of routine care of newborn
_—
i
3.1
------------ ---- —_____—
1
---------- ------- —
Introduction
The first hour after birth is the most crucial period and care provided during this period could help
in preventing complications and ensuring quality of life. A normal newborn weighs more than
2500 gms (2.5 kgs), breathes normally and regularly, has warm trunk and soles (temperature 36.5-37.2°C /
97.7- 98.60F), is pink in colour with spontaneous body movements and actively sucks on breast. Immediate
care of newborn would help in good adjustment from intrauterine life to extra-uterine life. PHC staff that
pay specific attention to the basic components of warmth, breathing, and breastfeeding initiation could
help in reducing risks of hypothermia and hypoglycaemia. In addition a quick screening for malformations
or birth trauma could assist in getting the right help for the newborn at the right time.
3.2 Components of Routine Care of Newborn at Birth and
their Importance
Call out the time of birth and sex of newborn
❖ Check the time of birth on the watch
❖ Record the time, date and sex of the newborn on the case sheet
❖ Call for help from other PHC staff if needed
Assess if newborn is breathing
Soon after birth, a newborn must have a strong cry, be pink and active. This indicates that the newborn is
breathing normally and is warm enough.
❖ Check if the newborn is breathing
❖ Check if the newborn is active and pink
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
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Dry and keep newborn warm with skin-to-skin contact
❖ Dry the newborn with towel. At the same time check for breathing or cry. If breathing well or crying,
place the newborn over mother's abdomen or on mother's chest as soon as possible for direct skin-toskin contact. Cover the newborn with the second clean towel/cloth.
Check APGAR score at 1 and 5 minutes:
APGAR is an acronym but used backwards i.e.
❖ R: Respiration
❖ A: Activity
❖ G: Grimace
❖ P: Pulse or Heart rate
❖ A: Appearance
It is used to determine the health outcome of the newborn and not to decide if resuscitation is needed.
Each criterion is scored from 0-2 and thus a total score of 8-10 indicates a healthy newborn newborn.
Clamp, cut and clean the umbilical cord
❖ Wait for cord pulsations to stop (1-3 minutes). Clamp the cord at approximately 2-3 cms from the
newborn's abdomen using umbilical clip and an artery damp placed 2-3 cms from the umbilical clip
❖ After the placenta is delivered, cut the cord between the clamp and artery forceps
❖ Clean the cord with dry sterile cotton
❖ Tie the napkin below the umbilical stump
Give eye care
❖ Clean eyes of newborn with a sterile cotton swab from the medial to lateral aspect of lid. Use a separate
cotton swab for each eye.
Give injection vitamin K
❖ Above 1500 gm give 1 mg of Vitamin K intramuscularly on day 1 of birth for all newborns
❖ Give 0.5 mg of vitamin K IM for newborns weighing less than 1500 gm (1.5 kgs) gm
Assist to initiate breastfeeding
❖ Help the mother to position herself and see that the newborn has attached correctly to the breast.
Check for malformations and trauma
❖ Quickly screen for malformations that require immediate attention within an two hours of birth.
3.3 Importance of Components
Call out the time and sex of newborn at birth
❖ The birth of a newborn is an important vital event. It has important cultural and legal implications.
❖ A PHC staff must thus record accurately the time and sex of the newborn on the case sheet after she
has confirmed with mother, significant family member or support person about so that there is no
confusion later.
Assess the breathing of the newborn
❖ The first minute is considered the golden minute of life.
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Mentors'Manual Volume 3
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❖ A newborn who does not cry or who is inactive soon after birth flags a danger sign that requires
immediate attention of the PHC staff to begin initial steps of resuscitation within 30 seconds of birth.
❖ Dry the newborn and keep warm by skin-to-skin contact
❖ A newborn is usually wet with the amniotie fluid when born. Since newborn newborns ability to maintain
temperature is not very good it is important that the newborn is dried immediately with a clean warm
towel/ cloth that is kept on the mother's abdomen (Figure 3.1). This could help in preventing heat loss.
❖ Skin-to-skin contact on the mother's abdomen or between the mother's breasts could help in transfer of
heat from the mother's skin to the newborn's skin.This could keep the newborn naturally warm and promote
comfort of the mother and newborn. The newborn must be covered with another dry towel (Figure 3.2).
❖ The large surface area of the head could contribute to heat loss easily. It is thus necessary to cover the
head with a cap.
❖ A newborn whose feet and palms are blue is a flag to the PHC staff that the newborn is not warm
enough. Action must taken such as drying the newborn, maintaining skin-to-skin contact with the
mother and covering the newborn with a clean warm towel or cloth. If needed additional heat source
could be used.
£
Figure 3.1: Dry newborn keep warm
I
Figure 3.2: Skin to skin contact
Check the APGAR score
❖ APGAR score could help to identify a newborn at risk for breathing difficulty. Since it is checked only at
1 minute after birth, it is not used as an indication for starting resuscitation.
❖ APGAR score also helps in determining the long term health outcome of the newborn.
❖ Thus APGAR score less than seven must make a staff PHC staff alert; she should refer the newborn and
watch the newborn for any possible complication till transport.
Clamp, cut and clean the umbilical cord
❖ Delay in cutting the cord (1-3 minutes depending on whether the newborn has cried or is breathing)
could help in more blood being delivered to the newborn. This is reported to have important health
benefits.
❖ The cord blood transports nutrients and stems cells to the newborn. The chance of the newborn to
develop anemia for as much as six months is reduced.
❖ In addition the placenta is known to shrink as it pumps out more blood. Thus the placenta can be
delivered more easily.
❖ The umbilical cord heals best when kept dry and clean (Figure 3.3).
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
•
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Figure 3.3: Clamp umblical cord at birth
Eye care
❖ A newborn newborn can pick up an infection. Thus it is important that the eyes are cleaned of any
secretions present as a result of the newborn's passage through the vaginal canal soon after birth.
❖ Using separate sterile cotton swabs could prevent spread of infection from one to the other eye.
Maintain skin-to-skin contact between mother and newborn
❖ This will help in transfer of heat from the mother's skin to the newborn.The temperature of the newborn
is stabilised.
❖ There are other benefits of skin-to-skin such as it helps the newborn to start breastfeeding early, since
the newborn smells colostrum at birth.This gives more chance to explore and search for milk when the
newborn is alert (usually for half an hour soon after birth).
❖ Place the newborn if stable between the mother's breasts, the newborn naturally moves towards the
nipple and starts feeding
Give injection Vitamin K
❖ Bleeding could occur within the first 24 hours of birth or within the first week of birth. Vitamin K helps
to prevent bleeding disorder of the newborn.
Assist to initiate breastfeeding
❖ Breastfeeding must be started as soon as possible
after the newborn is born. Early initiation of
breastfeeding is known to reduce neonatal deaths
by 22%.
❖ The PHC staff must be able to assist the mother and
the newborn to begin feeding. This can be done by
skin-to-skin contact and supporting the newborn.
I
............ .
❖ Other benefits of early breastfeeding include it helps
the uterus to contract and bleed less. It stimulates milk
production. The newborn is more comfortable and Figure 3.4: Place newborn in skin to skin
would be able to cope with pain of injection much
contact at birth
better.
Mentors'Manual Volume 3
Examinethenewbornforanymalformationsthatmightrequireaimmediatereferral
❖ Sometimes malformations might not be anticipated and it might be detected late. Thus a systematic
and targeted physical examination could help detect abnormalities fast enough to get the needed
action.Quickly screen for malformations that require immediate attention within an two hours of birth.
3.4 Requirements to Provide Care at Birth for Normal Newborns
Equipment and supplies
❖ Case sheet to document the time and date of birth, gestational age and sex of the newborn newborn
❖ Clean cloth / towels - two
❖ Cord clamps/tie
❖ Scissors to cut cord
❖ Cotton swabs for cleaning cord and eyes and administering injection Vitamin K
❖ Injection vitamin K ampoule
❖ Syringe and needle of appropriate size
❖ Thermometer
❖ Spirit to clean injection site, clean thermometer
Clinical skills
Provide ROUTINE CARE FOR NEWBORN AT BIRTH
1.
Place newborn over the towel on mother's abdomen
2.
Dry the newborn. Cover with the second dry clean towel /cloth
3. Check breathing
4.
Clamp and cut the cord
5.
Place between mother's breasts
6. Clean eyes
7. Give injection Vitamin K
8. Assist to initiate breastfeeding
9.
Monitor the newborn's vital signs every 15 minutes
2. How to WRAP THE NEWBORN
1. Wash hands
2.
Encourage the mother to watch the procedure so that she can learn how to do so when she is at home
3. Take a long clean cloth or towel. Spread the sheet on a flat surface. Fold one corner on itself- place the
newborn's head on the infolded corner so as to cover the head till the hairline on the forehead. Cover
the right shoulder and tuck on left side. Fold from the foot end and tuck beneath the chin. Finally
cover the left shoulder and tuck on the right side
____________ Bl
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
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-.... : I
1
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*
Figure 3.5: How to wrap the newborn
Check AXILLA TEMPERATURE
1. Wash hands before procedure
2. Collect all articles required (thermometer, cotton swab, kidney tray)
3. Clean the thermometer, shake it down so that the mercury reads less than 35° C (95°F)
4. Wipe the underarm of the newborn
5.
Place the bulb end of the thermometer under the arm, in the middle of the armpit. Hold the arm against
the body and keep the thermometer in place for 3 minutes
6.
Remove the thermometer, wipe it dry with cotton swab
7.
Read the temperature by raising thermometer at eye level
8.
Record the temperature in the case sheet
9. Wipe thermometer with spirit swab
10. Store in a clean container
Give INJECTION VITAMIN K INTRAMUSCULARLY
1. Collect all articles required such as injection Vitamin K ampoule, syringe (2cc/1 cc), needle (26 G),
cotton swabs, spirit, kidney tray, container to discard the needle and syringe
2. Wash hands
3. Assemble needle and syringe. Choose a 2ml or 1 ml and a 26G needle
4.
Break the ampoule carefully and draw the required amount in the syringe
5.
Identify the site for the injection mediolateral (Vastus lateral is). This means it is between the middle and
side surface of thigh
6. Wipe the site with spirit swab in a circular motion. Allow to dry
n
Mentors' Manual Volume 3
7. Grasp the muscle gently with thumb and fingers. Insert the needle at 90
degrees angle, aspirate and administer the medication if no blood visible
8. Withdraw needle. Massage the site
9.
Discard the needle in puncture proof container or use needle cutter, the
syringe in other materials in appropriate bin
10. Wash hands
11. Record the injection name, dose, site, and route in excel Sheet
12. Check if the newborn is comfortable
5. Check APGAR AT 1 AND 5 MINUTES
1. Assess the newborn at 1 minute for respiration, activity, grimace, pulse/
heart rate, and appearance. As given in the Table 3.1
2. Alertyourself if APGAR is less than 7. Watch the newborn carefully. Stimulate
if needed. Keep the newborn warm. Resuscitate if needed. Refer as soon
as possible to a higher center.
Use 26 gauge needles
Figure 3,6: Site for IM
injection for a NB
Table 3.1: APGAR scoring chart
Indicator
0
1
2
Respiration
(breathing/cry)
Activity (muscle tone)
Flaccid/floppy
(looks very weak
Limited movement
/ some flexion of
extremities
Grimace (frowning face,
Grimaces, weak cry to
.No responses
irritability)
- ■•'•I,
•,
-'Uv
Pulse (heart rate)
Absent
Appearance
Pale/blue
Moves all extremities
spontaneously / good flexion
Cries / pulls away to stimulation
Less than 100
More than 100
Blue extremities / body I
, .. . a
.
'
3. The APGAR (short form for each indicator Appearance, Pulse, Grimace, Activity and Respiration) score
is assessed by evaluating the newborn on five simple indicators on a scale of zero to two. The score
range is from 0 -10.
❖ Inference of APGAR score
♦ More than 8 = normal
♦ Less than 7= indicates asphyxia
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
3.5 Mentoring skills
Sample example for mentoring - observation
Instructions for mentor
❖ During a regular visit to the PHC make a random check of the following items as given as given
in Table 3.2
❖
After the observation tell the staff nurses about your observations starting and ending with
good points. Also highlight the points for improvement
❖ Brief the staff nurses and other members on the importance of maintaining the warm chain.
Use information given in Table 3.2
❖ Help them to make a plan on what they would want to achieve by the next mentoring visit
Table 3.2: Warm chain maintenance checklist
___________ At Birth___________
Delivery room temperature is warm
(250C/77°F)___________________
Windows / doors closed to avoid
drafts________________________
Y/N
__________After Delivery__________
Y/N
Newborn kept with the mother in the
same bed______________________
Newborn clothed adequately wrapped
with head covered________________
Newborn dried immediately
Newborn wrapped with clean cloth or
towel__________________________
Wet towel/ cloth removed________
Bath not given for the first 24 hours
Newborn kept on mother's abdomen
or between breasts for skin to skin
contact______________________
Newborn wrapped with clean dry
cloth
LBW newborns are given Kangaroo
mother care (KMC)
Sample example for observation - "Clean chain to prevent infection" during a
mentoring visit
Instructions for mentor
❖ During a regular visit to the PHC make a random check of the following items as given in Tabe 3.3
❖ After the observation tell the staff nurses about your observations starting and ending with good points.
Also highlight the points for improvement
❖ Brief the staff nurses and other members on the importance of maintaining the clean chain. See
information given in Table 3.3
❖ Help them to make a plan on what they would want to achieve by the next mentoring visit
Mentors' Manual Volume 3
J
Table 3.3: Clean chain maintenance checklist
Clean delivery
After delivery
Y/N
Attendant's hand clean (wear gloves)
All caregivers wash hands before
handling the newborn
Delivery surface clean
Only breast milk given, clean feed
Cord cutting instrument is clean
Clothes worn for the newborn are clean
Cord tie / clamp is clean
Nothing is applied on the cord. It is
clean and dry.
Cloth used to wrap the newborn is
clean__________________________
Napkin changed whenever soiled/wet
Mother used clean cloth to wrap self
Eyes are clean
Y/N
Sample case sheet audit
❖ Check if vital signs are recorded in the case sheet
❖ Check the newborn's breathing and temperature every 15 minutes for the first hour and then hourly
(See Table 3.4)
Table 3.4: What to audit in the case sheet for care of newborn
Parameter
Breathing
What to Look for
Look in the case sheet to see if breathing is recorded every 15 minutes for the
first hour
Check if any abnormalities are recorded_______________________________
Colour
See if colour of the newborn is recorded every 15 minutes for the first hour
Note if any abnormality is recorded. Check the recording with an examination
of the newborn
Warmth
Counter check if temperature of the newborn is recorded every 15 minutes for
the first hour
Observe directly
Does the mother know how to check temperature by touch method? This could
have been taught by the staff nurses
Can the mother recognise if the newborn's skin is mottled (spotty) it indicates
low temperature________________________________________________
Cord
Check if any recording is made on the case sheet about the cord such as
bleeding or discharge.
17 i
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Sample: How to do one to one mentoring for example on identification of
malformations
Instructions to mentor
❖ The chart (Table 3.5) could be a guide for you to teach staff nurses
❖ This could be a planned teaching, done later once the staff nurses have learned more important skills
❖ Teach staff nurses to identify malformations (see Table 3.5)
Table 3.5: Identify malformations / problems
Ask
Look for
Feel for
J Antenatal details such as
drug abuse or any other
problems
S Any breathing difficulty
S Colour: any cyanosis
Capillary refill time
J Any investigations done
during pregnancy that
showed a specific defect
J Any drooling of saliva
Palpate the abdomen
Newborn passed meconeum within 24 hours;
urine within 48 hours
J Flat abdomen and bulging
chest
S Any swelling
J Feel for testes in male
newborn
J Any defect in lips or palate
Any swelling on head
J Symmetry and posture
Any bulge or sac on the back
J Anal opening
J Simian crease
❖ Help staff nurses to recognise malformations: Although malformations are not very common (see against
each malformation approximate time of occurrence), it is important that life threatening malformations
are identified immediately, initial action is taken and referral is made to a higher center as soon as possible.
_____________ How to recognise_____________ _________ Malformations_________
❖ Breathlessness, cyanosis, empty abdomen
❖ Drooling sometimes with cyanosis_________
- Diaphragmatic hernia____________
-Tracheo esophageal fistula every 4 yrs.
❖ Anal opening absent____________________ - Anorectal malformation every 10 yrs.
❖ Swelling on head that does not cross suture
- Cephalhematoma once every 2mons.
❖ Cyanosis_____________________________
- Congenital heart malformation
❖ Swelling on back_______________________ - Spina bifida once every 5 yrs.______
❖ Opening on palate, newborn chokes when - Cleft palate once every 1.5 yrs.
feeding
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❖ Teach staff nurses to provide initial management for newborns with malformations
♦ Provide immediate care: warmth, cord care, eye care, Vitamin K and initiate breast feeding if not
contraindicated
♦ Refer urgently for immediate management:
♦ Newborn with respiratory distress
♦ Newborn with drooling
♦ Newborn with cyanosis
♦ Newborn who has not passed meconium x24 hours
♦ Newborn who has not passed urine x48 hours
♦ Any newborn with a malformation - to see the doctor within 1 week
❖ Teach staff nurses to monitor
♦ Help staff to maintain a register of all newborns that have been referred to a higher center for any
malformation.This can provide important information on the quality of care provided by the staff nurses
3.6 Key Messages - Do's and Don'ts
DO be prepared. Make sure all necessary equipment and supplies are available anc|
functional in the newborn corner. Being prepared makes it easy to complete the tasl<
fester ■ : ■ 34 7 ! 1 ■
!
Do's
la
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. ..................... .
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DO place the newborn immediately on the mother's chest/abdomen and dry with^
a warm cloth. This encourages skln-to-sldn contact, keeips the newborn warm and;
promotes bonding.
'
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DOcheck ifthe newbornis breathing and active soon afterbirth. Decide on need for:
resuscitation depending on whether or not the newborn is breathing, crying actively
and Is pink
• ' 3' 3 j J3:i333|33:® < ’ 3
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DO wait to damp and cut the umbilical cord till itstopis
it stops pulsating,
pulsating.
------------------------- —---------------------................ ~.
DO give Vitamin K injection intramuscularly io all newborns to help prevent
hemorrhagic disease of the newboip.
newborn, ;
\
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DO assist mother to initiate immediate breastfeeding. This releases oxytocin in th^
mother. This helps contract the uterus and prevent postpartum hemorrhage.
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Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
DO NOT delay In deciding if the newborn requires resuscitation or not.
DO NOT expose the newborn to external environment as it can cause sudden drop in
its body temperature.
DO NOT milk the umbilical cord before clamping and cutting it, since this procedure
has been linked with increased chance of neonatal jaundice.
Don'ts
DO NOT delay cutting the umbilical cord for those newborns requiring resuscitation
......... . ............... . .. .
. . . ......... .... . ............ ................. ..... -........ ............
DO NOT delay in initiating breastfeeding. If the newborn breastfeeds early, will be
established faster.
DO NOT forget to observe the newborn every 15 minutes for the first 1 hour of life
DO NOT forget to change the newborn's napkin if wet or soiled, cover the head and
feet always
DO NOT wrap the newborn too tight so that movements of the newborn is prevented
Mentors' Manual Volume 3
■ 'i
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14
Newborn Resuscitation including
Preparation of Newborn Corner
Learning Objectives
-- -------------------------------------------- . ,....................................... ... . .... . .. ...
