CARE OF NORMAL NEWBORN
This protocol should be extended to a normal neonate only and not the high-risk neonates.
Normal neonate :
• Birth weight greater than 2500 g and gestation of 37 weeks or more
• Birth weight between 10th to 90th percentiles as per intrauterine growth charts
• The absence of maternal illness or intrapartum event that may put a neonate at risk of illness like
gestational diabetes, antepartum hemorrhage etc
• Normal Apgar scores with no need for resuscitation at birth
• No postnatal illness such as respiratory distress, sepsis, dyselectrolemia, hypoglycaemia or
polycythaemia
CARE AT BIRTH
1) One health provider (physician or nurse) trained in neonatal resuscitation must be physically available at time of birth of all infant irrespective of its risk status (high or low). It is not good enough to have someone on call.
2) If the delivery is anticipated to be high risk because of presence of risk factors identified before birth more advanced neonatal resuscitation may be required. In these cases TWO persons should be present solely to manage the baby. The goal should be to provide a ‘resuscitation team’ with specified leader and an identified role of each member.
3) For multiple births there should be separate teams.
4) The resuscitation corner must be physically located in the delivery room itself. The health professional designated to care for the baby at birth should check for the “Resuscitation Preparedness” at the birthing place well in time before the baby is delivered (Table 1).
Standard Precautions and asepsis at birth:
1. The personnel attending the delivery must exercise all the universal/standard precautions in all cases.
2. All fluid products from the baby/ mother should be treated as potentially infectious.
3. Gloves, masks and gowns should be worn when resuscitating the new-born.
4. The protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other bodily fluids.
It is important to prevent infection at birth by observing FIVE CLEANS : 5
(1) Clean hands: appropriate hand-hygiene and wearing sterile gloves
(2) Clean surface: use clean and sterile towel to dry and cover the baby
(3) Clean cord: the umbilical cord should be cut with a clean and sterile blade/scissor
(4) Clean thread : The cord should be clamped with a clean and sterile clamp or tie
(5) Do not apply anything to the cord.
Prevention and management of hypothermia:
Immediately after birth the new-born is at maximum risk of hypothermia. This early hypothermia may have a detrimental effect on the health of the infant. Special care should be taken to prevent and manage hypothermia.
1. It should be ensured that the delivery room is 25*C and free from drift of air.
2. The paediatrician should receive the baby directly (no middle person should be allowed) in a pre-warmed sterile linen sheet.
3. The infant should be dried thoroughly including the head and face areas.
4. any wet linen should not be allowed to remain in contact with the infant.
5. The infant may be placed on the mothers abdomen immediately after the birth to ensure early skin-to-skin (STS) contact with the mother. (Kangaroo Mother Care). This will not only maintain the new-born’s temperature, but also promote early breastfeeding and decreases the pain and bleeding in the mother.
6. The baby should be observed for the transition period and made wear the caps and socks.
7. Delayed clamping of umbilical cord: Umbilical cord clamping must be delayed for nearly 2 minutes in order to allow transfer of additional amount of blood from placenta to the infant. This delayed cord clamping in term babies is associated with improved hematologic status, iron status and clinical anaemia at 2 to 6 months.
The cleaning of baby:
1. The baby should be dried and cleaned at birth with a clean and sterile cloth.
2. The cleaning should be gentle and should only wipe out the blood and the meconium and NOT be vigorous enough to remove the vernix caseosa (white greasy material on the skin). The vernix protects skin of the infant and helps maintain temperature. This gets absorbed of its own after some time.
3. Currently there is no evidence of advantage of cleaning the baby with paraffin or any other emollient at birth and the same is not recommended.
Clamping of the cord:
1. The umbilical cord should be clamped at 2-3 cm away from the abdomen using a commercially available clamp, a clean and autoclaved thread or a sterile rubber band.
2. The stump should be away from the genitals to avoid contamination.
3. When the commercial clamps are not available, the rubber band could be a better option than a thread as once cord starts shrivelling the rubber band would still maintain its grip while the thread might loosen up.
4. Inspect the cord every 15- 30 minutes for initial few hours after birth for early detection of any oozing from the cord
Care of the Eye:
1. At birth both the eyes of the neonates should be cleaned with separate swabs.
2. The sterile water or the normal saline may be used for this purpose.
3. The swipe to clean the eyes should be gentle and from the inner canthus area to the outer canthus.
4. The cleaning on a daily basis is not recommended as a routine.
Placement of identity band:
1. The birthing places with high birth rates should take utmost care to ensure the identity of the mother-baby duo by an appropriate method as per the hospital policy.
2. Each infant must have an identity band containing name of the mother, hospital registration number, gender and birth weight of the infant.
Recording of Apgar scores:
1. The apgar scores should be recorded at 1 minutes and 5 minutes of birth.
2. This score has a limited value in guiding for resuscitation and initial stabilization.
3. The prediction of the subsequent outcomes by Apgar scores is also poor.
4. However Apgar scores do help deciding the need for nursery admission.
CARE OF BABY DURING THE INITIAL FEW HOURS AFTER BIRTH
Weight record of the Baby:
1. The baby should be weighed after stabilization and after the temperature is documented to be normal.
2. A sterile preheated sheet (or a single use paper towel) should be placed on 5 to 10 gm sensitivity weighing machine.
3. Zeroing of the machine should be performed.
4. The baby is then gently placed on the weighing machine and the weight recorded.
5. Weighing of the baby is a complex skill and it requires adequate training of health providers.
Initiation of breastfeeds:
1. The breastfeeding should be initiated at the earliest time possible.
2. The health provider should actively assist the mother to put the baby on breast irrespective of the mode of delivery.
3. Breastfeeding counselling alone without any active proactive support is unlikely to result in high rates of successful breastfeeding.
