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Care of Newborn in delivery room and in early newborn peroid.

Neonatal resuscitation

Aim of every Doctor,Health care worker who are


taking care of mother during pregnancy and at the
time of delivery,to have healthy mother and newborn
at the end

During pregnancy in uterus, fetus grows in sterile atmosphere, gets oxygen


and nutrition from mother.
Temperature of fetus is always maintained irrespective of outside temperature

Basic need of newborn are


1. Warmth to maintain proper
body temperature
2. Normal breathing.
3. Protection from infection.

Ideally to reduce maternal


and neonatal mortality
delivery should be
institutional by trained
person.
Not always possible in our
country, so delivery may
take place in

Home :- Must be conducted by trained


dai, or ASHA worker.
PHC:-Should be conducted by ANM , Staff
Nurse
or by doctor (Rarely).
District Hospital
Medical College
Private hospital or nursing homes

Therefore Govt. is making every efforts for Safe


mother and baby outcome after delivery training
each and every medical and paramedical person.

Most important thing when delivery has to


take place is
Clean Environment
IT is only possible by applying 6
cleans
1.
Clean Hands.
2.
Clean Surface.
3.
Clean blade.
4.
Clean cord tie.
5.
Clean towels to dry and
wrap the baby.
6.
Clean cloth to wrap the
mother.

Neonatal Resuscitation
85% of delivered newborn need only basic
newborn care.
10% of cases need some help for survival.
Only 5% newborn need immediate life
support measures, so if not provided within
first minute called Golden minute of life,
newborn mortality or morbidity will occur.

So who are those 10-15% and


especially 5% nobody knows.
Therefore every delivery should be
anticipated as emergency so person
knowing newbon resuscitation must
be present.

Equipments
Two pieces of sterile cloth (one for cleaning
and another for wrapping the baby)
Clock with seconds hand.
Sterile gloves.
Sterile blade for cutting umbilical cord.
Umbilical cord clamp.
Radiant warmer
Oxygen (central supply or cylinder)
Suction device (mucus extractor or central
suction facility

Self inflating resuscitation bag (250-500ml)


with oxygen reservoir and pop off value.
Face masks (sizes 0 & 1)
Laryngoscope (straight blade No. 0, 1)
ET tubes (sizes 2.5, 3, 3.5,4 internal
diameter)
Drugs: Adrenaline 1:1000, naloxone, NS,
RL, IV cannula,
Umbilical catheter, syringes, needles of
various sizes.
8 and 6 F feeding tube.
Inj Vit K

Before discussing about Neonatal


Resuscitation
programe (NRP) we should keep in
mind basic
needs of baby at birth.
1. Warmth.
2. Normal Breathing.
3. Mothers Milk.
4. Protection of infection

Immediate care of normal


newborn at birth
1. Call out the time of birth.
2. Deliver the baby into warm, clean
and dry towel or cloth and keep on
mothers chest(in between breasts)
3. Clamp the cord.
4. Immediately dry the baby with a
prewarmed clean towel.
5. Assess the babys breathing while
drying.

6. Wipe the eyes from medial to lateral


canthi with separate sterile cotton
pieces.
7. Leave the baby between mothers
breasts and start skin to skin care.
8. Place an identity label or band on
baby.
9. Cover the baby head with cap if
delivery occurred in cold area.
10.Cover the baby and mother with
warm cloth.

At delivery
Ensure the delivery room is warm
(25 degree C. with no draughts).
Dry the baby immediately and
remove the wet cloth.
Keep the baby close to
mother( ideally skin to skin contact)
Postpone bathing/sponging for 24hrs

After delivery

Keep the baby clothed or wrapped


with head covered.
Minimize the bathing especially in
cool weather or for small babies.
Keep the baby close to mother.

Breast Feeding

STEP 1: Preparing the infant and mother


Ensure that infant is stable and alert
Make sure that the mother is
comfortable and in convenient
position.

STEP 2: Demonstrate various positions of


breast feeding the baby.

STEP 3: Demonstrate the four key


points in position
Babys head and body should be
stright
Babys face should face mothers
face
Babys body should be close to her
body
Mother should support the babys
whole body

STEP 4: Show the mother how to


support her breast with the other hand
She should put her fingers below her
breast.
Use her thumb above the areola
helping to shape the breast.
Use her first finger to support the
breast.
Not keep her fingers near the nipple.