—
By the end of this chapter you will be able to
❖ Recall the steps in basic newborn resuscitation with their indications and rationale
❖ Demonstrate the steps of basic resuscitation on the mannikin.
❖ Demonstrate accurate documentation of basic neonatal resuscitation measures done for the newbon
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❖ Demonstrate
mentoring skills
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4.1
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Introduction
The first few minutes soon after birth are important for the health of the newborn. It is important to make
sure that the newborn has a strong cry or breathes soon after birth. Approximately 10% of newborns
require some assistance to begin breathing at birth. Of these newborns, about 1% would need extensive
resuscitative measures to survive. It is sometimes hard to predict which newborns require resuscitation.
Hence it is important to be prepared at ALL times.
If initial steps of resuscitation are started as soon as required, it could help reduce long term sickness like
seizures, cerebral palsy and other disabilities and developmental delay or even death. Trained PHC staff
and a well equipped PHC are important factors for effective resuscitation.
4.2 Components of Basic Newborn Resuscitation
Anticipate before delivery
❖ Do a thorough initial assessment of a mother in labour at admission
❖ Keep all equipment, articles and supplies needed for resuscitation always ready for use
Key to Successful Resuscitation
❖ Anticipate - keep artldes/supplies/equipment ready
❖ Be prepared - see that articles and equipment are always
in working order
Be ready ALWAYS.
A newborn might require
resuscitation ANYTIME
❖ Call for help - to initiate resuscitation quickly step by step
Figure 4.1: Key to Successful Resuscitation
21
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Essential Newborn Care at 24/7 Primary Health Centres
-1
Assessment at birth and be ready to resuscitate if the newborn does not cry /
breathe at birth
❖ Follow the protocol always to decide when a newborn needs resuscitation as given in the Table 4.1 and
the Neonatal Resuscitation Chart (Figure 4.2)
Table 4.1: How to decide when to resuscitate a newborn at birth
Bh-^^lp^H^isin^^esperminute
' W
. NO resuscitation,. ,
It NO routine suctioning
* Give back to mother
toJ
‘ ♦ Give raotjne care
■
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_________________________
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The newborn is gasping, does not breathe The newborn is not breathing
regularly and there are long between each
breath
..................... . —:_ :-- '...........------------------- --__
♦ Needs help immediately with breathing
♦ Give help to breathe
♦ START resuscitation within 1 minute
]
J
♦ START resuscitation within 1 minute
Perform initial steps of resuscitation if the newborn does not breathe or cry soon
after birth
❖ Call for help
❖ Maintain warmth of newborn
❖ Keep airway open by positioning newborn in sniffing position and suctioning mouth and nose
❖ Give tactile stimulation to the newborn.
Provide positive pressure ventilation (PPV) even if after 30 seconds of initial steps
newborn does not improve
❖ Use bag and mask to provide PPV at a rate of 40-60/minute.
❖ Check heart rate after 5 inflations and chest rise
Evaluate the effectiveness ofPPV after 30 seconds
❖ Check heart rate and breathing
❖ Continue bag and mask if heart rate is good (more thanl 00/minute) but breathing is still less
❖ Add oxygen with bag and mask ventilation
Initiate chest compressions if after 30 seconds ofPPV, HR less than 100/minute
❖ Start chest compressions if after 30 seconds of PPV heart rate continues to be less, at a rate of 3:1
(compression to breath delivered through bag and mask).
Refer for further management if no improvement
❖ Continue same steps till the newborn can be transported to a higher center or stop if after 20 minutes no
improvement and the newborn fails to breathe
If newborn improves, give post resuscitation care
Mentors'Manual Volume 3
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. l Howf>:
sT,tatiort ;.
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BIRTH
ASSESS BREATHING/CRY
|
Breathing well or strong cry
>
Not breathing well/ gasping /no cry
Initial Steps
1. Cut the umbilical cord
2. Place on firm, flat surface
3. Provide warmth
4. Position newborn with neck slight
<U
o
extended
5. Suction the mouth, then the nose
6. Tactile stimulation
7. Renosition
J
I
■... ... r... i
Breathing well
ASSESS BREATHING
I
........
Not breathing well
Provide bag and mask ventilation for 30 sec
Ensure chest rise
o
o
I
Breathing well
ASSESS BREATHING
I
Not breathing well:
1 .Call for help
2. Continue bag and mask ventilation
3. Add oxygen, if available
I
Heart rate 100 or more
>
ASSESS HEART RATE
Contintie Ventilation
=s
I
Heart rate less than 100
■£
ASSESS BREATHING
1 .Continue ventilation with oxygen
2.Provide advanced care if MO is availble
(Chest compression, Medication, Intubation)
3.0rganise referral
I
€
£
CQ
Not breathing well
>
Post resuscitation care
Figure 4.2: Flow chart for resuscitation
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
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4.3 Important of Components
Anticipate before delivery and preparation of newborn corner
❖ The need for newborn resuscitation can be anticipated by presence of risk factors. Be alert of the
need for resuscitation in a mother with chronic illness, bad obstetric history; pre eclampsia, multiple
pregnancies, a preterm delivery, abnormal presentations of the fetus, cord prolapse, prolonged rupture
of membranes or of labour, meconium stained liquor. But for at least half of newborns the need for
resuscitation at birth may not be predicted before delivery.Therefore it is important, to be prepared at
every delivery for resuscitation.
❖ Being prepared could prevent loss of time, and thus promote better health outcomes. Being ready
includes, seeing that the temperature of the delivery room is comfortable (not too cold) -ideally more
than 25°C (more than 77°F). Th is will help the newborn to keep warm and to transition from intra uterine
to extra uterine environment.
❖ A newborn corner must be made in one part of the labour room. This must
♦ Have clear floor space: 20-30 square ft in size,
♦ Have large enough space to keep the radiant warmer and for personnel to resuscitate the newborn
♦ Be away from draught of air, so that the temperature of the newborn can be maintained.
♦ Have enough space to keep the oxygen cylinder so that oxygen could be administered if needed.
♦ Have an electric outlet
♦ Radiant warmer since any newborn requiring resuscitation would need to be kept warm;
♦ Suction apparatus for airway suctioning
♦ Other articles and equipment required such as gloves, bag and mask, feeding tubes, DeLee's mucus
trap, suction catheter and oxygen cylinder / source with flow meter and humidifier must always be
ready for use.
❖ The PHC staff must check the equipment and articles at each shift to ensure that they are clean and
in working condition. This could reduce the chance of infection and thus promotes better health
outcomes.
Assess newborn at birth and be ready to resuscitate based on protocol
❖ It is normal for a newborn to have a strong cry soon after birth. This is an indication that breathing has
been initiated. However few newborns may not cry immediately after birth. A newborn, who does not
cry soon after birth or gasps, is a flag to take immediate steps to help the newborn breath.
❖ The first minute is considered the golden minute and any action must be initiated before this one
minute.
❖ Ask the following question at birth
♦ Is the newborn crying or breathing? If yes, it means that there is no problem
❖ But if the answer is no to any one of the questions above, then it is important to begin initial steps
within seconds of birth.
❖ Ventilation would be the most important step if the newborn is not breathing. It can improve the heart
rate of the newborn. Ventilation also decreases the chance of hypoxic (reduced oxygen supply) injury
to the brain.This could help prevent long term damage.
Mentors' Manual Volume 3
Perform initial steps of resuscitation
❖ The initial steps of resuscitation include providing warmth by placing the newborn under a radiant
heat source, positioning the head in a sniffing position to open the airway, clearing the airway with
a suction catheter or DeLee's mucus trap, drying and stimulating the newborn. The initial steps must
be able to help the newborn establish regular respirations that are sufficient to improve colour and
maintain a heart rate.
❖ A heat source will help in reducing the risk of hypothermia, and this will stabilise the newborn faster.
Drying the newborn with a warm towel can help in preventing heat loss. A newborn who has cyanosis
(acrocyanosis/central) must be warmed fast for better health outcomes. Acrocyanosis (blue colour of
hands and feet alone) is a flag for cold stress. Central cyanosis (blue discoloration of trunk, extremities
and mucus membranes is a flag for low levels of oxygen circulating in the body (see Chapter 6).
❖ By opening the airway and clearing the air passages of secretions, a newborn that is not very sick will
be able to achieve and maintain pink mucus membranes (lips) without supplementary oxygen. It is
important to remember that this transition is a slow process.
❖ Rubbing the newborn gently on the back or the feet could help in stimulating the newborn to breathe
sooner.
Provide positive pressure ventilation after 30 seconds of initial steps
❖ Providing PPV means you are forcing the newborn to get oxygen within the first few minutes of life.
❖ If after initial steps the newborn still does not breathe, it indicates that the newborn would require
help. PPV administers room air through mask to the newborn provided the airway is clear of secretions
and the airway is open by a good position. This is enough to help the newborn breathe.
❖ The bag must be compressed at a rate of 40-60 times/minute to be able to get a heart rate to more
thanl 00 beats/minute.The bag and mask gives only 21 % oxygen.This is enough for the first 30 seconds
of PPV. If the heart rate (HR) does not increase or the breathing does not improve after 30 seconds of
PPV this is a flag to give more oxygen. If an oxygen tube is connected to the bag, 40-60% oxygen is
administered. But if a reservoir is connected to the bag, 100% oxygen is given.
❖ The pop up valve of the bag would help in delivering the required pressures of 30-40cm of H2O.
Evaluate the effectiveness of ventilation
❖ Evaluate the effectiveness of PPV after 30 seconds of its administration.
❖ PPV is considered as effective when there is increase in HR, improvement in colour and tone, audible
breath sounds and chest movements. But if these signs are not seen, then it is a flag more advanced
resuscitation steps.
Initiate chest compressions after 30 seconds ofPPV with 100% oxygen, if HR less
than 60 beats/minute
❖ Chest compressions would be needed if the myocardium (heart muscle) is depressed because of low
oxygen levels. Mechanical pumping of heart would help to increase the perfusion to the lungs and thus
reduce these effects.
❖ Chest compressions mean compressing the chest externally just above the xyphoid sternum, one third
the depth of chest wall, so that the heart is pressed against the spine. This will help to increase the
intrathoracic (space between ribs) pressure. Thus blood circulates to the vital organs.
25
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
❖
The PHC staff must reassess the condition of the newborn after 30 seconds to a minute. It can be
stopped when HR more than 60 beats/minute.
Refer for further management
❖ All those newborns who required initial steps of resuscitation could be transferred to the mother's side.
However these newborns must be monitored frequently for the first two hours to see if all was well
with them.
❖ Those newborns who required PPV or more advanced resuscitation must be referred for further
management as they might require intensive care
If newborn improves provide post resuscitation care
❖ Post resuscitation care is essential to know whether the newborn has stabilised or not.
❖ A newborn who has stabilised would have a heart rate between 120-130/minute; respiratory rate
40-60/minute; posture would be flexed; they would be active; colour would be pink.
❖ Thus monitoring these vital signs every 15 minutes for the first hour and every half an hour for the
next hour would help to know if the newborn has stabilised before referring to a higher center for
further management.
4.4 Requirements for Newborn Resuscitation
Equipment and supplies
❖ Ambu bag (250-500ml)
❖ Cord clamps
❖ Delee's mucus trap (Figure 4.3)
❖ Dextrose 5-10% for IV drip
❖ Glucometer
❖ Epinephrine 1:10,000 (if 1 ml ampoules of epinephrine 1:1000 is available then it must be diluted in
10ml of saline)
❖ Feeding tubes size 6 and 8
❖ Gloves
❖ Mask (0-1 size)
❖ Needles 23,24,26 Gauge
❖ Normal saline sterile to clean eyes
❖ Oxygen cylinder
❖ Oxygen tubing
❖ Radiant warmer and or 200 watt bulb source with electric outlet
❖ Ringer lactate for IV drip
❖ Scalp vein sets
❖ Shoulder rolls
❖ Sterile cotton swabs to clean eyes
❖ Stop clock indicating seconds and minutes
Mentors' Manual Volume 3
Figure 4.3: Delee's mucus trap
❖ Suction tubes 8,10 size
❖ Syringes 2,5,10cc
❖ Warm towels
Clinical skills
Checking EQUIPMENT/SUPPLIES IN NEWBORN CORNER
1 .Test all equipment and articles for working condition and availability
2. Bag and Mask
❖ Check if clean. Clean with soap solution and keep dry. Wrap with plastic sheet for next use after checking
working condition
❖ Fit mask onto the bag (Figure 4.4) and deliver test breaths against the palm of hand. If you feel pressure
in the palm as the bag is squeezed, it is working well (Figure 4.5).
❖ Once you release after squeezing the bag, it must re inflate quickly
3. Radiant warmer
❖ See that the radiant warmer tray is dean and dry. Clean with soap solution with a piece of doth and
Pop-off Valve
LT X
1 Qji
■ ;K
*
Air intet
Figure 4.4: Bag and mask
Figure 4.5: Testing bag and mask
dry daily.
❖ Check radiant warmer/overhead lamp. Switch on at least 20 minutes before anticipated time of delivery.
❖ In the event of power failure use a 200 watt bulb source, close the windows to avoid any direct wind to
the newborn. Keep two clean dry towels/clothes to wrap the newborn.
4. Suction apparatus
❖ Use mucus extractor that has a trap (20m). Remember it is for single use only. Discard in appropriate
plastics bin after use.
❖ Check if suction apparatus is working. See that suction is not more than a negative pressure of
10OmmHg or 130 cm of H2O.
5. Oxygen cylinder and tubing:
❖ Clean cylinder and tubing daily or as per need with soap solution and wipe dry.
❖ Check if the cylinder has sufficient oxygen at each shift. Keep a spare cylinder ALWAYS.
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
❖ Check if the oxygen flow meter is working, so that you can deliver 5-10L/minute of oxygen when
needed.
❖ Keep cylinder close to newborn corner as well as for mother if needed
❖ Use a "Y" connection so that the same cylinder could be used for both newborn and mother if needed.
6. Laryngoscope
❖ Clean the laryngoscope and blade with spirit and see that it dries.
❖ Check if the bulb is working by extending the laryngoscope
blade
❖ Remove battery and keep close at hand so that it could be
replaced immediately when needed.
Providing INITIAL STEPS OF BASIC NEWBORN RESUSCITATION
1. Decide if routine care is needed - newborn crying/breathing;
active; pink in colour; warm;
2. Provide a warm environment (See Chapter #)
❖ Keep resuscitation equipment on the radiant warmer locker so
that it can be accessed easily when needed
❖ Put radiant warmer on 20 minutes before its anticipated use.
3. Position the newborn and open the newborn's airway
Figure 4.6: Radiant warmer
❖ Place the newborn on the back
❖ Position the head so that it is slightly extended (this opens the airway) (Figure 4.7)
❖ Place a folded piece of cloth (not too thick or too thin) under the newborn's shoulder
Correct
Figure 4.7: Position of the head slightly extended
4.Suction the mouth and nose
❖ Insert suction tube not more than 5cm beyond the lip, apply pressure while withdrawing tube
❖ Insert the tube 1 -2 cm into each nostril, apply suction while withdrawing the tube
❖ Stop suctioning when all secretions are cleared
Mentors'Manual Volume 3
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Points to remember:
Suction mouth first then nose
Routine suction of all newborns is not needed
Suctioning alone may stimulate the newborn
to breath
Figure 4.8: Suction mouth then nose
5. Stimulate to breathe by using tactile stimulation (see Figure 4.9)
Forms of Tactile Stimulation that could be
Dangerous
Acceptable Forms of Tactile Stimulation
□
□
□
DO NOT slap the back
0
DO NOT dilate anal sphincter
□
□
DO NOT squeeze the rib cage
DO NOT force the thighs into the abdomen
DO NOT use hot or cold compresses or baths
DO NOT shake newborn vigorously or roughly
Use tactile stimulation gently
Do not use these methods at any time!!
J Flick the feet
J Rub the abdomen with back of fingers
J Rub the back with the palm
Figure 4.9: Forms of tactide stimulation
6.Reassess the newborn's breathing
❖ Place the newborn with mother, if the newborn starts breathing after either suctioning or tactile
stimulation
❖ Provide observational care
/.Observational care
❖ Keep the newborn warm and with the mother
❖ Teach mother skin-to-skin contact and encourage her to practice this
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Essential Newborn Care at 24/7 Primary Health Centres
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❖ Observe breathing and temperature every 15 minutes for the first one hour; every half an hour for next
hour; every hour for the next 4 hours
❖ Look for any convulsions, drowsiness, non response
❖ Refer if any complications present
❖ Initiate breastfeeding if vigorous (active, good colour).
Starting BAG AND MASK VENTILATION (BMV)
1. Start if at the end of 30 seconds of initial steps of resuscitation, the newborn does not breathe or the
breathing is abnormal.
2. Prepare for bag and mask ventilation
❖ Select the appropriate mask based on how well it fits the newborn's face (see Figure 4.10).
❖ Check the resuscitation bag and mask before usage
Correct and incorrect mask sizes
Remember
The rim of the mask must
cover the tip of the chin, the
mouth and the nose but not
the eyes
Incorrect
Too large: covers eyes and
extends over chin
Incorrea .................
- does
J ‘ not cover
Too small:
nose and mouth well
Covers'mottdt, nose^
chin but not eyes
Too large mask can cause eye
damage and will not seal well
Figure 4.10: Correct size of mask for resuscitation
Table 4.2: Check bag and mask before using
The resuscitation bag
Remember
Check the safety mechansim in the form of a pressure release valve to Check if the bag and mask
prevent too much pressure to the newborn's lungs. It is set to release at work by pressing the mask
against your palm
30-40cm of water. It is called the pop up valve.
The ideal size of the bag is 250-500ml capacity
The bag and mask must be assesmbled correctly and connected to
oxygen only when indicated.
Feel pressure
J Force pressure-release
valve open
Valve moving well
When self inflating bag is used be sure to attach the oxygen reservoir.
3. Clear the airway and be assured it is open
❖ Suction the mouth and nose one moretime to assure the airway is clear
❖
Check if the newborn's head is in sniffing position
❖ Use shoulder roll if needed
4. Position yourself at the bedside
❖ Position yourself either at the side or head of the newborn (Figure 4.11)
Mentors' Manual Volume 3
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1111
❖ Control the bag with your dominant hand (right hand for the right handed person) and the hold the
mask with the other hand
❖ Be sure that you can observe for chest movement of the newborn during ventilation
Correct positions to visualise chest movement
Be sure that you can
Hold the mask comfortably on the
newborn's face
Observe chest movements of the
newborn during ventilation
Figure 4.11: Position yourself at side or head of newborn for BMV
5. Position the bag and mask
❖ Place the mask first by cupping the chin and then cover the nose
❖ Ensure that the mask is placed correctly so that its rim covers the nose, mouth and tip
of the chin (Figure 4.12)
❖ Hold the mask on the face with the thumb, index and /or middle finger encircling the rim in a ‘C shape.
Use the ring and fifth fingers to bring the chin forward
❖ Use slight downward pressure on the rim to form an air tight seal.