4. Time of initiation of the breastfeeding should be documented.
Vitamin K administration:
1. Vitamin K should be administered to all the babies (0.5 mg for babies less than 1000 grams and 1 mg for babies more than 1000 gms).
2. It is preferable to administer the K1 however if not available the K3 may be administered.
3. This should be administered as an IM injection using the 26 G (1/2 inch) needle and a 1 ml syringe on the anterolateral aspect of the thigh.
First Examination:
1. The baby should be thoroughly examined by the attending person from head to toe and the findings should be recorded in neonatal record sheet.
2. It is very important to examine midline structures for malformations (e.g. cleft lip, neck masses, chest abnormality, omphalocele, meningocele, cloacal abnormality etc.).
3. Special attention should be given to identify and document the anal opening.
4. There is no need for routine passage of catheter in the stomach, nostrils and the rectum for detection of oesophageal atresia, choanal atresia and ano-rectal malformation, respectively.
5. The baby should be examined for presence of birth injuries in cases with difficult extraction.
6. The axillary temperature of the baby should be recorded before the baby is shifted out from the birthing place.
Communication with the Family:
1. Before leaving the birthing place the health professional should communicate with the mother and the family members. The following facts should be clearly told to the family: (1) gender of the baby (2) birth weight (3) well being of the baby.
2. One should ensure that the family members and the mother get to witness the gender and the identity number of the baby
Rooming-in:
1. Under no circumstances, a normal newborn should be separated from the mother.
2. In the initial few hours of life, the baby is very active, and the closeness of the baby to the mother will facilitate the early breastfeeding and bonding.
3. The studies have shown that any separation during these initial hours may have a significant adverse impact on various outcomes including successful breastfeeding in later stage of life.
CARE OF BABY BEYOND FEW HOURS AFTER BIRTH
Care of the cord:
1. The umbilical stump should be kept dry and devoid of any application.
2. The nappy of the baby should be folded well below the stump to avoid any contamination.
Oil Massage:
1. The benefits of the oil application have been described for the low birth weight babies in both the developed and the developing countries.
2. Oil massage is a low cost traditional practice that is well ingrained into the Indian culture, with no reported adverse outcome.
3. The same may be allowed in a gentle way and with clean hands.
4. Care should be taken not to use oils with additives or the irritant oils (such as mustard oil) for this purpose.
Exclusive breastfeeding :
1. A proactive and a systematic approach should be followed to initiate, support and maintain breastfeeding.
2. The various advantages of the breast feeds should be discussed with the mother to motivate her for breastfeeding.
Bath:
1. The routine dip baths should be avoided till the baby is in the hospital premises as this increases the risk of hypothermia.
2. The sponging of the baby should be done once a day with clean water as per the requirement.
3. The dip bath may be undertaken once the cord has fallen and the baby is discharged from the hospital.
Powder application: Currently there is no evidence to suggest the regular use of any powder and the same should be avoided.
Position of sleep:
1. No Indian study has addressed the issue of relation of sleep position to occurrence of SIDS.
2. There is substantial evidence in the literature from the developed countries of an association of prone position and the SIDS independent of the other variables.
3. Considering the above all the healthy term new-borns should be preferably made to sleep on their backs.
Traditional practices that should be discouraged:
1. The application of Kajal/ surma in the eyes.
2. Putting oil in the ear.
3. Applying the cow-dung on cord must be strongly discouraged.
Timing of discharge in a Normal Newborn:
1. Whenever possible the baby should undergo an observation period of 48 to 72 hrs in the health facility (for establishment of breastfeeding and observation for any morbidity including jaundice).
2. However, an early discharge within 24 to 48 hrs may be considered for the non
primigravida mothers who have a history of successful breastfeeding.
The following criteria should be met in all the babies prior to discharge planning:
1. The routine formal examination of the new-born has been performed and documented
2. The new-born has received the immunization as per schedule.
3. The mother is confident and trained to take care of the neonate.
4. The new-born is not having a significant jaundice or any other illness requiring close observation by a health provider.
5. The new-born is breastfeeding adequately.
6. The adequacy of feeds can be determined by :
a) Passage of urine 6 to 8 times every 24 hrs
b) Baby sleeping well for 2- 3 hrs after feeds
c) There is no excessive weight loss (normally babies do not lose more than 8 to 10% in
initial 3 to 4 days)
7. The mother has been counselled regarding routine new-born care and her queries are answered.
8. Follow-up advice should be communicated to the mother of the baby.
9. Babies particularly born to primigravida mothers should be called for follow up visit at 48 hrs of discharge if discharged before 48 hours.
10. The breastfeeding and the jaundice in these babies should be evaluated.
ADVICE ON DISCHARGE: NORMAL NEW-BORN :
2. Immunization: The mother should be explained the schedule of the immunization and the date of the next immunization should be mentioned on the discharge card.
3. The follow-up: Follow up date for the babies discharged early (within 48 hrs) for assessment of jaundice should be communicated to the parents.
4. The danger signs:
The danger signs should be documented and mother should be educated to recognize the same and report early when they are recognized. They are :
a. Difficulty in feeding
b. Convulsions
c. Lethargy (movement only when stimulated)
d. Fast breathing (RR > 60/min)
e. Severe chest in drawing
f. A temperature of more than 37.5 deg C or below 35.5 deg C
Contributed by
MBBS MD.
Consultant Paediatrician and neonatologist
Star Hospital
Sanat Nagar Srinagar
KASHMIR
9906691966
yasirwani1234@gmail.com
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