STEP 5: Showing the mother how to


help the baby to attach.
Ask the mother to
Express a little milk on her nipple
Touch the babys nipple with her
nipple
Wait until the babys mouth is wide
open, and the tongue is down and
forward.
Move the baby quickly onto her
breast, aiming the nipple towards the
babys palate and his lower lip well

STEP 6: Look for signs of good attachment

The four key signs of good attachment


are:
More areola is visible above the
babys mouth than below it.
Babys moth is wide open
Babys lower lip is turned outwards.
Babys chin is touching the breast.

STEP 7:Assess if the infant is suckling and


swallowing effectively

Effective sucking:
Infant takes several deep sucks
followed by swallowing and the
pauses
Ineffective sucking:
Infant sucks for short time but tries
out and is unable to continue for long
time.

Frequency of breast feeding


ON DEMAND i.e. whenever the baby
cries for feeds.
Normal time interval should be 2 to 3
hrs.
Feeding must be there for at least 810 times in 24 hrs and importantly
not to omit night feed.

Assessing the adequacy of breast


feeding
I. Passes urine 6-8 times in 24 hrs.
II. Goes to sleep for 2-3 hrs after the
feeds.
III. Gains weight @ 10-15gm/day
IV. Crosses birth weight by 2 weeks.

Post natal care after delivery


At the time of discharge few basic
information should be given to
mother.
Exclusively breast feed the baby.
Prevention from infection.
Watch for icterus, can be taught
assessment of jaundice by skin pinch
method.
Watch for danger signs.

Danger signs

Lethargy
Breathing difficulty
Temperature instability
Failure to pass urine/meconium in 24hrs/48hrs
Vomiting
Diarrhea
Cyanosis
Jaundice
Abdominal distention
Convulsions
Bleeding
Excessive weight loss.

When mother suspects child is sick or


having any danger sign and
approach to doctor and health
provider , then rapid assessment of
sick newborn should be done to
decide whether to send home or shift
to sick newborn nursury.

Acute care of at risk newborn


(Acorn)

Respiratory care

Common Causes of respiratory


distress
Preterm
Term

Respiratory
distress
syndrome
Congenital
pneumonia
Miscellaneous
causes:
hypothermia ,

TTN
Meconium
aspiration
syndrome
Pneumonia
Asphyxia

RECOGNITION
Tachypnea (RR >60)
Chest indrwaing, Inter and subcostal
retraction.
Grunting
Apnea/Gasping are signs of extreme
illness.
Cyanosis/Need for oxygen to
maintain saturation.

Pulse oximetry:Single non invasive method for


measuring oxygen saturation.
Oxygen must be adminstered if
saturation less than 90%

Supportive Care

Positioning (mild extension of neck with


shoulder roll)
Warmth (use a radiant warmer or other
methods)
Assessment of perfusion.
Spo2 monitor if available.
Blood gas check.
IV assess if required.
Orogastric tube insertion.

Temperature

Assessment by touching his/her


abdomen , hands
feet with dorsum of your hand.
Euthermic :-newborn has both feet
and
abdomen warm
Cold stress :- Feet cold and abdomen
warm.

Temperature can be recorded by


thermometer
Axillary or Rectal
Axillary thermometer must be kept in
axilla with bulb in center of axilla
with body parallel to longitudinal axis
of humerus.
Keep it there for 3 minutes.

Maintenance of temperature
Cold stress:
Remove the baby from cold
environment, remove cold/wet
clothes.
Give Kangaroo mother care to baby.
Normally every baby must be given
KMC as it has many benefits despite
preventing from hypothermia.

KANGAROO MOTHER CARE


(KMC)

3 Components are:1. Skin to skin contact.


2. Exclusive Breast feeding.
3. Early discharge
BENEFITS
Effective thermal control, increased
breast feeding, early discharge , less
incidence of apnea and infection. Less
stress and better mother infant bonding.

KMC procedure

Baby must be placed between the


mothers breast in upright position.
Head should be turned to one side and
slightly extended which keeps the
airway open and eye to eye contact
between mother and baby.
Hips should be flexed and abducted in
frog position, Arms should also be
flexed.
Babys abdomen should be at level of
mothers epigastrium.

Infection in newborn

Superficial infection
Omphalitis:- infection of umbilicus.

LOCAL INFECTION
Redness around umbilicus less
than 1 cm and absence of signs
of sepsis
Treatment
Local cleaning with
antiseptic lotion followed by
application of gentian violet
0.5% qid till redness subsides.