Correct position of newborn and mask
•^1
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3
Follow these precautions
❖ Do not'jam'the mask down the face. Too much
pressure can bruise the face
❖ Do not rest your fingers on the newborn's eyes
❖ Check for airtight seal so that ventilation is
effective
Figure 4.12: Position newborn and mask correctly
6. Initiate ventilation
❖ Squeeze the bag with enough pressure so that chest rises gently
❖ Check for chest rise and heart rate after five ventilations. If no chest rise follow steps given in Table 4.3
❖ Deliver 40-60 breaths per minute during the initial stages of resuscitation. Say breathe-two-three, say
"breathe" when you squeeze the bag; and then "two-three" when you release it, to ensure proper rate
(Figure 4.13)
31
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Breath* . ?
(squeeze)
Figure 4.13: Deliver 40-60 breaths per minute
Table 4.3: Reasons for inadequate or absent chest rise
What to do?
Reasons for inadequate or absent chest rise
n>
if
ilit
II.
of nose*
J
Check the newborn's position, extend the neck a bit
farther
Check the mouth and nose for secretions
The airway is blocked
Ventilate if needed with newborn's mouth slightly
open
:
.
__
Pllii p see rise of chest
/.Insert oro gastric tube
❖ Measure the infant feeding tube from the tip of the nose to ear lobe and then to midway between the
xiphoid sternum and umbilicus
❖ Insert the feeding tube through mouth into the stomach
❖ Aspirate contents with a syringe and discard the content in kdney tray
❖ Fix the tube on the cheek with micropore or remove it if the abdomen is soft
❖ Discard the tube in the appropriate bin
❖ Record the amount of aspirate
Use size 6 or 8 based
on size of newborn
Discard feeding tube
after use
Figure4.14: Measure orogastric tube
Mentors' Manual Volume 3
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■
8.Evaluate the effectiveness of ventilation
Table 4.4: Evaluate the effectiveness of ventilation
Spontaneous breathing
■Lt.,'
Ask yourself is'the newborn breathing on its own after 3C
seconds of ventilations ^7 ' ■
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If yes reduce the rate and volume; of breaths, watch fort
': ;breathing
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❖ A newborn who is breathing well will be crying or breathing quietly and regularly (chest movements
symmetric) and with frequency of 30-60/minute
❖ Stop ventilation
❖ Provide observational care
No spontaneous breathing or gasping
Ask yourself is the newborn breathing on its own after 30
seconds of ventilation
■t,. •
■■■'
j
Ifyes, continue ventilation and do further evaluation
I
\
❖ Call for help
❖ Continue bag and mask ventilation
❖ Provide oxygen through bag and mask if available
❖ Assess heart rate
Feel the pulse in the umbilical cord oh
on
Ask the person who helps you to use a stethoscope to coun^
heart rate within 6 seconds
'
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Multiply this rate by 10 to give you beats per minute
Figure 4.15 Feel umbtlcal pulse
❖ Heart rate of 100 per minute but Heart rate is slow (less than 100 beats per minute)
newborn is not breathing well
Continue ventilation for 30 seconds
j
J
Continue ventilation and reassess heart rate after 30 seconds!
Does not change, continue ventilation Call doctor to provide advanced care such as endotracheal
■nfi iKa+irtt** rhacf/■AmrvraeciAne
c'*
intubation,
chest compressions and medications
and organise referral or advanced care
Arrange for referral if advanced care not available
❖ Stop all procedures if after 20 minutes of birth, ther« is no signs of breathing or heart rate
J
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Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Providing EXTENSIVE RESUSCITATION
1 .Start chest compression:
❖ Begin chest compressions if heart rate is less than 60 beats per minute.
❖ Locate the site on the lower two third of sternum, avoiding the xyphoid (Figure 4.16)
❖ Place the thumb (preferred) or fingers immediately above the xyphoid (Figure 4.17) and NOT on it
❖ Apply pressure one third of anteroposterior (front to the back) diameter of the chest (Figure 4.18)
❖ Take compression of chest followed by release as ONE COMPRESSION (Figure 4.19)
❖ DO NOT lift thumb or finger off the chest between compression as it would waste time, risk
of trauma by compressing the wrong area or loss of control over depth of compression
❖ Give one chest compression and follow it with three breaths
❖ Count heart rate after 30 seconds and if it is above 60 per minute, stop chest compressions
❖ Continue bag and mask method till heart rate is above 100/minute or the newborn is
breathing spontaneously
Sternum
Nippleline
Fingers must be placed on the lower third of the
sternum:
❖ Feel for intermammary (between nipples) line
V
❖ Feel the xyphoid
❖ Place finger just above xyphoid
Avoid the xyphoid process
Xyphoid
\7
am*
Figure 4.16: Location of site for chest compression
Figure 4.17: Preferred technique: thumb technique over the two finger technique
2.What is the rhythm to be followed?
❖ Deliver one breath, for every third compression given.
❖ Give in ratio of 90 compressions to 30 breaths (3:1)
Mentors' Manual Volume 3
Approximately one third of the anterioposterior
diameter of the chest
Do not lift fingers between compressions as
you will
One third
❖ Lose location
❖ Damage to internal organs
❖ Lose time
Figure 4.18: How much pressure is needed?
Figure 4.19: Phases of one chest compression: Apply pressure and release
3.When to stop chest compressions
❖ Count the heart rate, after approximately 30 seconds of chest compressions and positive pressure
ventilation (bag and mask). If it is more than 60 per minute, stop chest compressions.
❖ Continue PPV if heart rate is 40-60beats/minute till heart rate is to "more than"100/minute or newborn
is breathing spontaneously.
❖ Refer the newborn if no improvement and if the medical officer is available assist in endotracheal
intubation before transfer of the newborn.
Provide POST RESUSCITATION CARE
1 .Give newborns who have received ventilation for a short time observational care
2.Give those newborns who required prolonged positive pressure ventilation supervised medical care
and refer to a higher center as sooon as possible. This includes the following
❖ Provide warmth
❖ Check the vitals (temperature, breathing, colour and capillary refill time)
❖ Monitor blood sugar if available or watch for signs of hypoglycaemia such as lethargy, cold extremities,
drowsiness, seizures
❖ Initiate breastfeeding if well, or give slow feeding
❖ Record all information and events and refer.
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
4.5 Mentoring Skills
Sample case study for mentoring
Case Study 4.1 - Normal delivery
A 19 year old comes to the PHC in active labour at term. She said her bags had burst (membranes ruptured)
1 hour before arrival. Amniotic fluid was clear. She delivered a newborn girl through a normal vaginal
delivery. The newborn cried at birth, became pink quickly and is placed on mother's chest to remain warm
and to complete transition.
What questions will you ask to decide if action is to be taken?
-------------------------------______------------ „-------- _------- ----------------------......................... ......... r-.---- -------------------------
Key for case study 4.1
Possible questions that I will ask to decide action that needs to be taken;
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❖ Is this amniotic fluid clear of meconium?
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❖ Is the newborn breathing or crying?
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❖ Is there good muscle tone?
❖ Is the colour pink?
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❖ Was the newborn born at term?
If all the answers are "yes" the newborn can receive routine care to continue transition. If the answer i$"no"
to any one question or if the newborn is preterm, the newborn might require some form
I of resuscitation. 1
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Use A.M.M.A. approach at mentoring visits for newborn corner
1. First Visit
❖ Use self assesment tools, assess the availability of the equipment in the newborn corner, if any of the
equipment is not functioning or not available (assess), consider the solutions if available (Table 4.3)
❖ Take appropriate action such as assisting staff to indent for reused equipment or teaching them how to
maintain and use equipment (manage)
❖ Demonstrate if needed how to use various equipment. This could be planned or incidental based on
the need and time available.
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Mentors' Manual Volume 3
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Table 4.5: Troubleshooting for equipment in newborn corner
Equipment
Difficulty
Trouble shooting -what can be done
♦♦♦ Power alarm goes
:
No current
❖ To keep a 200 watt bulb source always at hand.This will work witfv
the inverter when there is no current
System alarm
❖ Otherwise look for alternative source such as KMC
❖ Change warmer since there would be an error in the electric andelectronic circuit. It would need to be repaired
Skin probe
Radiant warmer failure alarm
❖ Reconnect or change the sensor as the alarm sounds when the
probe sensor is not connected properly or it is not working
Skin
temperature
alarm high or
low
❖ The alarm goes when the newborn's temperature differs from;
the SET temperature by more than 0.5° C. Change from servo to;
manual mode with maximum output if newborn is having low
temperature
i
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Suction
apparatus
**♦ To keep the manual operated suction apparatus or the DeLee's
mucus sucker at hand
No current
❖ Keep enough mucus suckers at hand
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....teecis replacingsvery three months.
unless it is cracked or it looks dirty br there is humidified water
inthe tubing..^
.
Oxygen tubing
Does, not look
clean
*
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❖ The cylinder and tubinjg' cari.be; wiped externally with a clean
damp cloth once a week unless indicated more often
» The tube and mask can be washed with soap and water and dried,
' packed in.plastic bags for heA use . ' . '
;
Syringe and
needles
Bag and mask
.
„
,
■..............
:
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Used needles
and syringes
found lying
around
Bag and m^sk
look dirty
.
..____ __________
❖ Check with staff for what purpose the syringe and needle
was used.
❖ Inform to discard in the appropriate container (for needle use
needle burner / for syringe in plastic container)
❖ Check with staft how they clean the bag and mask, how often they
clean it and when must they clean the bag and mask
❖ Inform them that the bag and mask can be washed with soap and
water, dried and replaced for next use.
;
.
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Essential Newborn Care at 24/7 Primary Health Centres
I
Essential Newborn Care at 24/7 Primary Health Centres
❖ Check number of deliveries in a month
Mucus sucker
Newborn
corner
Only one left
Dusty
❖ Ask them to indent for the average number required per month
plus three more if the indent happens once a month.
❖ Check if the area has been cleaned
❖ Remind staff nurse that the surface of the radiant warmer must be
cleaned with soap water solution and allowed to dry.
2. At each subsequent visit make sure to check the newborn corner for equipment/articles and
supplies
❖ Reinforce all the positive changes that you see occurring such as the checklist is filled completely; all
articles are available, equipment in working condition etc. (monitor)
❖ Reinforce the need for this to be maintained all the time (advocate)
4.6 Key Messages - Do's and Dont's
DO be prepared. Make sure all necessary equipment and supplies are available and
functional in the newborn corner.
DO dean all artides / see that all artides and equipment are deaned before using.
Soap solution can be used to clean surface of radiant warmer, suction apparatus and
tubing, oxygen tubing and cylinder. The mask and ambu bag can be washed with;
soap and water, allowed to dry before reuse.
Do's
DO dry the newborn immediately with a dean towel and place on the mother's chest/ i
abdomen if stable, cover with a second dry towel/cloth.
------------------------------------------------------------------------------------------------------------- DO provide routine care to the newborn if the newborn is breathing and active soon j
after birth.
DO follow the protocol for starting resuscitation measures for a newborn. Remember;
the golden minute.
, Do refer all newborn who require either bag and mask ventilation or more intensive ;
form of resuscitation.
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DO NOT delay in deciding if the newborn requires resuscitation or not.
DO NOT clean the radiant warmer, oxygen tubing, etc with oil or alcohol based
solution since they are easily combustible and thus not safe. Use soap solution to
clean the surface of radiant warmer; oxygen cylinder and tubing's
DO NOT expose the newborn to external environment as it can cause sudden drop in
its body temperature.
DO NOT suction mouth and nose with a bulb mucus sucker. The bulb mucus sucker
could be a source of cross- infection as it cannot be cleaned easily.
Don'ts
DO NOT suction using pressures more than 130cms of Hp. This can cause a vagal
response causing heart rate to slow down or breathing to stop
DO NOT use an ambu bag without a pop up valve. The pop valve ensures pressure of
30-40cms of H2O is delivered. Any pressure more than this can be harmful.
DO NOTjam the mask down the face. Too much pressure can bruise the face
DO NOT use 100% oxygen for newborns who are premature
DO NOT give chest compressions without identifying the site correctly
DO NOT lift the fingers from the chest compression site once you start administering it.
This will prevent injury to internal organs and xiphoid process by wrong positioning.
DO NOT forget to monitor the newborn once every 15 minutes for the first hour of life
and once every half an hour for the next hour, till stable.
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
15 Breastfeeding
Learning Objectives
•.. ... n'Tij’
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Attheendofthischapteryouwil|beableto^^^^^^^^^^^^^^^^^
❖ Recall the physiology of lactation, benefits of breastfeeding, role of the health care personnel in
assisting mother to initiate and establish breastfeeding and manage breastfeeding problems
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❖ Demonstrate how to assist a mother to establish breastfeeding
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❖ Demonstrate where to document counselling on breastfeeding
❖ Demonstrate how to mentor staff on initiating and assisting women to establish breastfeeding
5.1
Introduction
Breast milk is the best food for a newborn. All healthy normal weight newborns must be exclusively breast
fed till the age of 6 months. Breastfeeding has several advantages and must be encouraged as the best milk
for newborns.(Table 5.1)
Table 5.1: Benefits of breast milk
Benefits to newborn
❖ Complete food
❖ Best for newborns
❖ Easily digested and well absorbed
❖ Protects against Infections
(diarrhea, ear and chest infections)
❖ Promotes emotional bonding
❖ Better brain growth
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Mentors' Manual Volume 3
Benefits to mother
Benefits to family/society
❖ Helps involution of uterus
❖ Saves money
❖ Delays pregnancy
❖ Promotes family planning
❖ Lowers risk of breast and
ovarian cancer
❖ Decreases need for
hospitalization
❖ Decreases mother's
workload
❖ Contributes to child
survival
;
I
5.2 Components of Implementing Breastfeeding Practices
Preparation during pregnancy
❖ Do a breast examination
❖ Counsel on benefits of breastfeeding
❖ If HIV positive counsel about benefits and risks of breastfeeding and dangers of mixed feeding (giving
both breast milk and artificial milk). Help a woman make choice of feeding based on availability,
feasibility, acceptability, affordability, safety, sustainability and support (AFAASSS)."Only if the woman
is sure that she can say yes to AFAASSS, can she be supported to give alternate feeding. However it
must be her choice.
❖ Ask history
❖ Is this your first newborn?
❖ How did you feed your previous newborn for the first 4-6 months?
❖ Did you give your newborn...food? If so when? and why?
❖ How do you plan to feed this newborn?
Preparation during labour and delivery
❖ Avoid use of sedatives unless absolutely essential
❖ Give extra support and encouragement to high risk mothers and those who had caesarean section
❖ Place newborn on mother's abdomen or between breasts. This stimulates the oxytocin reflex and milk
will be secreted easily
Helping mother to breastfeed
❖ Prepare the newborn and the mother by placing newborn with direct skin-to-skin contact between
mothers breast
❖ Demonstrate correct position for breastfeeding
❖ Assist mother to support her breast
❖ Help her to help the newborn to attach to the breast
❖ Check if newborn is suckling and swallowing effectively and feed is adequate
Express breastfeeding if needed
❖ Identify mothers who have to be taught the skill
❖ Educate and teach mothers how to express, store, feed the newborn expressed breast milk
Manage breastfeeding difficulties
❖ Assess breastfeeding problems daily
❖ Teach mother how to manage various breastfeeding problems such as inverted nipple. Sore nipple,
breast engorgement, too little milk, breast mastitis
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Essential Newborn Care at 24/7 Primary Health Centres
4:
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53 Importance of Components
Preparation during pregnancy
❖ All women must have their breasts examined during pregnancy When a woman comes for antenatal
visits, she must be educated about breastfeeding, its advantages and examined for any possibility of
feeding difficulty (flat nipple) or asked about any previous history of such difficulty.This could reinforce
that a woman could be successful in breastfeeding and identify mothers with potential problems for
breastfeeding.
❖ In addition a woman with a flat nipple or inverted nipple could be taught how to manage the same
during pregnancy so that she will be able to feed her newborn without much difficulty in the postnatal
period.
Preparation during labour and delivery
❖ It is known that if a woman is given adequate support during labour and the early postnatal period,
breastfeeding outcomes are better both in the immediate postpartum period as well as several weeks
after birth.
❖ Pain during labour that is beyond the woman's ability to manage, could also have a negative impact on
breastfeeding. A woman who has had an episiotomy could also have a lot of pain. This could affect the
let down reflex and thus milk will not flow easily to the newborn. A woman in pain is a flag to the PHC
staff to look for breastfeeding difficulty.
❖ Breastfeeding success is also affected by the behaviour of the newborn. Depressed or delayed suckling
which can be caused by medications given to the mother, could lead to delayed or suppressed
lactogenesis (production of breast milk) and this is a flag to act by the PHC staff.
Helping mother to breast feed
❖ The newborn's suckling instincts are very strong soon after birth. However a mother soon after birth
might be very exhausted. This might prevent her from making efforts to help the newborn to feed.
Thus keeping the newborn with skin-to-skin contact soon after birth between the mother's breasts has
several advantages:
♦ The smell of the newborn could stimulate milk to be secreted
♦ Breast milk smells similar to amniotic fluid.Thus in the first half an hour after birth when the newborn
is very alert, this could help the newborn search for breast milk (remember the breast crawl video)
♦ The newborn will naturally search for feed when placed in contact with skin.
♦ It keeps the newborn warm. This could prevent the newborn from losing energy. The newborn will
be active and thus be able to feed
❖ Getting started with breastfeeding however does not come naturally. Both mother and the newborn
may need practice at breastfeeding. Thus it is important that PHC staff help the mother to assume the
most comfortable position and the newborn to latch correctly.
❖ Mothers with newborns who have cleft lip and palate might require extra help to initiate breastfeeding
using the dancers hold. "Refer such newborns to a higher center, as soon as stable". The dancers hold
helps to support the breast as well as the jaw of the newborn (Figure 5.1).
❖ The football hold/underarm position can be used for mothers to feed twins. This can help both
newborns to feed together. In addition if one newborn is suckling well, it would stimulate the milk to
Mentors' Manual Volume 3
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drip from the other breast. The newborn who does not feed will automatically start drinking as milk
drips in his/her mouth
Expressing breast feed if needed
❖ Not all newborns can breast feed directly at birth. Some examples are premature newborns. These
newborns may not attach on breast easily. Such mothers and newborns could be helped by expressing
breast milk. Expression of breast milk could also help mothers who have engorged breasts or those
who have to be out for a long time.
❖ Expression of breast milk can be done using the hand efficiently. We do not need any special equipment
to express breast milk. The oxytocin or let down reflex helps women to relax and breastfeed. Skin-toskin contact stimulates oxytocin reflex. Secondly gently massaging breasts and asking the mother to
relax could stimulate the milk to flow easily.
❖ It is important that the thumb is placed 4-5cm away from the nipple and other fingers below so that
they form a "C" around the areola. The fingers are squeezed together, pushing the hand back against
the chest wall. This must be continued in a circular motion around the areola. If the finger and thumb is
too close to the nipple the squeeze will hurt and be ineffective as the ducts will not be compressed. If a
mother has pain when she expresses breast milk it is a flag she is using the wrong technique.
Managing breast feeding difficulties
❖ Most breastfeeding problems can be prevented or managed. It is important to teach mothers how
to manage the various difficulties. The various difficulties include inverted nipple, sore nipple, breast
engorgement, too little milk, mastitis.
♦ Inverted nipple: This must be detected in the antenatal period and corrected then. But if not
corrected then it must be corrected in the postnatal period. A newborn suckling at the breast is the
best remedy. There are other ways by which it could be corrected such as by using a syringe. If a
mother is feeding only from one breast, it could be a flag that she might be having difficulty feeding
from the other. Hence it is important to examine the breasts of the woman and assist her.
♦ Sore nipples: Are common among new breastfeeding mothers especially in the first week. Sore
nipples are a flag to poor attachment or thrush (yeast infection of the mouth) in the newborn that
could spread to the mother.
♦ Breast engorgement: This is most likely to occur in second to the fifth day after birth. It would be
normal for the breasts to feel heavier, little tender as they begin to produce greater quantities of
milk. Some of the fullness could be due to extra blood and lymph fluid in the breast tissue. However
it is a flag that the mother is not feeding the newborn frequently or thoroughly enough to drain the
breasts.
♦ Low milk supply: Many women think that their milk supply is inadequate. This is most often when
they first begin to breast feed, or if milk stops leaking from nipples or they lose the feeling of
fullness in the breasts. However these are signs that the body has adjusted to the newborn's feeding
requirements. However if a woman voices this feeling it is a flag to check if the mother is feeding the
newborn often enough. Reasons for this could be because of nipple pain, lethargic newborn, poor
latch on.
♦ Mastitis: When the breast become painful, hard, red, feel warm and inflamed (usually one breast at
a time) it is called mastitis. It might be a flag for infection or caused by milk staying in the breasts.
Infection might result from cracked nipples. Stress, fatigue and first time mothers are at higher risk
of mastitis.
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
5.4 Requirements to Initiate Early Breastfeeding for Newborn
Equipment and supplies
❖ Syringe 10cc to express breast milk or for inverted nipple
❖ Cups with a lid to collect expressed breast milk
❖ Paladai to feed expressed breast milk
❖ Soap and water to wash hands
Clinical skills
Implementing GOOD BREASTFEEDING PRACTICES
1. Preparation during pregnancy:
❖ Do a breast examination
❖ Counsel on benefits of breastfeeding
❖ If HIV positive counsel about benefits and risks of breastfeeding. Help a woman make choice of feeding
based on availability, feasibility, acceptability, affordability, safety, sustainability and support
❖ Ask history of how she fed previous newborn
2. Preparation during delivery
❖ Avoid use of sedatives
❖ Give extra support and encouragement to high risk mothers and caesarean mothers
3. Help a mother to breastfeed
Dancer's hold
Football hold
Figure 5.1 Position for breast feeding
Table 5.2: Steps to intiate breastfeeding
p
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Stepl
❖ Check if the mother is comfortable and relA^H
.inltlate breaSt feed Withinhatfan h0Uf °tbil
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Demonstrate positions for breastfeeding
Step 2
❖ Help mother to assume the different positions (Figure 5.1 and 5.2) based on her comfort
❖ Check if newborn's position is correct
❖ Remind her to always support the newborn's back and head with one arm
❖ Assist her once and then supervise when she decides to feed the newborn, even when
providing KMC__________________________________________________
Show mother how to support her breast with other hand
Step3
❖ Put her fingers below her breast
❖ Use her first finger to support the breast
❖ Put her thumb above the areola, helping to shape the breast
❖ Avoid keeping her fingers near the nipple using a scissor shape since it will compress the duct
Show mother how to help the newborn to attach
❖ Ask mother to express little milk on her nipple
Step 4
❖ Touch the newborn's cheek to her nipple.The newborn will naturally turn in the direction of
the breast.
❖ Wait until newborn's mouth is wide open, and tongue is down and forward. Help the
newborn attach by supporting the head
❖ Avoid keeping her fingers near the nipple
❖ Look for signs of good attachment
Assess if newborn is suckling and swallowing effectivelyand]
adequacy of feed
❖ Check if newborn is sucking effectively
Step 5
Observe if newborn is sleeping enough, contended and alert when awake
❖ Encourage to feed on demand during day and night
❖ Check if breastfeeding is adequate for newborn by the following signs
♦ Passes urine 6-8 times in 24 hours
♦ Goes to sleep 2-3 hours after the feed
♦ Gains weight at the rate of 10-15 gm / day
♦ Look for signs of good attachment
A
Underarm -football hold
Position
Using the opposite arm
Mother in lying down position
Figure 5.2 Positions for breastfeeding
____ El
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
■I
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| Remember. Regardless ofposition, newborn's position is
correct ifnewborn's
♦ Head and body is straight
♦ Face, faces mother's breast
♦ Body is close to mother's body
♦ Body is fully supported
Remember
Skln-to-skin contact as soon as the newborn is born and rooming in are two
important factors that aid in initiating breastfeeding
Four key signs of good attachment
More aroela is visible above the
newborn's mouth than below it
/ Newborn's mouth wide open
[
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Newborn's lower lip is turned outwards I
Good attachment
Poor attachment
J Newborn's chin is touching the breast
... -------------------- —,——
Figure 5.3 Attachment for breastfeeding
How to EXPRESS BREASTMILK
1. To whom should we teach expressing breastmilk?
❖ All mothers must be taught so that when and if the need arises, they will know how to do so.
❖ Indications
♦ Sick mother, local breast problems
♦ Preterm / sick newborn
♦ Working mother
❖ Storage
♦ Clean wide-mouthed container with tight lid
♦ At room temperature: 6 hrs
♦ Refrigerator: 24 hours; Freezer (-20°C): for 3 months
Mentors' Manual Volume 3
Figure 5.4 Choose cup for EBM
I
2. How to prepare a container for EBM?
❖ Choose a cup, glass with wide mouth
❖ Wash it with soap and water
❖ Pour boiling water into it and leave for a few minutes
❖ When ready to express milk, pour water out
3. Teach a mother how to express breast milk adequately. Inform her it would take 20-30 minutes, especially
in the first few days when only a little milk is produced. However this time can shorten as more milk is
produced (see Table 5.3 / Figure 5.8).
Table 5.3 Steps to express breastmilk
Preparation of container
❖ Choose a cup, glass, with a wide mouth
❖ Wash the cup with soap and water
Step!
>
.
❖ Pour boiling water into the cup, cover and leave it for a few minutes (kills the germs) or boil
the cup in water, keep covered till needed
❖ When ready to express milk, pour water out of the cup or take cup from the container where
it was
boiled
_——
----------------- ;---------- ---------- --------------------------- - -------- i
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Massage the breast before expression (10-15 minutes before expression)
Step 2
❖ Take a wet warm towel and wrap the breast in it for at least 5 minutes
❖ With two fingers massage the breast towards the nipple using circular motion. Use the pads
of fingers only with modest pressure or use the base of the fist.
Expression of milk
❖ Wash the hands thoroughly
❖ Make mother sit or stand comfortably and hold the container near her breast
i
❖ Encourage her to visualise the newborn
J
❖ Encourage her to put her thumb above the nipple and areola and her first finger below the?
nipple and areola opposite the thumb, and to support the breast with rest of the fingers
Step 3
❖ Press thumb and first finger slightly inward towards the chest wall Avoid pressing too far a^
it might block the ilk ducts
.
j
❖ Press and release, press and release.This should hot hurt untess the technique is wrong. Milk
will start dripping after pressing a few times
1
❖ Press the areola in the same way from the sides to make sure milk is expressed from alC
segments
J
❖ Express one breast for at least 3-5 minutes until the flow slows; then express the other side?
and then repeat both sides. She can use either hand for either breast and change when they!
tire
,
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Essential Newborn Care at 24/7 Primary Health Centres
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Avoid when expressing breast
milk
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> Squeezing the nipple itself as it
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Figure 5.5 How to express breast milk
4.How to use a syringe pump to express breast milk
❖ Put plunger inside the outer cylinder
❖ See that the rubber seal is in flexible condition
❖ Ensure it touches skin all around - airtight seal
❖ Pull the outer cylinder down, the nipple is sucked into the funnel
❖ Release the outer cylinder and then pull down again
❖ Milk flows after a minute and collects
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Figure 5.6 Syringe to express breast milk
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Figure 5.7 Warm bottle for
expressing breastmilk
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Mentors' Manual Volume 3
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5. Follow Algorithm for Expressing Breast Milk
6. Other methods to express breast milk - warm bottle method
❖ Pour hot water into a bottle
❖ After a few minutes, pour out the hot water
❖ Hold warm bottle over the nipple in an air tight seal
❖ Store the breast milk safely
❖ Feed EBM with a palada or spoon
Cite i
EXPRESSING
BREASTMUJC
Wash your hands well with soap and
water
PI.ce. dem eontelnerbel.M your bre.st to'
collect milk
Massage the breasts gently
toward the nipples
^^^^^flflflflflflflflflfll^^^^^^
4
Pl«e your thumb .nd index finger opposite e«h other just
outsido the dark circle around the nipple
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mMMhhmmHmMmHmmHmMHHHMmmHHMmmbmmWmhBmmHmmmmhI
Now press back toward your chest, then gently squeeze to
release milk
<
6
’J
Repe.t step S .t different positions .round the
ireoli
Figure 5.8 Steps for expressing breastmilk
Essential Newborn Care at 24/7 Primary Health Centres
t
Essential Newborn Care at 24/7 Primary Health Centres
How to Manage BREAST PROBLEMS PROMPTLY
1. Use information in Table 5.4 to manage breast problems
2. Refer if needed
Table 5.4: Manage BREAST PROBLEMS PROMPTLY
❖ Build mother's confidence
❖ Ensure that the newborn suckles'i
. breast not nipple
❖ Help mother position newborn!
early
❖ Try different position - e.g.
underarm
Inverted or flat nipple
❖ Help her to make her nipple
stand out more
❖ Use pump, syringe
❖ If needed, express milk feed
with cup_________
Newborn refuses
breast milk
to
❖ Check
and
observe
a
breastfeeding episode especially
see if the mother is positioned
well and attachment is good.
Sick, pain from bruise after ❖ Advise mother to help newborn
feed on one breast completely
take instrumental delivery, blocked
and to alternate breast with each
nose, sedation due to intrapartum
feed
sedation for mother,
❖ Teach to feed till newborn is
satisfied
❖ Encourage to lie on the back to
feed
Sore nipple
❖ Continue breastfeeding and
change position
❖ Help newborn to attach correctly
to the breast
❖ Apply hind milk to nipple after
Incorrect attachment, nipple
breast feed
sucking
❖ Expose nipple to air between
Frequent use of soap and water
feeds
Fungal infection of nipple
s_____
Mentors' Manual Volume 3
❖ Do not wash breast each time
before and after feed. Daily bath
and change of clothes is enough
❖ If fungal
infection
apply
medication on the nipple and
inside mouth of newborn
!
"S./
J
4^
MANAGE
ASSESS
Problems
Causes
❖ Help in establishing breastfeeding early
❖ Encourage frequent breast feeds
❖ Supervise for correct attachment
❖ Apply local warm water packs for 15 minutes
❖ Stimulate breast and nipple skin
❖ Massage back /neck
Delayed and infrequent feeds ❖ Encourage a warm shower
❖ Administer Tab Paracetamol to relieve pain
Breast engorgement Poor attachment
❖ Gently express milk to soften breast and then
Ineffective suckling
help mother to correctly latch newborn to
the breast
❖ Put a cold compress on breast to reduce
edema if present
❖ Administer analgesic for fever and pain
■ i
<• Administer antibiotic prescribed for inf&‘Ction |
s
■’
Breast abscess
'p'"'
/‘J
Delay in treatment of breast
engorgement, cracked
nipples, blocked duct or
mastitis
■’y
I
1
❖ Prepare motherforincision and drainage of
abscess
b b b b... b'J
❖ Advice mother to continue to breast feed
. from other breast, .
. b \
:
. ..
❖ Advice frequent feeds, gentle massage
toward nipple and warm compress
b application
■
j
❖ Advice complete rest
'■ bb
Not breastfeeding frequently
Too short or hurried breast
feeds
Poor position
Not enough milk
Breast engorgement or
mastitis
b
■:
❖ Check if this is just mother's perception (how the
mother feels).
❖ Advice mother that milk supply will increase
after 4 days
❖ Assure mother if newborn is gaining weight
adequately
❖ Encourage mother to feed frequently and
during the night
❖ Ensure attachment is correct
❖ Administer medications for pain or infection
as appropriate
❖ Give a balanced diet daily
❖ Encourage family support to mother
Essential Newborn Care at 24/7 Primary Health Centres
fit
MM
5.5 Mentoring Skills
Sample examples to use for mentoring episode
Sample mentoring - Case sheet audits
❖ On a particular day of mentoring visit make it a point to observe the case sheets (Section 3: Delivery
Notes -part B) to determine
♦ When breastfeeding was initiated for newborns
♦ Any feeding difficulties and action taken
♦ Whether counselling was given based on record of it
❖ Use this information to provide one to one or group mentoring based on availability of staff
Audit of breastfeeding practice within the system
Instructions for mentor
♦ During a regular visit to the PHO make a random check of the breastfeeding practice. This can bd
• Ji- /
‘
J
J' W
♦ Interviewing the mothers on what advise and help was given to them by nurses on breastfeeding
using'checklist given below
‘
3
|
♦ Interviewing staff nurses on their practice
;
♦ Actually observing mothers breast feed their newborns (see breastfeeding observation for-rri
• given below) - J v ? : \
;
♦ Reviewing the case sheet on how fast breastfeeding was initiated
;
|
I
♦ After the observation tell the staff nurses about your observations starting and ending with good
points. Also highlight the points for improvement.
r >p |
• p a ?i; f |
♦ Brief the staff nurses and other members on the importance of initiating breastfeeding early andj
helping a mother to'breast feed her newborn successfully.
♦ Summarise the findings of observation and help staff to find out areas of strength’ and’areas
for improvement. Help them to make a plan on what they would want to achieve by the next
Mentors' Manual Volume 3
iSSoi—
'i'- '
Breastfeeding observation form to use at PHC
Mother's Name:
Date
Signs that breastfeeding is going well
Age of newborn:.
Sex:
Signs ofpossible difficulty
BODY POSITION
♦ Mother relaxed and comfortable
♦ Shoulders tense, leans over newborn
♦ Newborn's body close, facing breast
♦ Newborn's body away from mother's
♦ Newborn's head and body straight
♦ Newborn's neck twisted
♦ Newborn's chin touching breast
♦ Newborn's chin not touching breast
♦ [Newborn's bottom supported]
♦ [Only shoulder or head supported
RESPONSES
♦ Newborn reaches for breast if hungry
♦ No response to breast
♦ [Newborn roots for breast]
♦ [No rooting observed]
♦ Newborn explores breast with tongue
♦ Newborn not interested in breast
♦ Newborn calm and alert at breast
♦ Newborn restless or crying
♦ Newborn stays attached to breast
♦ Newborn slips off breast
♦ Signsof milk ejection [leaking, after pains] O
♦ No signs of milk ejection
EMOTIONAL BONDING
♦ Secure, confident hold
♦ Nervous or limp hold
♦ Face-to-face attention from mother
♦ No mother/newborn eye contact
♦ Much touching by mother
♦ Little touching
♦ Shaking or poking newborn
ANATOMY
♦ Breasts soft after feed
♦ Breasts engorged
♦ Nipples stand out, protractile
♦ Nipples flat or inverted
♦ Skin appears healthy
♦ Fissures or redness of skin
♦ Breast looks round during feed
♦ Breast looks stretched or pulled
SUCKLING
♦ Mouth wide open
♦ Mouth not wide open, points forward
♦ Lower lip turned outwards
♦ Lower lip turned in
♦ Tongue cupped around breast
♦ Newborn's tongue not seen
♦ Cheeks round
♦ Cheeks tense or pulled in
♦ More areola above newborn's mouth
♦ More areola below newborn's mouth
♦ Slow deep sucks, bursts with pauses
♦ Rapid sucks only
♦ Can see or hear swallowing
♦ Can hear smacking orclicking
TIME SPENT SUCKLING
♦ Newborn releases breast
Newborn suckled for
♦ Mother takes newborn off breast
minutes
53 I
Essential Newborn Care at 24/7 Primary Health Centres
i
5.6 Key Messages - Do's and Don'ts
7
DO be prepared to assist a mother and newborn to initiate breastfeeding as soon as
possible after birth, but definitely within half |n hour.The best way would be to keep
the newborn in skin-to-skin contact between mother's breasts.
z-7
-
-■
..... -———----------------
DO give colostrum to the newborn. It is rich in antibodies, has all the required nutrients
and although little in amount, is sufficient to meet the needs of the newborn
—----------- —......
Do's
-7-7----- O--------------- :------ —
DO supervise breast feed to reassure the mother that position is good and attachment
of newborn to breast is correct. This could help the toother to relax and prevent sore
nipples.
------- - ----- ------------- 7... ..
. .. j
DO take time to help a mother, counsel her about breastfeeding.
---------------------- ———————,——----------DO encourage mother to feed the newborn on demand, both nig ht and day and gM
only breast milk (exclusive breastfeeding).
- ------- :------- ------ ------ ---- ----------------------------------------------------- - —_
DO check if the breastfeeding is adequate and mother knows how to check for
adequacy of feed before discharge
--------- i------------- ----------- ----- ------ ------ ..... ...... —-—-J...........
---------------- —_
J
DO reassure a mother when she feels that milk is too little that the supply is enough;
for the newborn as long as the newborn suckles on demand and is satisfied, active
and comfortable.
--- --------------------------------------------- ---------- --------------------- -- --------------------------
DO express breast milk ifthe mother is away for a long time or if she has engorged breasts.
Do refer all newborns who are not feeding adequately, having feeding difficulty
such as choking, refusing feeds or not feeding at all or lethargic or very small
(less than 1.8kgs/1800gm).
DO NOT give prelacteal feeds. It will reduce the chance of establishing breastfeeding
DO NOT discard colostrum. It is useful for the newborn and prepared to meet all the
needs of the newborn.
Don'ts
DO NOT restrict food or water for mother. A good nutrition and adequate fluid intake
could help in adequate milk supply.
DO NOT give honey, janamghutti, gripe water, bonnison etc. There is a high risk
the newborn will pick up infections and it would reduce the chance of successful
breastfeeding
Do NOT give bottle feeding or pacifiers. For newborns who cannot suckle express
breast milk and give it with the help of a palada or cup.
Mentors'Manual Volume 3
■HHB
16
Thermal Control and Kangaroo Mother
Care (KMC)
Learning Objectives
i«S«^lseh.pter,Ouwmb.ablet.
.
♦ Recall factors which contribute to heat loss
'■
I: ? f
♦ Demonstrate ways to prevent heat loss in a newborn
♦ Document the temperature accurately In the case sheet
♦ Demonstrate mentoring skills for KMC and thermal control
6.1
"II
i
I
Mud
t
j
Introduction
A newborn's skin temperature will fall within seconds of being born. If the temperature continues to fall
the newborn will become ill and may even die. Hence it is important to follow the warm chain protocol for
the newborn before and soon after birth. Warmth is a basic need of the newborn. Maintaining warmth of
a newborn is important for his / her survival and well being. Unlike adults, newborn newborns are often
not able to keep themselves warm particularly if the environmental temperature is low. This results in low
temperature or hypothermia.