SEVERE INFECTION
Redness around umbilicus
greater than 1cm and signs of
sepsis.
Treatment
Same as for local infection + IV
antibiotics.

Oral Thrush:- Fungal infection of oral cavity. White patchy lesion on


tongue and mouth can occur in health infants also. True oral
thrush is difficult to wipe of and leads to bleeding mucosa after
wiping.
Treatment:- Local nystatin or clotrimazole application
four times a day is recommended.
Conjunctivitis:- Infection of conjunctiva caused by various bacteria ,
viruses and chalamydia. Manifests with purulent discharge and
inflammation.
Treatment with NS cleaning of eyes from medial canthi to
lateral and instillation of local antibiotics like
gentamycin,tobramycin and ciprofoxcin.
Note:- Sticky eyes also has mucioud discharge but no inflammation.
Treatment is only NS cleaning
Blocked nasolacrimal duct:-Presents with persistent or intermittent
discharge which can be mucopurent.
Treatment: Massage and local instillation of antibiotics

Systemic infection(Neonatal sepsis)

Every newborn with signs and


symptoms of sepsis should ne
managed and NICU level 3/4 care.

Immunization
All neonates should be immunized at
birth or with 2 days with BCG OPV
and Hep B vaccines.
All care givers of attends should be
advised about follow up vaccination
as per vaccination schedule.

Low birth weight babies less than


1500gm or any unstable newborn with
danger signs,signs of sepsis should be
referred to proper NICU.

SUMMARY

Care of a normal newborn at birth includes the


components of essential newborn care such as
prevention of asphyxia, prevention of
hypothermia, early rooming-in and initiation of
breast feeding.

Each infant must have an identity band


containing name of the mother, hospital
registration number, gender and birth weight of
the infant.

All newborns should be weighed within first hour


of birth and receive intramuscular vitamin K.

First examination of a newborn should attempt to

The health provider responsible for care at


birth must communicate with the mother
and family regarding time, weight at birth,
gender and well being of the infant. The
infant should be shown to the family with
particular attention given to the fact that
family members get to know the gender of
the infant.

Management in the first few days of life


primarily focuses on cord care, eye care,
exclusive breast feeding, evaluation of
jaundice, vaccination and asepsis.

Ideally, newborns should be discharged


after 72-96 h when breast feeding has been
established, mother is confident and baby

In case of early discharge, which is


common because of overcrowded
labor rooms, the newborn should be
thoroughly examined and a
discharge weight and visual (or
transcutaneous) estimate of jaundice
recorded. A follow up visit after 48 to
72 hrs should be arranged.
Parents should be taught to
recognize the danger signs and seek
health care accordingly.

Neonatal Hyperbilirubnemia
Definition :Increase in level of bilirubin
in circulation.
Occurs as a result of
imbalance between bilirubin
production and excretion.

Neonatal jaundice can be :Physiological


Pathological
Physiological:Appears after 24hrs.
Peaks between 3-5 days in term and 5-7
days in preterm.
Peak bilirubin is 15mg/dl.
Pathological :Jaundice within 24 hrs of life.
Peak more than 15mg/dl
Jaundice persisting beyond 2 weeks.

Clinical assessment

All Newborn should be assessed for


jaundice at least once a day during first
72hrs.
Jaundice is assessed by inspecting skin ,
sclera or mucous membrane. Best and
convenient is skin blanching by digital
pressure :-

Assessment in neonates discharged


early
All newborns should be assessed for presence of risk
factors at the time of discharge.
Risk factors
Primipara mother.
Visible jaundice at birth.
Gestation < 38 weeks.
History of jaundice requiring treatment in previous
sibling.
ABO/Rh incompatibility.
Geographic presence of G6PD defeciency.
Weight loss at discharge >3%/day or >7% cumulative
weight loss.

More the risk factors more the chances


of severe hyperbilirubinemia , less
risk factors lesser the chances of
severe hyperbilirubinemia.
If newborn discharged at less than 24
hrs , those with risk factors should be
seen within 24-48hrs and those
without risk factors within 72hrs.

Investigations

All neonates with jaundice that is not


considerd physiology, investigation
needed to be done to assess severity of
jaundice for planning treatment and
etiology of jaundice.

Treatment of Unconjugated
Hyperbilirubnemia
Phtotherapy
Exchange Transfusion.
IVIG in Case of incompatibilities.
New modalities like Tin porphyrins,
Phenobarbitone in special cases.

Prevention

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