Hypothermia is a significant problem in newborns at birth and beyond. It contributes to significant
morbidities. Preterm newborns have higher risk for hypothermia that could lead to hypoglycaemia and
ultimately death if not corrected soon enough. Mortality rate is twice in hypothermic newborns than
newborns with normal temperature.
6.2 Components of Maintaining Thermal Control
Preparation before delivery
❖ Close doors and windows of the labour room
❖ Ensure that temperature ismore than 25°c (comfortable enough for an adult)
❖ Make sure that radiant warmer, 200 watt bulb source or room heater are in working condition
❖ Ensure that two clean towels or soft clothes are ready
Maintaining the warm chain
❖ Place the newborn soon after birth on a towel or cloth that is kept over the mothers abdomen.
❖ Dry the newborn, keep in direct skin-to-skin contact with mother. Cover with a second dry towel.
❖ Assist mother to initiate breastfeeding
❖ Put clothes for the newborn, wrap with towel, place a cap on the head when the newborn is shifted to
postnatal ward with mother
_________ s
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
ilUlllili
■■■■■■■■■■
❖ Keep the newborn next to mother
❖ Monitor temperature, feeding and activity of the newborn
Kangaroo mother care
This is a method used to help maintain the newborn's temperature, by direct skin-to-skin contact.
6.3 Importance of Components
Preparation before delivery
❖ A fetus is nursed in the warm environment of the mother's uterus. At birth the newborn is suddenly
exposed to a much cooler environment (from 37.20C/98.60F to more than 25°C /77°F).This can cause the
newborn to lose heat very easily to the cooler environment either by radiation (loss of heat from warm
body to cold objects in the environment) or convection (loss of heat through the circulating cooler air).
Maintaining the warm chain
❖ A newborn newborn can loss heat easily due to
♦ Its large body surface area,
♦ Lesser thermal insulation due to less subcutaneous fat. This is more for LBW newborns,
♦ Decrease heat production due to less brown fat (fat present around the adrenal glands, kidneys,
interscapularand axillary regions)
♦ Immature central nervous system that helps in regulating body temperature
❖ Heat production of newborns occurs through break down of brown fat. When skin temperature is low
35-36°C (95-96.8°F), skin receptors feel this and the hypothalamus helps noradrenalin to stimulate the
breakdown of brown fat. Blood that passes though this gets warmed and this helps raise the body
temperature. LBW newborns lack this kind of heat production and thus can lose heat faster. When heat
is lost rapidly the body does not function well. A newborn who is not warm enough is less active, feeds
poorly, has a weak cry and might have respiratory distress. Thus if a newborn presents with any of these
signs, soon after birth or in the neonatal period it is a flag for hypothermia.Take the needed action.
❖ A newborn's skin temperature can drop within seconds of being born. This can happen due to loss of
heat by evaporation (when amniotic fluid is allowed to dry on the skin) or by conduction (if a newborn
is placed on a cold towel or clean cloth, heat from the newborn's body can be transferred directly to the
cold towel; or the newborn can lose heat to the cold surface of the weighing machine tray or warmer).
Thus follow these steps.
♦ Keep the newborn on a warm towel or dean cloth over the mother's abdomen
♦ Dry the newborn immediately with a clean dry towel or clean cloth
♦ Keep in direct skin-to-skin contact,
♦ Replace the wet towel with a dry one to cover the newborn and maintain warmth.
❖ Checking the newborn's temperature by touch / observation is important after birth so that additional
measures could be taken. When a newborn's feet and hands are blue, but body is pink, it is called
acrocyanosis, this is a flag that the newborn is hypothermic (cold stress). Immediate measures must be
Mentors' Manual Volume 3
fl
RM
taken to prevent heat loss through evaporation (wipe the newborn dry), conduction (use a warm towel
and keep in mother's abdomen / between mother's breast for skin-to-skin contact), convection (switch
off fan, do not place in draft), and radiation (see that labour room temperature is warm enough (ideal
more than 25°C).
Brown Fat
Present around the adrenals, kidneys, inter J
scapular and axillary regions
Figure 6.1: Brownfat
.
.
,
■ r
3. Kangaroo mother care (KMC)
❖ KMC prevents heat loss through evaporation, conduction, convection and radiation. Loss of heat
through conduction to a cold surface is prevented as the newborn is with skin-to-skin contact. Since the
newborn's head is covered with a cap, and body is covered completely loss of heat through convection,
evaporation and radiation is also limited.
❖ The big advantage of KMC is the mother acts like an incubator.
♦ For every 10°C drop in newborn's temperature, the mother's temperature increases by 20°C;
♦ If the newborn's temperature increases by 10°C, the mother's decreases by 10°C.
❖ The greatest advantage of KMC is that no incubator can give what the mother gives, love and comfort.
In a newborn whose weight is less than 2500 gms / 2.5 kgs and who is not maintaining temperature,
PNC staff must be alert to teach mothers how to give KMC before they leave the PNC.
6.4 Requirements to Provide Thermal Control for Newborn
Equipment/supplies
❖ Radiant warmer
❖ Clean cloth /sheet /towel to place on the mattress of radiant warmer
❖ 200 watt bulb heat source
❖ Soap and water solution to clean radiant warmer
❖ Thermometer to measure temperature
❖ Towel or long cloth to wrap around the newborn and mother for KMC
❖ Newborn clothes
❖ Cap and socks for the newborn
_________ ar
Essential Newborn Care at 24/7 Primary Health Centres
■
Essential Newborn Care at 24/7 Primary Health Centres
ItSirw ,pf ’
Clinical skills
Use of RADIANT WARMER
1. Clean the radiant warmer with soap solution and wipe dry
2.
Switch the radiant warmer on 20 minutes before birth of newborn
3.
Place a sheet over the mattress of the warmer
4.
Place the newborn under the radiant warmer. Remove extra clothing and just keep the napkin alone
5. Connect the probe by placing it midway between the xiphoid sternum and the umbilicus once
the newborn is placed under the warmer
6.
Put the radiant warmer on manual mode so that the temperatures of all items that come in contact
with the newborn are warm. Read the temperature on the display and adjust the heater output
•
If below 36°C -High (75%-100%)
•
If between 36 and 36.5°C -Medium (25%—75%)
•
If between 36.5 and 37.5°C - Low (25%—50%)
•
If more than 37.5°C-Remove newborn/Switch off warmer.
7.
Once the radiant warmer is ready, switch to skin mode with desired setting. If servo set the skin
temperature to be set between 36-37.5°C. If temperature is lower it will automatically increase
8.
Keep the side walls fastened safely to prevent any falls
9.
Check if the probes are connected and feet are warm
10. Respond to alarm: power failure, probe displacement, system failure or over or under heating
11. Check temperature half hourly for two hours and respond based on newborn's temperature.
12. Record the temperature in the case sheet
Checking TEMPERATURE BY TOUCH METHOD
1.
Use dorsum of hand to measure temperature by touch. Place hand over abdomen then trunk and then
the feet.
2.
Interpret as follows
♦ Trunk and extremities warm
temperature normal
♦ Trunk warm and extremities cold
cold stress (mild hypothermia)
♦ Trunk and extremities cold
hypothermia (moderate to severe)
3. Teach mother how to check temperature using touch method before going home.
Check TEMPERATURE USING THERMOMETER
1. Collect thermometer, dry cotton swab, spirit swab and kidney tray
2. Wash hands
3. Wipe the thermometer from bulb to stem end with dry cotton swab
Manual Volume 3
mhHHMmI
4.
Shake the thermometer so that mercury reading is below 35°C
5.
Place the bulb of thermometer in the axilla of the newborn. Keep the stem parallel to the newborn's
body. Hold the arm close to newborn's body.
6.
Remove the thermometer after 3 minutes
7.
Read the temperature holding the thermometer at eye level
8.
Record the temperature in case sheet.
9. Take measures if needed to keep the newborn warm.
10. Clean the thermometer, with spirit swab from stem end to bulb end. Wipe dry with cotton swab.
Replace in container.
Assist MOTHER TO GIVE KMC
1. Educate mother on the importance and benefit of KMC
❖ Temperature maintenance
❖ Better weight gain
❖ Able to tolerate pain better
❖ Increased breastfeeding rates
❖ Early discharge from the health facility
❖ Less morbidities such as apnea and infections
❖ Less stress
♦♦♦ Better mother infant bonding
2. Check if mother has the required dress - preferable a front open
3. Provide privacy based on cultural values
4. Put a napkin, cap and socks for the newborn
5. Place the newborn in direct skin-to-skin contact with mother. Help the mother place the newborn in frog
like position against the chest between the breasts
Newborn placed in frog
like position against
mother's chest
■" ■■
..,3
*
Figure 6.2: Position newborn for KMC
6. Turn the newborn's head to one side slightly extended to keep the airway open and permit eye to eye
contact with the mother.
7.
Place the newborn's abdomen at the level of the epigastrium of mother so that the mother's breathing
could stimulate the newborn and thus prevent chance of apnea.
Essential Newborn Care at 24/7 Primary Health Centres
vt:; IIlfiili
Essential Newborn Care at 24/7 Primary Health Centres
8. Support the newborn's buttocks with a long towel or cloth wrapped around the mother and the
newborn.
9.
Encourage the mother to give KMC at regular intervals of at least 2-3 hours duration and then extend
to how long it is tolerated by the newborn and the mother up to even 24 hours.
10. Encourage the mother to breast feed, sleep or do routine work with newborn in KMC position
11. Caution mother to watch the newborn for any danger signs or to change the newborn's nappies if and
when wet
12. Record the condition of the newborn; whether the newborn fed during KMC, whether the newborn
and the mother were comfortable in the case sheet.
13. Teach other family members how to give KMC. Encourage any other member to provide KMC so that
the mother can get needed rest periods when at home.
6.5 Mentoring Skills
Sample examples to use during a mentoring episode
Sample aid to mentor (one to one) about thermal protection of newborns
❖ During rounds with the PNC staff, observe whether newborns are at riskof losing temperature by evaporation,
conduction, convection and radiation.
❖ Reinforce with PNC staff what they know and review methods of heat loss and gain in a newborn.
❖ Use the given information (Figure 6.3) or draw a similar picture on a chart to help the PHC staff understand
the mechanism of heat loss and gain, and how simple steps can be used to prevent hypothermia.
Newborn loses heat by
Conwaicm
Evaporation
Conduction
1. Evaporation (particularly soon after birth due to(
evaporation of amniotic fluid from skin)
2. Conduction (by coming in contact with cold
objects, e.g. cloth, tray etc.)
3. Convection (by air currents in which air from
open windows replace warm air around;
newborn)
4. Radiation (to colder solid objects in vicinity e.g.
walls)■
;
Figure 6.3: How a newborn loses heat
Heat gain
*
♦ Conduction (e.g. from direct skin-to-skin contact with mother)
♦ Convection (e.g. by switching of the fan, closing the door)
♦ Radiation (e.g. ensure that the newborn is not close to the wall that is cold)
♦ Non-shivering thermogenesis
j
a
Mentors' Manual Volume 3
1
HbmI
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2. Sample example for mentoring - Observation (warm chain)
Instructions for Mentor
❖ During a regular visit to the PHC make a random check of the maintenance of warm chain.This can be done
by actually observing. Observe for the following situations (SeeTable 6.1) and whether the correct steps are
taken in the labour room / postnatal room to reduce heat loss in a newborn.
❖ After the observation tell the staff nurses about your observations starting and ending with good points.
Also highlight the points for improvement
❖ Brief the staff nurses and other members on the importance of maintaining warm chain.
❖ Summarise the findings of observation and help staff to find out areas of strength and areas for
improvement. Reinforce all the correct steps.
❖ Help them to make a plan on what they would want to achieve by the next mentoring visit.
Table 6.1: Common situation that could increase cold stress risk and steps to be
taken to prevent heat loss in newborn
I®? r..... aB
I iMOd'S
postnatal room afeW
IKeep delivery room and postnatal room warm by closing door/1
windows; seeing that labour room table is not at the doorwayl
♦ At birth
♦ After bath
♦ During
nappies
changing
clothes/
♦ Malfunctioning heat source
♦ Removing newborn from heat
source
♦ While transporting the newborn
♦ No current
as every time the door is open cool air can enter inside.
>
Keep newborn corner in a corner away from a window, notJ
directly opposite the door. The temperature must be such that!
an adult would feel slightly uncomfortable without a fan
z Dry newborn immediately after birth with a pre-warmed towel/
cloth
;J
Replace wet towel/cloth with dry pre-warmed towel
Encourage skin-to-skin contact between mother and newborn j
z Assist mother to initiate and continue regular breastfeeding
z Cover newborn head with cap, feet with socks and wrap the!
newborn well
■
Postpone bathing till the newborn is discharged or weight is
more than 2500 gms / 2.5 kgs or the cord has fallen
|
Take precautions while checking weight such as switching offi
the fan, completing the procedure quickly etc
[
z Use radiant warmer/extra light source when needed
Essential Newborn Care at 24/7 Primary Health Centres
j
Essential Newborn Care at 24/7 Primary Health Centres
Sample example for mentoring: One-to-one to manage hypothermia
in newborns
❖ Use information Table 6.2 chart to teach the staff nurse
Table 6.2: How to assess and manage hypothermia
ASSESS
MANAGE
Category
Temperature
Feel by Touch ,
'' 1 _.
.M,. 'Th '36.5M7.5
oC
^Q7
c
Normal
Clinical features
r
(977°F-99.5'’F)
• ., I / .
“ .
?
: ' j
;.
Wrap newborn with
orewarmed cloth
'/[
Encourage breastfeeding
1
t
.-T'm’L : '.J-1,/..!
Mild
hypothermia
36-36.5°C
(96.8QF-97.7°F)
(cold stress)
♦ Extremities bluish
and cold
♦ Poor weight gain if
chronic cold stress
♦ Warm trunk
♦ Cold
extremities
"T C T
u;
..
32-36°C
(89.6^96.8°F)
■
'
■
ink
icoirrunkHu
■■ r-
extremities
‘
.
V - Z*'
■
;
'
*
♦ Fast breathing
;:-
hypothermia
Less than 32°C
(89.6°F)
to
I gi1
.
Pyrexia
♦ Lethargic
♦ Poor capillary refill
time
♦ Fast or slow
breathing
♦ Slow heart rate
♦ Hardening of skin
♦ Temperature with
redness and edema
♦ Bleeding
♦ Low blood sugar
more than
38°C
(>38°C)
Mentors'Manual Volume 3
Encourage breastfeeding
_____
_ and
_____
Cover
mother
newborn Jl
:f J
< -i .Mi •1 .|,H A
• "i«.1.":
with pre-warmed clothes
< Use radiant warmer
Reassess after 15 minutes
Provide additional heat if there
is no improvement
/ Encourage breastfeeding
;
z
J
/
J
Z
Rapid re-warming till
newborn's temperature is 34°C
Then slow re-warming
Give oxygen
Administer IV fluids-warm
dextrose
Administer vitamin K
Reassess every 15 minutes
Provide additional heat if no
improvement
—
J
'CT*' J V Place the newborn in a normal
temperature environment
/
- \ '/»'.
♦ Roomistocrn
''.m• ■
, ■ '-T..' •
hot
Severe
hyperthermia
♦ Cold trunk
♦ Cold
extremities
/
f ' Oi.
MlBMi
Severe
Wrap newborn well
z Ensure room is warm
z Use radiant warmer
/
I*.
♦ Poor suckling
.
Moderate
hypotjiermi^
z Skin-to-skin contact
' • 'I \
» Newborn
# Dehydration
covereb
Con'u|sions
with too
♦ Shock
many layers
of clothes * ,♦ Coma and even
death
♦ Newborn is
♦ Newborn irritable
dehydrated *
♦ Skin is hot and dry
♦ Newborn
has
;!
infection
.
1
■
*
-
"
'
(25 to 280C), away from any
source of heat
Undress the newborn
partially or fully, if necessary
Give frequent breast feeds; give
breast milk by cup if unable to
suck
i
If temperature more than
I
39°C, sponge the newborn
with tap water; DO NOT use Ij
cold / ice water for sponge
I
Measure the temperature
hourly till it becomes normal j
■BHBII
I
6.6 Key Messages - Do's and Don'ts
DO see that the temperature of the labour room is warm enough i.e you are.
comfortable (ideal temperature is more than 250C and the newborn corner >3OOC)J
The best way you can ensure this, close the doors or windows so that wind does not]
come into the room.
5
5
DO be prepared. Make sure all necessary equipment (radiant warmer/200 watt heat
source/heater; thermometer) and supplies (towel/longcloth/capand socks/soapand(
water) as well as uninterrupted power supply (electricity/solar/UPS) are available.
DO place the newborn immediately on the mother's abdomen/chest and dry with a;
warm cloth.
DO know the normal temperature for a newborn is 37.5°C (99.3°F). If the temperature'
falls below 36.5°C it is called cold stress and efforts must be made to increase thej
body temperature.
Do rememberthat a newborn's temperature could be maintained by simple measures I
such as drying, skin-to-skin contact, wrapping and breastfeeding.
Do's
Do keep in mind a newborn newborn who is between 1800 gms /1.8 kgs and
2500 gms/2.5 kgs can be managed in the PHC but the risk for hypothermia in such
newborns is much higher.
DO recommend KMC for all newborns, but definitely for LBW newborns
DO give KMC for at least 2-3 hours. Remember that there is no contraindication for KMC
if the newborn is stable, and that it can be given for as long as possible.
DO give extra milk if the newborn is nursed under a radiantwarmer since the newborn'
can lose more water.
DO record the temperature of the newborn every 15 minutes for the first hour from}
birth and then once every fourth hour. When in doubt check the temperature more,
often using the touch method.
; DO teach all mothers how to assess temperature using the touch method before theyJ
’ are discharged and how to keep the newborn warm at home.
. Do refer those newborns who are consistently not maintaining temperature despite?
' all measures taken, it could be a sign of sepsis.
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
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Do check to see if mother is eligible to be a beneficiary of the Madilu kit programme
(based on social and economic status) of the Government of Karnataka (GoK); if
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so, ensure documents
are- obtained
during
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and
the Madilu
kit is
opened at the time of delivery. This Contains:
I
i. | Mosquito curtain
it
Medium sized carpet
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..
iii.
Medium sized bed sheet
iv.
A thick blanket for mother
v.
Bathing Soap
vi.
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lip •’
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Washing soap
vil-l Cloth to tie abdomen of mother
viii.
Sanitary pads
■■
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■
|;
.
$
■
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lx.
Comb and coconut oil
x’
Towel
xi.
Tooth paste and brush
xii.
bed spread over rubber sheet for the newborn
xiii.
Bed sheet for newborn
xiv.
Bathing soap for newborn
xv.
Rubber; sheet for newborn
xvi.
Diaper
h '
i. -
■
.
.
■
—
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H
1
.
t
xvii. Newborn vest
xviii. Sweater, cap and socks for newborn
xix.
One plastic kit bag.
DO NOT delay in drying and keeping the newborn in skin-to-skin contact soon after
birth.
DO NOT expose the newborn when checking the weight or making observations
of physical characteristics for assessing the gestational age. This could lead to
hypothermia in the newborn.
Donis
DO NOT delay referral of a newborn who is constantly hypothermic. These
newborns are at high risk for problems such as hypoglycemia, breathing difficulty,
seizures and infection
DO NOT leave the newborn unattended soon after birth
DO NOTgive KMC for less than halfan hour at a stretch to reduce risk of over handling
and thus loss of temperature
DO NOT use air conditioner even in summer
___________________
Mentors' Manual Volume 3
Care of the Newborn
at Facility till Discharge
ai
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u
Learning Objectives
By the end of this chapter you will be able to
♦ Recall the components of care in the first 48 hours of life till discharge
♦ Demonstrate skill in counselling and assisting mothers in components of care in the first 48 hours of life
♦ Document components of care in the first 48 hours of life in the case sheet
♦ Demonstrate mentoring skills for care provided in first 48 hours of life
7.1
Introduction
All mothers'especially first time mothers would require support, advice and education on how to care for
their newborn newborn. PHC staff must take every opportunity to teach mothers and help them to get to
know their newborns, what care their newborns require, when to report and what to do if their newborns
are not well. It is also important that they get the required rest soon after delivery.
7.2 Components of Care in the First 48 Hours of Life till Discharge
Every day's care for newborn
❖ Breastfeeding
❖ Warmth,
❖ Cord care and hygiene
Watch for danger signs
❖ Observe the newborn / teach mother to watch for danger signs
Monitor newborn's readiness for discharge
7.3
Importance of Components
Every day care for the newborn
❖ Newborns need special attention separate from that of their mothers to assure a healthy start of life. The
immediate causes of newborn deaths include birth asphyxia, complications related to premature and
or low birth weight newborns or birth anomalies. Simple cost effective interventions such as providing
warmth, assisting the mother to initiate and continue breastfeeding, cord care and hygiene have been
shown to reduce neonatal deaths.
❖ These interventions help reduce hypothermia and hypoglycaemia, both of which are closely linked
with more serious complications if not managed on time. Provision of essential newborn care could
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
'A
L
help reduce the risk of illness and enhance growth and development. For example breastfeeding
has been reported to reduce the risk of infections. This coupled with keeping the newborn close to
the mother has shown to cause reduction in hypothermia and hypoglycaemia. Hypothermia and or
hypoglycaemia in a newborn is a flag to indicate lack of one of these components
Watch / teach mother to watch for danger signs
❖ A newborn can present with danger signs at any time before or after birth. The most number of deaths
among newborns occur in the first day of life. The next crucial period is the first week of life. If PHC staff
watch for / teach mothers to identify danger signs early, required initial management can be taken. This
could reduce mortality rates.
Monitor newborn's readiness for discharge
❖ It is important to monitor breathing, temperature or warmth, activity and feeding of the newborn
before discharge. If a newborn presents with any danger sign it is a flag for an underlying problem and
the PHC must start initial management, stabilise the newborn before referral to a higher center.
7.4 Requirements for Care of Newborn at Facility
Equipment and supplies
❖ Case sheet to use as checklist for topics on counselling mothers before discharge
Clinical skills
Assessing READINESS FOR DISCHARGE: FEEDING WELL, NO DANGER SIGNS
1. Use information in Figure 7.1 to assess if the newborn is feeding well
2. Check if any danger signs are present by asking the mother or observing the newborn
Report immediately and refer if the newborn
a,
Mentors' Manual Volume 3
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♦ Newborn has good attachment?
♦ Newborn positioned correctly?
♦ Newborn suckling effectively?
♦ Newborn satisfied with feed?,
♦ Feeding at least 8 feeds per day?
♦ Breasts feel soft and comfortable?
♦ Any concerns?
Si" i
F’S.g difficulty^^ ’ ”
♦ Less than 8 feeds/ not yje^staried
f ? (more than 1 hour of life) • ' ; p
-KjNut suckling well ., ppyj .Jf'? ••
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Not attached weli p
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♦ Not suckling
♦ Stopped feeding
: ■. ♦ Educate and counsel ■;
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, t• feedingbreastfeeding ?
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Feeding well
Z . Yes for ail ; ■
Ask/Check
;
311
........... ▼...............
- Corr?.:!- any
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♦ Refer urgently
♦ Give required treatment j
♦ Start BF when possible J
Figure 7.1: Is the newborn fcelling well?
Are all danger signs absen t
1
Assess for any danger signs (Ask / look / Feel)
❖ Breathing difficulty?
♦ breathing, (more than 607 min)
♦ Moderate or severe chest in-drawing-'
♦ Grunting
'
Convulsions or jerky movements?;
1
Discharge or Erythema (redness) from urhbilicus?
<♦ Feeding difficulty?
❖ Gastrointestinal: vomiting or bleeding in stools
❖ Hypothermia (less than 35°C) or fever (more than 37.5°C)!
•> Icterus (yellow skin)
■■d
❖ Stiff or floppy newborn
♦> Irritability or lethargy
❖ . Pustules in skin/more than 10) or ope large boil
I
J
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Counsel a mother on CARE OF NEWBORN AT HOME
1.
Introduce self to the mother and greet the mother
2. Check how much she knows about maintaining warmth, breastfeeding, preventing infections and
reporting danger signs
3.
Reinforce information on the feeding, warmth, hygiene and prevention of infection
4. Check whether the mother has any doubts and clarify them
5.
Make sure that the mother is confident about daily care of the newborn
6.
Use the case sheet as a guide for counselling on all important aspects of mothers and newborns
7.5
Mentoring Skills
Sample examples for mentoring episode
Sample Case Study 7.1
A 20 year old delivered a term healthy newborn. The mother wishes to go home on the first postnatal day.
1 How would you know the newborn is ready for discharge?
Table 7.1: Key for case study 7.1
Signs of a healthy newborn ready for discharge
Feeding well
Weight gain
Absence of danger signs
❖ Takes at least 8 feeds per day
❖ Sucks well
❖ Is satisfied for 2~3 hours
❖ Sleeps well
❖ Feeds on demand
❖ Has no difficulties
❖ Passes urine 5-6 times a day / after
each feed for next 3 months
Mentors'Manual Volume 3
❖ Loss of weight <10% in ❖ No danger sign present
first week of life
❖ Alert, active, newborn,
❖ Average daily weight gain
that sleeps and feeds
is around 10-15gm/day
well, maintains body
temperature and breaths
❖ Newborn crosses birth
normally.
weight by two weeks
_______________ .________
Sample audit- breastfeeding practice
Instructions for mentor
❖ During a regular visit to the PHC make a random check of the breastfeeding practice. This can be done by
♦ interviewing the mothers on what advise and help was given to them by nurses on breastfeeding
using checklist given below
♦ interviewing staff nurses on their practice
♦ actually observing mothers breast feed their newborns
♦ reviewing the case sheet on how fast breastfeeding was initiated
❖ After the observation tell the staff nurses about your observations starting and ending with good
points. Also highlight the points for improvement
❖ Brief the staff nurses and other members on the importance of initiating breastfeeding early and
helping a mother to breast feed her newborn successfully.
❖ Summarise the findings of observation and help staff to find out areas of strength and areas for
improvement. Help them to make a plan on what they would want to achieve by the next mentoring visit.
Sample of exit interview questions to check readiness for discharge
Instructions to mentor
❖ Use questions given to assess how well staff nurses are preparing mothers for discharge during a planned
mentoring visit
❖ Reinforce the positive points to staff nurses
Breastfeeding
❖ Is the newborn feeding well?
❖ How often is the newborn being fed?
❖ Are any feeds other than breast milk being given?
❖ Is the newborn fed on demand both day and night?
❖ Has one feeding episode been observed?
❖ Has the mother been told about breastfeeding
Warmth
❖ Is the newborn being kept warm?
❖ Is the newborn's temperature normal?
❖ Does the mother know how to check temperature by touch method
❖ Does the mother know how to give KMC?
❖ Has she given KMC by herself?
❖ Is there any other person in the family who will be able to assist the mother and also provide KMC?
Essential Newborn Care at 24/7 Primary Health Centres
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Essential Newborn Care at 24/7 Primary Health Centres
^'8
Danger signs absent
❖ Is the newborn passing urine adequately (6 times in a 24 hour period)?
❖ Has the newborn passed stools?
❖ Are any of these problems present? Eye or umbilical discharge, jaundice, rash?
❖ Are there any other danger signs?
❖ Has the mother been told about danger signs that need immediate reporting?
Cord care and hygiene
❖ Does the mother know that nothing must be applied on the cord?
❖ Does the cord look clean?
❖ Is the napkin tied below the level of the umbilical cord?
❖ Is anything applied on the cord?
❖ Has bath been delayed till after the newborn reaches home?
❖ Does the mother know the precautions to be taken at bath to ensure the temperature of the newborn
is maintained?
❖ Does the mother know what she must avoid to prevent infections
Immunization
❖ Has the newborn been given the BCG, oral polio and hepatitis B vaccine before discharge?
❖ Is the mother aware of the follow up routine of 3,5,7 14,28 days for newborns born in the PHC; 1,3,5
days etc for home born newborns?
❖ Does the mother know the immunisation schedule?
iSl______
Mentors' Manual Volume 3
7.6 Key Messages - Do's and Don'ts
DOassess whether a newborn is feeding Well by a direct observation of breastfeeding
episode and finding out from the mother.
|• ''J ■ - M1
. !ake atl..st6^feedsper(la,.
-
H
❖ pass urine 3-4 times a day,
❖ sleep for a few hours,
■
'W
❖ be active and satisfied.
------ ------------------------ ---------- - --------- -------- ----- r----- ---------•
j
DO observe if the newborn has any danger signs before discharge,
—--------------------- .•......... . ............... ............. ------------------------------.
DO know that a newborn is ready to be discharged If the newborn Is feeding well, has
no danger signs ahd the mother is confident in the care of the newborn.
!
——
—— ------- - —i
—-———
------------ 5
Do remember that a newborn's temperature could be maintained at home by
wrapping the newborn, keeping the newborn dose to the mother, feeding the;
newborn on demand and practidng KMC.
—4
D°'s
------ ---------------------------—
——
,——,------- —--------------— -----------------
...... ----------------------------- ——-r—:-------------------- - ---- -
DO remember to teach mother's one topic at a time, so that they can understand and:
remember it well.
J
DO complete the case sheet about counseling done for the mother before discharge
and the condition of the newborn,
DO ensure that if the Madilu kit (of the GoK) was not available/opened at time o^
delivery, it is obtained and given at least at the time of discharge
DO NOT forget to observe the newborn carefully for any danger signs
DO NOT discharge a newborn who is not feeding well.
DO NOT delay referral of a newborn who presents with a danger sign.
Don'ts
DO NOT forget to tell mother to avoid the following practices
❖ Instilling oil in nose, mouth, ears
❖ Branding the newborn
❖ Applying anything to the umbilicus
❖ Applying kajal to eyes
Giving any other feed
______________ Q
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
IQ
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Common Problems of Newborn
Newborns and Referral
Learning Objectives
z-
At the end of this chapter you will be able to
.
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.
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■
■■
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♦ Recall the causes and initial management of common neonatal problems
♦ Demonstrate skill in identification and initial management of common neonatal problems
♦ Mentor staff nurses on care of newborns with specific problems such as asphyxia, sepsis, hypothermia, ;
hypoglycemia
=
.
♦ Identify records on which the details of care provided could be documented in the PHC
.
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8.1
Introduction
The common causes of neonatal deaths are sepsis, asphyxia, and LBW that account for more than 70%
of neonatal deaths. Respiratory distress, sepsis and LBW are special challenges in caring for newborns.
Respiratory distress occurs in 4-6% of newborns. While neonatal sepsis is the single most important cause
of neonatal deaths in the community. Other important problems include jaundice, hypoglycaemia, and
hypothermia, respiratory distress, sepsis if identified early enough could help reduce major long term
complications as well as neonatal mortality.
8.2 Components of Initial Management of Common
Neonatal Problems
1. Identification of common neonatalproblems
❖ Monitor the newborn every 15 minutes for the first one hour of birth for any danger signs
❖ Record the same in the postnatal section of the case sheet.
Remember to look for common problems or signs. These
signs have been grouped so that you can remember them
easily as "B-l, SIP"
.....
'W
❖ Breathing difficulty
❖ Convulsions
❖ Discharge (pus) or Erythema (redness) from umbilicus
❖ Feeding difficulty
❖ Gastrointestinal - vomiting or bleeding in stools
❖ Hypothermia or fever
❖ Icterus (yellow) or pallor
❖ Stiff or floppy newborn
❖ Irritability or lethargy
❖ Pustules in skin >10 or large boil
Initial management of common neonatal problems
❖ Start initial management before transfer of the newborn to higher facility
Referral and transport of newborns with common problems
❖ Decide which newborn requires urgent referral and which newborns need referral, but not urgently.
❖ Follow the principle of STABLE while transporting the newborn.
♦ Sugar to prevent hypoglycaemia, either feed expressed breast milk or if not possible, 5% dextrose
(5ml/kg every 2 hours)
♦ Temperature to maintain warmth within normal limits
♦ Airway, to ensure the airway is clear and newborn is breathing
♦ Blood pressure and perfusion - checked by skin colour and capillary refill time (less than 3 seconds)
♦ Lab reports need to be transported with the newborn to the higher center
♦ Emotional support to the family
Documentation of initial management of common problems identified
All interventions must be recorded in the case sheet, and details in the referral form to be complication
before the newborn is transferred to a higher center.
8.3 Importance of Components
Identification of common neonatal problems
❖ Newborns that are healthy will be pink, feed well, keep normal temperature, be active, pass urine and
stool. The chance of death for a newborn is highest in the first week of life. Some simple signs, also
called danger signs can direct or be a flag for a serious problem. Hence the PHC staff must be alert to
look for these closely in the first hour till discharge. These problems can be identified by looking, asking
or feeling for the specific symptoms
❖ Breathing difficulty could present as flaring of nares; respiratory rate of more than 60/minute; grunting;
chest indrawing and or cyanosis.This is a flag for asphyxia or respiratory distress (typically seen in a preterm)
73 J
Essential Newborn Care at 24/7 Primary Health Centres
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11 Hm
Hui
Essential Newborn Care at 24/7 Primary Health Centres
or infection or a cardiac problem. The PHC staff must anticipate asphyxia in the following situations
❖ obstructed labour
Chest indrawing
❖ hypertension
❖ prematurity
❖ growth retardation
❖ cord related problems such as cord around the neck, cord
prolapsed
❖ abruption placenta
❖ placental insufficiency
❖ Breathing difficulty could also flag a trachea oesophageal fistula
or diaphragmatic hernia. It could be accurately assessed using
APGAR and the respiratory distress score.
Figure 8.1: Chest indrawing
❖ Convulsions could present very subtly in a newborn such as blinking of eyelids with a fixed stare;
eye deviation; apnea (no breathing); cyclic movements of limbs (pedalling); tonic posture (stiff and
extended limbs). The newborn might also be drowsy. It is flag to the PHC staff that there is something
wrong such as hypoglycaemia, or infection
❖ Discharge (pus) or redness of umbilicus is a flag for possible sepsis and must be managed.
Normal umbilicus of a 4 day old newborn
Figure 8.2: Normal umblicus
❖ Feeding difficulty
❖ Gastrointestinal problems such as vomiting or diarrhea: this usually is not so common in the first week
of life. If present it is important to watch the newborn for signs of dehydration such as a depressed
anterior fontanel, decreased urine output, dry skin, dry /cracked lips etc. A newborn can present with
blood in the stools. This is a flag for a more serious problem.
❖ Hypothermia or fever most newborns could become hypothermic if measures are not taken to maintain
warmth. But hypothermia is also a flag for sepsis. Sepsis must be suspected in a newborn presenting
with hypothermia or fever (rarely) especially in the following situations
♦ LBW/preterm preterm newborn
♦ history of prolonged rupture of membranes,
♦ Infection in the mother.
❖ Typically the newborn with sepsis could also have additional signs such as feeding difficulty, breathing
difficultyjaundice or icterus and or irritability.
❖ Icterus or jaundice. Yellow skin must be identified early. Early management of it could help in getting
1..... ,.
better health outcomes. Icterus or jaundice must be assessed in the natural light. The finger must
be pressed on the newborn's skin preferably over the bony part, till it blanches. The underlying skin
must be observed for yellow colour. If jaundice is only present in the face it might indicate physiologic
jaundice that usually appears between 24-72 hours. But if the soles and feet are also yellow it indicates
a more severe form, occurring within the first day of Iife/after 72 hours and would require immediate
management. This type of jaundice is a flag sign that the newborn would require further management
♦ Within 24 hours: indicate ABO /Rh incompatibility, intrauterine infections
♦ After 72 hours: indicate sepsis, biliary atresia, metabolic disorder
❖ Stiff or floppy: this could be a flag sign for asphyxia or respiratory distress, hypogylcemia, and or lack of
oxygen to the brain.
Floppy
Stiff
Figure 8.3: Stiff and floppy newborn
❖ Irritability or lethargy: a newborn who is healthy is satisfied, sleeps at least 20-22 hours. However if a
newborn is crying constantly /easily one must check whether the newborn has other problems such as
fever, feeding difficulty etc. A newborn who is weak or lethargic is a flag for possible sepsis.
❖ Pustules more than 0: is a flag for infection. Sometimes a newborn might have one large boil.This could
also indicate infection.
Initial management of common neonatal problems
❖ The principles of the initial management of common neonatal problems are similar. To maintain
temperature, ascertain newborn is breathing, feeding well are important early interventions. In
addition it is important to give the newborn an initial feed if not taking direct breast feed, and starting
the initial dose of antibiotics before transporting the newborn.
♦ Keeping the newborn warm is important to prevent hypothermia and thus prevent other
complications.
♦ Clearing the airway so that the newborn breathes normally or assisting the newborn with the bag
and mask for ventilation. Oxygen could be given to those newborn whose skin colour is not pink,
and with respiratory rate of more than 60/minute.
♦ Maintaining sugar levels by feeding the newborn or giving 5% dextrose to the newborn. This
is important so that the newborn does not become hypoglycemic (low blood glucose level).
Hypoglycemia could worsen the condition of the newborn.
❖ The first dose of antibiotics could be administered based on the order of the medical officer.
_____________ ©
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
♦ Injection ampicillin or cloxaciIlin and gentamycin for pneumonia or sepsis
♦ Injections ampicillin or cefotaxim and gentamycin or amikacin for meningitis
♦ Chloramphenicol eye drops for those with conjunctivitis
♦ Puncture and clean pustules and boils and apply local microbial ointment
❖ Counsel on prevention of infection since this is an opportunity for the mother and family to learn what
measures could be taken to reduce the risk of infection. These could include
♦ Breastfeeding
♦ Washing hands before handling the newborn
♦ Keeping the cord dry
♦ Maintaining hygiene of newborn
♦ To avoid any traditional practices
Referral and transport of newborns with common neonatal problems
❖ Before referral all attempts to stabilise the newborn first must be taken such as maintaining the
temperature, breathing and feeding (by mouth or orogastric tube).
❖ It is important to identify those newborns that require immediate attention and intervention (within
hours of birth). These include those newborns with suspected
♦ Diaphragmatic hernia: breathing difficulty, abdomen will be saucer shaped (scaphoid) and chest
bulging, cyanosis
♦ Tracheoesophageal fistula:(Figure 8.5) frothing from the mouth, cyanosis, choking on feeding
♦ Respiratory distress or prolonged ventilation with bag and mask
Figure 8.4: Diaphragmatic hernia (abdomen
saucer shaped)
Figure 8.5: Tracheoesophageal fistula
♦ Convulsions
❖ Conditions that would need referral but not urgent / immediate attention (within 24 hours transfer
preferable) include
❖ Other danger signs where the newborn would require further investigations and interventions
Mentors' Manual Volume 3
such as discharge from umbilicus, feeding difficulty, gastrointestinal problems (diarrhea, vomiting),
hypothermia orfever, icterus and palor, stiff or floppy newborn, irritability and lethargy, pustules in the
skin
❖ Follow the principle of STABLE during the transfer.
❖ The mother or support person and health care personnel must be with the newborn during transport
especially if the newborn requires ventilation support.
Documentation of details in the case sheet
❖ Documenting details of danger signs identified and measures taken to manage them initially is
important for continuity of care when a referral is made. The details must be recorded in the respective
part of the case sheet.
❖ Documentation is like a legal record and thus must be done carefully.
8.4 Requirements to manage common neonatal problems
Equipment/Supplies
❖ Oxygen canula
❖ Oxygen cylinder
❖ Ambu bag and mask
❖ Radiant warmer
❖ Towels or cloth to wrap the newborn
❖ Injection ampicillin
❖ Injection gentamycin
❖ Injection cioxacillin
❖ Case sheet
❖ Syringe and needles
❖ Scalp vein or jelco needle for intravenous
❖ Cotton swabs
❖ Spirit
❖ Kidney tray
❖ Puncture proof container to discard the needles
Clinical skills
Assessment of RESPIRATORY DISTRESS
This is done by checking the respiratory rate, presence of grunting, cyanosis, retractions and air entry(See table 8.4).
Assessment ofJAUNDICE
1.
Do assessment in natural light.
2.
Wash hands
3.
Press finger on the newborn's skin, preferably over a bony part till it blanches (becomes white).
4.
Note the underlying skin for yellow colour.
5.
Interpret the extent of jaundice using the clinical criteria given below. Remember this is an approximate
estimate of jaundice and the best way to get an accurate value is by doing a blood test.
Essential Newborn Care at 24/7 Primary Health Centres
s
Essential Newborn Care at 24/7 Primary Health Centres
Table 8.1: Assesment for Jaundice
Range of bilirubin (mg/IOOml)
Area of body
Face
Upper trunk
5-12
Lower trunk and thighs
8-16
1
____
_________ i—
Arms and lower legs
11-18
Palms and soles
>15
6.
__
Refer all newborns with jaundice in the first day of life.
Assessment of DEHYDRATION
Table 8.2: Assesment and action for dehydration
Assess for signs of dehydration to choose the appropriate plan of action.
Signs
Type of dehydration
:
Action to be taken
Wilf need IV line
Two of the following srghi
signs
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t rut Skin pinch very slow
,
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Two of the following signs
Moderate dehydration (some)
♦ Restless, irritable
Same as above
♦ Sunken eyes
♦ Skin pinch slow
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h^tfopJlinn
| signs to classify as ;
Mild dehydration (little)
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Assessment of CAPILLARY REFILL TIME (CRT)
1. Wash and dry hands
Press the forehead or sternum using indexfinger/thumb for 5 seconds.
SB--------------- ------------ Mentors' Manual Volume 3
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follow uplh 5 days if no'
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Assessment of TEMPERATURE
2.
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3.
Release and look at the blanched area (whitish/pale part) to check how fast it will return to the
normal colour
4.
Note the time taken for return of the colour. The colour should return within 3 seconds.
5.
If the colour does not return within three seconds and is beyond three minutes, this indicates poor
tissue perfusion. Remember that this finding might be wrong if the newborn is hypothermic.
Giving an OROGASTRIC FEED IF THE Newborn IS TOO SICK
1. Wash hands
2. Take either size 6 or 8 F size feeding tube
3.
Measure from tip of nose to tip of ear, from ear tip to midway between xiphoid sternum and umbilicus
4.
Extend the head slightly
5.
Lubricate the tube with sterile water
6.
Insert the tube gently through the mouth to the stomach
7.
Check if tube is in place. If it is in place
❖ Use a 5cc syringe, aspirate and check for gastric content
❖ Push 0.5ml of air and auscultate over epigastric region. You must hear the sound of air entering
❖ Place the end of the tune into water, no bubbles must come out.
8. Give the required amount of feed to the newborn using a syringe
❖ 60ml/kg/day for a term
❖ 80ml/kg/day for a preterm)
9. When feeding, avoid pushing the fluid with force allow it to flow with gravity
10. Document the amount of fluid given in the case sheet
11. Administer feed every 2-3 hourly
12. Check for adequacy of feeding: newborn passing urine, warm, no abdominal distension, not vomiting
feed.
Administering OXYGEN THROUGH CANULA OR MASK
1.
Select oxygen canula
2.
Insert the canula. Tape the canula to the cheek or apply the mask, see that both mouth and nose are
covered.
3. Check if the oxygen is humidified.
4. Adjust the flow meter of oxygen to the required amount of oxygen
5. Administer 2-5L of oxygen as free flow oxygen to the newborn
6.
DO NOT give 100% oxygen to a preterm newborn
7. Observe the newborn's respiratory distress score
8.
Record the details in the case sheet
Provide SUPPORTIVE CARE
1.
Keep the newborn warm both before and during transport
2. Get assistance to start an IV line if needed and for administration of first dose of antibiotics
3. Give the needed feed (Expressed breast milk) through the orogastric tube
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4.
Explain the condition of the newborn, the plan for the newborn to the parents and the advantages as
well as challenges that they would face, so that they could make an informed decision on care of the
newborn.
5.
Find out from the parents and support person their preference on management of the newborn
6.
Refer for further management
How to manage a REFERRAL AND TRANSPORT OF A NEWBORN
1.
Identify the need for referral
2.
Counsel parents regarding need for referral and transport
❖ What is the condition of the newborn?
❖ What is the prognosis without and with treatment?
❖ What transport is needed and risks of it?
❖ What arrangements are made/need to be made?
❖ What is the preference of the family?
❖ What their role is if accompanying the newborn?
3.
Inform referral doctor/ hospital
4.
Fill in referral form:
❖ Condition and reason for transport
❖ Name of mother, time of birth, sex and date
❖ Problem
❖ Name of facility, doctor
❖ Signature of person referring
5.
Record all vital information in the case sheet
❖ Just as given above
❖ Any action taken and response of newborn to it
❖ Whether newborn has been stabilised
❖ Medications given as per doctors order (normal saline, dextrose, vitamin K, antibiotics,
phenobarbitone, epinephrine)
6.
Provide safe transport:
❖ One health care personnel to be with the family during transport to monitor and resuscitate
newborn if needed
❖ Continue bag and mask ventilation if needed
❖ See that oxygen in available in the trolley/ambulance; equipment for resuscitation bag, mucus
suction catheter, nasal canula, thermometer)
❖ Ensure newborn is kept warm (thermocol box, well wrapped and in closed vehicle prior to transport
Mentors' Manual Volume 3
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Table 8.3: Safe transport during referral
Essential communication to family member
and
doctor/nurse
accompanying
the
newborn
Prevent complications during transport
I--’-Uv
.HtvwK. .c,♦
Need for transport
temperature and; ❖ Positioning of newborn
Medina schedule
33.
Hypoxia -' maintain airway
airway '
. X.':
xX'; i
-•
♦ oe.™, secretions
:
❖ Gentle stimulation
❖ Feeding newborn If needed
... Keeping newbOrn warm
MMre.r.,'
. ........’...... ......... L... I... .t....'
Howto PREVENT INFECTION IN A NEWBORN
1. Perform thorough hand washing before handling the newborn
2. Give /advise to mother exclusive breastfeeding
3. Keep cord dry. Avoid any application on the cord
4. Teach mother how to maintain hygiene of newborn
5. AVOID unnecessary invasive interventions such intravenous lines
6. Disinfect equipment and maintain cleanliness of the environment - resuscitation equipment, feeding
articles, etc
8.5 Mentoring Skills
Sample Examples for Mentoring Episode
Sample example of mentoring using direct observation
You visit the PHC and staff nurse tells you that she is unsure whether a newborn is having respiratory distress
or not. You go to the bedside of the mother and the newborn.
You ask the staff nurse what she has observed. She tells you, "I have counted the respiratory rate and it
is 70/minute, the newborn is pink but the mother tells me that the newborn is not breastfeeding well".
You check with the staff nurse about the details of the newborn (whether term or not, Whether born by
normal vaginal delivery, whether the newborn cried soon after birth, what the APGAR was at 1 minute and
5 minutes).
The staff nurse tells you, "This is a term male newborn, 2.8kgs, born by normal delivery, cried at birth,
APGAR at 1 minute was 9 and at 5 minutes was 9".
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Appreciate the staff nurse for the right things she has done and said so far
❖ Respiratory rate
❖ Newborn pink
❖ Newborn not feeding well
❖ Details of the newborn
Reinforce that she is right in thinking the newborn is having respiratory distress since the respiratory rate
is more than 60/minute and the newborn is also having feeding difficulty. Tell her that it is important to be
mindful of the following
❖ When the breathing became more rapid?
❖ What is the gestational age of the newborn?
❖ Was the mother on steroids?
❖ Did the mother have premature rupture of membranes, fever?
❖ Was there meconium stained amniotic fluid?
❖ Was there any birth asphyxia?
In this situation, only the first question is relevant as everything is normal.
Then the severity of the respiratory distress must be assessed.Teach the staff nurse how to assess respiratory
status (Table 8.4).
Table 8.4: Safe transport during referral
2
0
Score
I!. .
______
]
Res irator rate/minute
I ess th an 60
60 'aL>
morethans0
Central cyanosis
None
None with 40% oxygen
Needs more than 40% oxygen
__ r°ne__ Lm"j
Obvious
None
Grunting
Severe
I
...... ___________ _ ...I.
....
Then tell the staff nurse given that the newborn's respiratory rate is 70/minute but there is no
grunting, cyanosis, retractions and good airentry it indicates a score of 1 .This means the newborn
does not have distress.
But if the newborn has breathing difficulty, difficulty in feeding then she must ask/look for other
features such as hypothermia or fever; any other danger signs and refer accordingly. Since this
could indicate a possible sepsis or other problems.
Sample: Audit of working condition of equipment needed
1.
Plan to do an audit at a regular time (once in three months).
2.
Check the register that is to be maintained. If there is no register show the staff how to start and
maintain a register. A sample register could be formatted as given in table 8.5
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Table 8.5: Safe transport during referral
Date
3.
Equipment
Working
condition (Y/N)
Checked by
Next due date
Take a walk around the set up and check the equipment required if clean and in working condition.
Some examples of equipment that would need to be maintained are given:
❖ Radiant warmer
❖ Suction apparatus
❖ Oxygen cylinder
❖ Bag and mask
❖ Flow meter of the oxygen cylinder
❖ Weighing machine
4.
Appreciate the staff if all equipment in working condition and maintained clean. If not still give
positive reinforcement on equipment that has been maintained.
5.
Tell staff about the importance of maintaining equipment in working condition always, since no one
can anticipate when they would be needed.
Sample format: Audit of transport of newborns to higher center
❖ Use the following format / checklist to assess whether transport of a sick newborn is done safely
Checklist for safe transport
♦ Has referral doctor/hospital been contacted?
Y/N
♦ Has referral note been written? Are lab reports available?
Y/N
♦ Has condition of newborn been noted just before transport?
Y/N
♦ Does the newborn require ventilation support (bag and
mask)?
Y/N
♦ Have the parents been counselled?
Y/N
♦ What arrangements have been made for transport for
newborn? (warmth/feed/oxygen/resuscitation equipment)
Y/N
♦ Which doctor /nurse will accompany the newborn and
mother?
Y/N
11
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8.6 Key messages for mentors - Do's and don'ts
I
1 'yi
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DO check if the temperature of the postnatal room is comfortable, (Ideal >250C).'
, !
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DO be prepared. Make sure all necessary equipment (radiant warmer/200 watt heat
source/heater; thermometer, resuscitation equipment) and supplies (towel/long:
cloth/cap and socks/soap solution) are available for the birth of a newborn. ;
DO Watch all newborns in the facility carefully for any danger signs and assess the
vitals such as temperature, breathing, colour and heart rate every 15 minutes for the
first hour of fife, then if stable every 4th hourly till discharge.
------------------- —
:
............. '
........... —__—.—t-------------------------------r—-—
—..
DO be aware that appearance of danger signs is highest in the first day of life. The
newborn must be assessed carefully to now for other associated problems.
.
-.. ..
...
. — . . . —
. .
DO teach all mothers what danger signs to look for in the newborn before they are
discharged and when to report to the health facility.
!
,
.
—
.
,
.......
? i
;
i
Do refer those newborns who present with danger signs based on urgent / Immediate
needs to a delayed referral within 24 to 48 hours.
DO NOT delay referral of a newborn who presents with a danger sign.
DO NOT forget to explain about the don'ts such as
Don'ts
❖ Giving oil if the newborn has not passed stool
❖ Branding the newborn for respiratory distress, diarrhea, abdominal distension,
seizures
❖ Applying something on the umbilicus
❖ Giving the newborn any home remedies
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s9 Feeding a Low Birth Weight Newborn
Learning Objectives
I
At the end of this chapter you will be able to
❖ Describe the dietary requirements of a LBW newborn and how they can be met with by use of j.
expressed breast milk.
❖ Describe the method of feeding for different categories of LBW newborns.
❖ Demonstrate how to feed a LBW with a palada
❖ Demonstrate mentor skills in meeting the nutritional need of LBW newborns in the PHC
9.1 Introduction
LBW newborns have special challenges (Table 9.1).They are either born term or preterm (before 37 weeks).
They require more calories and protein than normal weight newborns, and might have difficulty sucking
at the breast directly. They also may require more help and frequent monitoring.
Table 9.1: Types of LBW Newborn and Method of feeds
I
Problems of LBW
Types of feed
Indications for type of feed
! Less than i soogm
Inability to suckle effectively
?
Gavage feeding
| ❖ Sp-aon
❖ Orogastric tube feed
' '❖ PaJadai
Some tube feed
❖ Spoon feed
Inability to coordinate
swallowing and breathing
<♦ Cuporpalada
Depends on factors:
Inability to coordinate
swallowing and sucking
❖ Behaviour of newborn
t*-—
1500-2000qm :
Breastfeeding
❖ . Paladai
Hl
❖ Observe response of newborn
2000gm
to feed
❖ Breast feed
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9.2 Components of Care of LBW
Identifying and Classifying LBW
❖ Follow methods described in Chapter 2 to classify the newborn
newborn at birth
Screening for common problems
❖ Screen all LBW newborns for common danger signs as given
in Chapters
Maintaining warmth
❖ Teach mother KMC before she leaves the facility
❖ Show mother other ways such as extra clothing, keeping room
warm. Refer to Chapter 5 on Thermal control and KMC
Figure 9.1 LBW newborn
Feeding a LBW
❖ Teach mothers that LBW newborns require extra feeds and
nutrients to maintain their growth requirements.
❖ Reinforce the need to feed LBW newborns only breast milk (see Table 9.2).
Table 9.2: Howto feed a LBW newborn
Breast milk or expressed breast milk
Type of feed
Method of feeding
Direct feeding: Paladai / katori / spoon/ feeding tube
Frequency
Initial feed within half an hour, then 2 hourly
Volume of feeds
60-80 ml/kg on day 1
Increments
15 ml/kg upto a maximum of 150ml/kg/day by day 7
❖ Teach mother or other significant family member how to feed the newborn, if LBW but is stable, and
more than 1800 gms / 1.8 kgs as given in the Table 93/9.4
Table 9.3: Types of LBW Newborn and Method of feeds
Gestational Age/
birthweight
10-15 days
5-7 days
Day 1
j Direct
2000 gms'
:
?
breastfeeding
more thin 35 weeks
J!(DBF)
O
SS'
; If net,taking give palada
[Try direct breast 'w
1800 gms
■■
more than34 weeks | feeds
Shift quickly, to DBF • ‘
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__ ____
2-3 weeks
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Table 9.4: Feed volumes recommended based on the weight of the LBW newborn
ml/kg/day
Dayl___________ 03/3
Day4
Days
Day 6
Day? ..
.60
— '
100
120
.
80-
1
HO
.120 :
~ |
|
:...... . _.__,80____........................... |
03X2
• .
.
__________
,
;
'■...... ■.1.. '
140
ISO
. . 160
'
- ■
130
"
,
L
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|
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9.3 Importance of Components
Identifying and classifying LBW
❖ Prematurity, small for gestational age and intrauterine growth retardation (IUGR) are the commonest
reasons for a newborn being LBW. Common causes of prematurity include low maternal weight,
teenage or multiple pregnancies, previous history of preterm newborn, cervical incompetence,
antepartum hemorrhage, acute systemic infection, and induced premature delivery. But in majority of
cases, cause is unknown.
❖ Common causes for SGA and IUGR newborns include poor nutritional status of the mother, hypotension,
pre eclampsia, anemia, multiple pregnancy, post maturity, chronic malaria, chronic illness and tobacco
use. Thus if the PHC staff is aware of these causes in the mother it is a flag for her to be alert for the birth
of a LBW newborn.
❖ Identification of and classification of newborns at birth itself could help to determine if additional
interventions must be done for the newborn.
❖ A LBW newborn has a greater risk to present with danger signs such as asphyxia, breathing difficulty,
convulsions, discharge or erythema from the umbilical cord, feeding difficulty, hypothermia or
hypoglycemia, icterus, stiff or floppy newborn, irritability or lethargy and pustules
❖ Thus a newborn who either is less than 34 weeks or if the weight is less than 1800 gms must be referred
immediately if this was not anticipated before birth.
Screening for common problems
❖ Anticipation of any danger sign or identification of them at birth could help in being prepared to
provide initial steps of management before referral. This could help in initiating management early
and could result in better health outcomes.The common problems include
♦ Birth asphyxia and breathing difficulty is typically higher in LBW and premature newborns especially
since their lungs are not developed enough,
♦ Convulsions, could occur either since the newborn is at higher risk for intraventricular hemorrhage
or infections. A newborn with severe infections could present with any of these danger signs such
as convulsions, discharge or erythema (redness) from the umbilicus, feeding difficulty, stiffness or
floppy, irritability or lethargy, pustules. Thus if any of these danger signs are present the newborn
must be referred to a higher center for further management
♦ Hypothermia risk is higher among newborns who are premature or LBW due to less amount of
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111
brown fat. Thus it is important to maintain their temperature within normal levels. A newborn with
hypothermia has greater risk for hypoglycaemia. In addition such newborns could lose more fluids
due to their large head surface area, thin skin and greater metabolic rate. Hence their need is greater
for calories and fluids than term newborns.
♦ Icterus could occur due to several reasons. In premature newborn the chance of jaundice is higher
due to polycythemia (increased amount of RBCs). Thus if a preterm newborn's birth is anticipated
it is ideal to refer the mother to a higher center. But if not possible to refer, then the newborn's
umbilical cord must be clamped without delay to facilitate resuscitative measures and reduce the
chance of polycythemia.
❖ Any danger sign if present in a preterm or LBW newborn must be immediately reported to the medical
officer and such newborns must be referred since the risk for them developing serious infections are
higher.
❖ All newborn less than 1800 gms, less than 34 weeks, unable to feed or sick must be referred to a higher
center for further management.
Maintaining warmth
❖ A LBW newborn has decreased thermal insulation due to less subcutaneous fat and reduced amount
of brown fat. Prevention and management of hypothermia is considered a key intervention in reducing
neonatal mortality and morbidity. Specifically in LBW newborn, plastic caps, plastic wraps, skin-to-skin
contact have been reported to be effective low cost interventions in reducing risk of hypothermia
❖ Acrocyanosis, apnea, bradycardia (low HR), cool and mottled extremities, distress, feeding poorly,
hypoglycaemia, lethargy are flags for hypothermia.
Feeding a LBW newborn
❖ A LBW or a preterm newborn must be assessed for ability to feed before oral feeds are started. If
these newborns are stable (respiratory rate less than 60/minute, no breathing difficulty, convulsions,
hypothermia, alert and have a soft abdomen) they could be given oral feeds provided this ability has
been assessed.
❖ Newborn who are less than 34 weeks do not have mature suckling patterns or good suck swallowing
coordination and thus these newborns must be referred immediately to a higher center for further
management.
❖ Transportation to a higher center can take time. The newborn must thus be fed by an orogastric tube
or by spoon/palada to prevent hypoglycaemia. LBW newborn have less glucose stores and thus require
more frequent feeding.
❖ Feeding must be progressed to oral feeds and then direct breast feeds based on the newborn's ability
to suckle effectively and to coordinate suckling and swallowing of breast milk.
❖ The best milk for the newborn is still breast milk. It is known to reduce the risk of necrotising enterocolitis
(NEC) a common problem among premature newborns where the intestines become infected. These
newborns present with abdominal distension, vomiting that is bile stained (greenish in colour) or blood
tinged fluid, black or blood stained stools, edema and will be lethargic and weak.
♦ A newborn must be observed for adequacy of feeding.The following are flags for inadequate feeding
in a LBW or premature newborn
•
feeding less than 8 times in a day
•
poor attachment and suckling.
Mt.. ..
Mentors' Manual Volume 3
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gets tired easily
•
mother has sore nipples or breast engorgement
❖ A LBW and SGA newborn usually will not lose weight as term newborns do, in the first week of life. The
newborn must gain approximately 1 -1.5% of its birth weight (15-30 gms/day). If a LBW or SGA newborn
is not gaining adequate weight it is a flag sign for poor or inadequate feed intake.
9.4 Requirements to Feed LBW Newborn
Equipment and supplies
❖ 10 ml syringe
❖ Infant feeding tube 6 or 8F size
❖ Micropore to fix the tube
❖ Feeding cup
❖ Paladai
❖ Spoon to feed the newborn
❖ Katori
❖ Steriliser to boil the feeding cup / palada / katori or spoon
Clinical skills
Identification and CLASSIFICATION OF NEWBORN
i.
Keep articles ready such as Infant weighing machine; clean towel/cloth; cleaning solution - 0.5%
chlorine solution to wipe tray and clean cloth to wipe the wet tray.
2. Wash hands thoroughly before handling the newborn.
3.
Explain the procedure to the mother and ensure that the newborn's weight is checked before the
mother is transferred out of the labour room.
4.
Place the newborn on the towel. Wait till the weight stops fluctuating to the nearest 10gms /0.01 kgs.
5. Cover the newborn immediately and hand over to mother or rewarm by asking the mother to provide
kangaroo mother care (KMC) or keep under radiant warmer if needed
6.
Record the weight in the newborn's case sheet.
7.
Refer a newborn with birth weight "less than 1800 gms"for further management
Assessment of METHOD OF FEEDING FOR LBW OR PRETERM NEWBORN
1. Assess the newborn at birth for prematurity or being LBW
2. Check if the newborn is able to suckle, breathe and swallow
3. Check for any danger signs in the newborn
4. Check if the newborn is physiologically stable
❖ No breathing difficulty
❖ No chest in drawing
❖ No hypothermia
❖ No convulsions
❖ No lethargy or drowsiness
❖ No feeding difficulty
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5.
Explain to mother and support person the method of feeding the newborn
6
.Reinforce the importance of giving only breast feed to the newborn
ACTION
ASSESSMENT
REFER. Manage as per sick
NB guidelines
»< Takeser^uah mill
'x No;
z
Is the NB able to take feeds by
alternative methods? When offered
feed NB
j
♦ Opens mouth, take mild
swallows without coughing?
♦ Takes enough quantity of feed?
Figure 9.2 Guideline for feeding of LBW
Feeding byPALLADA
Feeding by Cup
Steps of the procedure
1. Wash hands
2. Check if the newborn is awake
3. Check ifthecup/katori was cleaned, boiled
4. Place a measured amount of feed in the cup
5. Place the newborn on the lap
6. Support the newborn's head and back to a semi- sitting
position with one hand
7. Touch the edge of the cup / katori to the outer parts of the
upper lip
♦ DO NOT allow the head of the
8. Tip the cup / katori so that the milk reaches the newborn's
i newbblnh to hyperextend
lips
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9. Allow the newborn to take the milk by her/himself (when
the newborn smells the breast milk, /he /she becomes alert,
opens its mouth and puts the tongue into the milk to start
the feed)
<• DONOTtafcdlh.^bom
10. See that the newborn takes it at a speed that is comfortable. The
❖ PQ NOT. pour, the feed jn.. the
newborn will close the mouth and will not take the milk once
satisfied.
11 • Record the amount of feed given
•
r 12. Wash the cup / Katori, boil, dry and store in a covered clean
container
S.Feeding by SPOON
Steps of the procedure
11
1.
Wash hands
2.
Check if the newborn is awake
3.
Check if the spoon has a smooth edge, is cleaned and
boiled before use
4.
Place a measured amount of feed in the katori
5.
Place the newborn on the lap
6.
Support the newborn's head and back to a semi- sitting
position with one hand
7. Take a little feed on to the spoon
8. Touch the edge of the spoon to outer parts of the upper
Lfe
I'P
9. Tip the spoon gently so that the milk reaches the
newborn's lips
10. Allow the newborn to take the milk by her/himself (when
the newborn smells the breast milk, he/she becomes >
❖ DO NOT feed a newborn whose
alert, opens its mouth and puts the tongue into the ?
‘ z^,.suckling.and swallowing is not
milk to start the feed)
coordinated
11. See that the newborn takes it at a speed that is •
•
■' DO NOT force feed the newborn
DO NOT stop giving, the
comfortable. The newborn will close the mouth and
recommended amount of feed
will not take the milk once satisfied.
because It is a slow method of 12. Record the amount of feed given
feeding
13. Wash the spoon, boil, dry and store in a covered clean
container
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Feeding by OROGASTRIC tube
Steps of the procedure
1. Wash hands
2. Take either size 6 or 8 size feeding tube
3.
Measure from tip of nose to tip of ear, from ear tip to midway between xiphoid sternum and umbilicus
4.
Extend the head slightly
5.
Lubricate the tube with sterile water
6.
Insert the tube gently through the mouth to the stomach
7. Check if tube is in place. If it is in place
❖ Use a 5cc syringe, aspirate and check for gastric content
❖ Push 0.5ml of air and auscultate over epigastric region. You must hear the sound of air entering
❖ Place the end of the tune into water, no bubbles must come out.
Give the required amount of feed to the newborn using a syringe
8.
❖ 60ml/kg/day for a term
❖ 80ml/kg/day for a preterm
9. When feeding, avoid pushing the fluid with force allow it to flow with gravity
10. Document the amount of fluid given in the case sheet
11. Administer feed every 2-3 hourly
12. Checkfor adequacy of feeding: newborn passing urine, warm, no abdominal distension, not vomiting
feed.
Ensure ADEQUACY OF FEED
1. Assess: Ask
❖ How many feeds the newborn takes in 24 hours?
❖ What is the volume of each feed given?
❖ By which method is feed given?
❖ Does the NB have any feeding difficulty?
2. Observe
❖ Is the newborn sputtering or spitting out the milk?
❖ is the newborn tiring or takes too long to take the required amount?
❖ Check weight daily
3. Features indicating inadequate feed
❖ If each feed volume is less than that indicated
❖ Feeding the newborn less frequently than recommended
❖
If there is excessive spilling during feeds
❖ Takes too long to finish the required amount
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❖ Refer THE Newborn FOR FURTHER MANAGEMENT if inadequately fed
4. REMEMBER: Adequate feed is assured when the newborn
❖ Passes urine 6-8 times in 24 hours
❖ Goes to sleep for 2-3 hours after the feeds
❖ Gains weight
9.5 Mentoring Skills
Sample examples for mentoring episode
Sample format for one-to- one mentoring a staff nurse to assess adequacy of feeding either direct breast
feeds or spoon / katori /palada feeds
❖ Ask the staff nurse how she would assess if a LBW newborn is getting adequate feed
❖ Based on the response check if the staff nurse mentioned the following points
♦ Asks the mother how many times the newborn is taking feeds in a day
♦ If breastfeeding
Checks if the newborn's attachment is correct
J Checks if the newborn is suckling well
Checks if the newborn is getting tired before the feed is complete
Checks if the mother has sore nipple / breast engorgement
♦
If on katori / palada / spoon feeding
Asks mother how much of feed is given
Checks if there is spitting or spluttering of milk
Checks if the newborn is taking too long to take the required amount
Checks if the newborn is getting tired before the feed is complete
♦ Informs that
J If the newborn is getting less than 8 feeds/day, not attaching or suckling well, tires before completing
the feed or if the mother has sore nipple or breast engorgement it indicates inadequate breastfeeding.
J If the newborn is getting less than the indicated volume, feeding less frequently, is spitting out
milk, is tiring before the feed is complete or is taking too long to feed, it indicates inadequate
spoon / katori / palada feeding
If the newborn is not gaining weight as expected then it indicates poor feeding
❖ Start with all the correct points that the staff nurse mentioned, highlight other points that could
be mentioned and complete with what the nurse could do to ensure that the LBW newborn has
adequate feed.
❖ Reinforce to the staff nurse why it is important to check if the newborn is getting adequate feed.
Sample format for clinical skills demonstration ofpallada feeds
❖ Observe the procedure while the PHC staff is demonstrating to the mother how to give pallada feed
❖ Check if the PHC staff did the following steps
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
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Table 9.5: How to give pallada feeding
Q 1. Wash hands just before feeding the newborn
2. See that the newborn is awake and wrapped well
j
p] 3.
Hold in sitting semi upright position on the lap or bed
W 4.
Put a measured amount of expressed breast milk in the palada
i||| 5.
Hold the palada so that the pointed end rests on the infants .
lower lip
6. Tip the palada to pour out a small amount of milk into the i
newborn's mouth
7.
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DO NOT force
the 8.
feed
fete*
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Feed slowly or allow the newborn to suck as it wants
Make sure the newborn has swallowed the milk already taken
before giving any more
, f
9. Check if the newborn refuses any more feed, this indicates that
newborn is satisfied.
10. Record the amount of feed given (amount left subtracted from
original amount)
11 ■Wash the
_ ______ _
__.... _ ___
palada with
soap and water'then
boiled water and air
dry it before and after use or boil and store in covered clean
container till next use.
❖ Appreciate the PHC staff for the correct steps preformed
❖ Highlight the importance of adequate feeds for the preterm or LBW newborn
❖ Inform of how the PHC staff could ensure that the newborn is getting adequate feeds
❖ Demonstrate if possible the next feed to the PHC staff
❖ Ask PHC staff to recount the steps of palada feeding after you have completed it
❖ Give feedback to the staff nurses starting and ending with good points
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9.6 Key messages - Do's and don'ts
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DO maintain the temperature of the postnatal room
DO be prepared. Make sure all necessary equipment (radiant warmer/200 watt heal
source/heater; thermometer, resuscitation equipment) and supplies (towel/long^
cloth/cap and socks/soap solution) are available for the immediate care of the LBW
or premature newborn.
■
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T—
;—
a------------------------------------ i--------------- i-------------------------------------- a----------------- - ------- -- —;—j
DO watch the newborn carefully for any danger signs and assess the vitals such a^
temperature, breathing, colour and heart rate every 15 minutes for the first hour of
life, then if stable every fourth hourly till discharge.
|
---------- 4-,-------------------------------------------- ------------------- - ---------------- --------- ------ ---------------------------------------------------------------- ---------- -
DO be aware that appearance of danger signs is highest in the first day of life, the;
newborn must be assessed carefully to note for other associated problems
-------- j:---------------- -- —
■— --—,—i------------- i--------------------------,
a
DO assess LBW orpremature newborn's ifphysiologicallystable and whether able to feed ■
...
Do's
■ .
—J*——
..
DO give all stable LBW and premature newborns only breast milk
_
Do refer those newborns who are less than 1800 gms (1.8 kgs) or 34 weeks of
gestation or if present with danger signs based on urgent / immediate needs to a;
delayed referral within 24 to 48 hours.
------------------------------ ———-— --------—------------- - ---------------------Do assess all LBW or premature newborns in the facility for adequacy offeeding and
warmth at regular intervals
- -------------------- ■■■'"■
.............. 1----------------- !---------------- *—»—---------------------------------------------------------------------------------------------------------- ———----------- *4
DO give LBW or premature newborns more than 34 weeks direct breast feeds and
additional feeds with either a katori or palada or spoon as they will tire easily.
DO remember that LBW or premature newborns have more fluid requirement than;
term newborns (80ml/kg/day)
DO watch a newborn on spoon /palada/katori feeds and check whether newborn is;
spitting, taking too long to finish the required feed, taking lesser than recommended;
amount as this indicates inadequate feeding* Refer urgently
_____________ ®
Essential Newborn Care at 24/7 Primary Health Centres
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■
'■
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Essential Newborn Care at 24/7 Primary Health Centres
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DO NOT forget to observe the newborn carefully for any danger signs during the stay
at the facility.
DO NOTdelay referral ofa LBWorpremature newborn who presents with a danger sign.
DO NOT feed a LBW or premature newborn with breathing difficulty (respiratory
rate more than 60), severe chest in drawing, convulsions, hypothermia, drowsy or
lethargic, abdominal distension. These newborns are not physiologically stable and
would require care in a higher center
Don'ts
DO NOT give direct breastfeeding to a newborn with poor suckling and poor suckling
swallowing coordination.
DO NOT forget to wash hands before feeding the newborn
DO NOT forget to keep the LBW newborn warm during feeding
DO NOT use formula feed unless advised by the doctor
DO NOT force feed the LBW newborn particularly if lethargic
Mentors' Manual Volume 3
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References
1.
ANKUR Project: a case study of replication of home based newborn care: case study. SEARCH, Society
for Education Action and Research in Community Health, Gadchiroli, Maharashtra. Ahmedabad: I IMA.
23 p. nipccd.nic.in/dcwc/research%20bulletin/apr-jun2008.doc
2.
Apfel D (2011) When every minute counts. Medical Negligence 47 (5) (internet source) http://www.
justice.org/cps/rde/justice/hs.xsl/15273.htm (7.6.13) of Disease: 2004 (update 2008)
3.
GAVI Alliance (2012) Investing in immunisation through GAVI Alliance.The evidence base
4.
Lawn JE, Carsens S, Zupan J (2005). 4 million neonatal deaths:when? Where? Why? http://www.who .
int/maternal_child_adolescent/documents/pdfs/lancet_neonatal_survival_paper1.pdf
(accessed
june7,2013).
5.
Maternal Health Division and NRHM (2010) Skilled Birth Attendant Guidelines for LHVs, ANMs and
SNs. MoHFW, Government of India. New Delhi
6.
NRHM (2009) Navjaat shishu suraksha karyakram. Basic newborn care and resuscitation training
manual. MoHFW, Gol, New Delhi
7
The Million Death Study collaborators (2010) Causes of neonatal and child mortality in India: a
nationally representative mortality survey. The Lancet 376(9755): 1853-1860. doi:10.1016/S01406736(10)61461-4
8
UNICEF (2012) Committing to child survival-a promise renewed. Progress Report UNICEF, USA
9
WHO (2012) Recommendations for management of common childhood conditions-newborn
conditions, dysentery, pneumonia, oxygen use and delivery, common causes of fever, severe acute
malnutrition and supportive care. Evidence for technical update of pocket book recommendations.
WHO, Geneva, Switzerland.
10
WHO, UNICEF, NRHM (2009) Facility based IMNCI - facilitators guide. MoHFW, Gol, New Delhi
11
WHO and UNICEF (2010) Improving newborn survival in India, (internet source) http://www.
unicef.org/india/Newborn_Fact_sheet_Final_21 _june_2010.pdf (accessed June3, 29013) In WHO
The Global Burden Birth Asphyxia. A major killer of newborns (internet source) in http://www.
icddrb.org/what-we-do/publications/cat_view/52-publications/10042-icddrb-periodicals/10075mothernewbornews/10125-vol-1 -no-2-2006/11736-birth-asphyxia-a-majorkiller-of-newborns
(7.6.13)
12
http://apps.who.int/rhl/newborn/cd004210_Warikiwmv_com/en/index.html
13
http://www.newbornwhocc.org/pdf/teaching-aids/2010/Newborn-health-in-lndia-ENC1.pdf
97
Essential Newborn Care at 24/7 Primary Health Centres
Essential Newborn Care at 24/7 Primary Health Centres
Bibliography
1
ANKUR Project: a case study of replication of home based newborn care: case study. SEARCH, Society
for Education Action and Research in Community Health, Gadchiroli, Maharashtra. Ahmedabad :
IIMA. 23 p. nipccd.nic.in/dcwc/research%20bulletin/apr-jun2008.doc
2
Apfel D (2011) When every minute counts. Medical Negligence 47 (5) (internet source) http://www.
justice.org/cps/rde/justice/hs.xsl/1 5273.htm (7.6.13)
3
Birth Asphyxia. A major killer of newborns (internet source) in http://www.icddrb.org/what-we-do/
publications/cat_view/52-publications/10042-icddrb-periodicals/10075-mothernewbornews/1 0125vol-1-no-2-2006/1 1736-birth-asphyxia-a-major-killer-of-newborns (7.6.13)
4
GAVI Alliance (2012) Investing in immunisation through GAVI Alliance.The evidence base
5
Lawn JE, Carsens S, Zupan J (2005). 4 million neonatal deaths:when? Where? Why? http://www.who.
int/maternaLchild_adolescent/documents/pdfs/lancet_neonatal_survival_paper1.pdf
(accessed
june7,2013)
6
The Million Death Study collaborators (2010) Causes of neonatal and child mortality in India: a
nationally representative mortality survey. The Lancet 376(9755): 1853-1860. doi:10.1016/S01406736(10)61461-4
7
UNICEF (2012) Committing to child survival- a promise renewed. Progress Report UNICEF, USA
8
WHO and UNICEF (2010) Improving newborn survival in India, (internet source) http://www.unicef.
org/india/Newborn_Fact_sheet_FinaL21 June_2010.pdf (accessed June3,29013) In WHO The Global
Burden of Disease: 2004 (update 2008)
9
http://www.newbornwhocc.org/pdf/teaching-aids/2010/Newborn-health-in-lndia-ENC1.pdf
a
Mentors'Manual Volume 3
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Improved Maternal, Newborn & Child Health
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Centre for
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St John's National Academy of
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