Objectives
• to adequately prepare for a delivery by
assembling the necessary equipment,
supplies and personnel in an ideal
environment
• to describe and carry out the evidence-based
care of a newborn baby at the time of birth
Basic Needs of a Newborn
• To breathe normally
• To be warm
• To be protected
• To be fed
Phil. ENCC
3
Preparing for Delivery
1. Notify appropriate staff
2. Check temperature of the delivery room
3. Arrange needed supplies in linear fashion
4. Check resuscitation equipment
5. Perform hand hygiene
6. Wear sterile gloves
At Perineal Bulging
Environment
• Check temperature of the
delivery room *
– Ideal temp: 25°C – 28°C
• Check for air drafts
• Turn fans and air
conditioners off before
the delivery
*non-mercury thermometer
Equipment
• Equipment must be checked daily, before
every delivery
• Resuscitation equipment should always be
close to the delivery area
• Health workers must know how to use the
equipment
• Arrange equipment according to sequence
of their use
• Restock equipment after every delivery
Linear Arrangement of Instruments
Resuscitation Equipment
• A newborn-sized self-inflating bag
• Infant masks sizes 0 and 1
• A suction device (mechanical or electrical or
mouth-operated)
• Oxygen Source
• Stethoscope
• A supply of warm towels and blankets
Perform hand hygiene
• Wash hands with clean water and soap
• Double glove just before delivery
Within 30 seconds after delivery
Call out the time of birth
Deliver and place on the
mother’s abdomen
Drying should be the first action,
IMMEDIATELY
for a full 30 seconds
unless the infant is both
floppy/limp and apneic
Immediate and Thorough Drying
• Immediate drying:
 Stimulates breathing
 Prevents hypothermia
• Hypothermia can lead to






•
•
•
Infection
Coagulation defects
Acidosis
Delayed fetal to newborn circulatory adjustment
Hyaline membrane disease
Brain hemorrhage
Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000,
Imperial College Press: London, UK. p. 207-220;
TollinM,etal.. Cell Mol Life Sci 2005
Immediate and Thorough Drying
• Dry the newborn thoroughly for at least 30
seconds
o Do a quick check of breathing while drying
o >95% of newborns breathe normally after birth
Immediate and Thorough Drying
• Follow an organized sequence
• Wipe gently, do not wipe off the vernix
• Remove the wet cloth, replace with a dry one
Immediate and Thorough Drying
• If baby is not breathing,
STIMULATE by DRYING!
• Do not slap, shake or rub
the baby
• Do not ventilate unless
the baby is floppy/limp
and not breathing
• Do not suction unless the
mouth/nose are blocked
Guidelines on
Basic Newborn Resuscitation
2012
• No suctioning for babies who are breathing
on their own, amniotic fluid is clear
• If not breathing, positive pressure ventilation
could be given, NOT suctioning
• Suctioning should be done only if ventilation
is not adequate and there are secretions
WHO. Dept. of Maternal, Newborn, Child and Adolescent Health. Guidelines on Basic Newborn Resuscitation.
Forthcoming.
Routine nasal and oropharyngeal suctioning
Adverse effects if inexpertly performed:
• Apnea (cessation of breathing)
• Vagal-induced bradycardia (slow heart rate)
• Slower rise in oxygen saturations
• Mucosal trauma with possibly an increased
risk for infection
S.N. Wall et al. Neonatal resuscitation in low-resource settings: What, who, and how to overcome challenges to scale up? International
Journal of Gynecology and Obstetrics 107 (2009) S47–S64
Gungor S, Teksoz E, Ceyhan T, Kurt E, Goktolga U, Baser IOronasopharyngeal suction versus no suction in normal, term and vaginally born infants:
a prospective RCT.Aust N Z J ObstetGynaecol. 2005 Oct;45(5):453-6.Turkey. sgungor@gata.edu.tr
Gungor S, Kurt E, Teksoz E, Goktolga U, Ceyhan T, Baser I.Oronasopharyngeal suction versus no suction in normal and term infants delivered by
elective cesarean section: a prospective RCTGynecolObstet Invest. 2006;61(1):9-14. Epub 2005 Aug 19. Ankara, Turkey. sgungor@gata.edu.tr
Early Skin-to-skin Contact
Early Skin-to-skin Contact
• General perception is that it is purely for
mother-baby bonding
• Other benefits:
 Provides warmth
 Improves bonding
 Provides protection from infection by exposure
of the baby to good bacteria of the mother
 Increases the blood sugar of the baby
•
•
•
Moore E, et al. Cochrane Rev. 2007 Jul 18;(3).
Anderson GC, et al. Cochrane Rev 2003;(2).
Brandtzaeg P. Ann N Y AcadSci 2002;964:13–45
Early Skin-to-skin Contact
• If breathing or crying:
– Position prone on the
mother’s abdomen or
chest
– Cover the newborn
• Dry linen for back
• Bonnet for head
• Temperature Check
– Room: 25-28 °C
– Baby: 36.5 – 37.5 °C
Properly Timed Cord Clamping
Benefits:
• Allows the newborn to get a free blood
transfusion from the placenta
• Reduces the risk of anemia in both term and
preterm babies
• Reduces the need of transfusions and brain
hemorrhage in preterms
•
•
•
•
•
•
•
CerianiCernadas ,et al. 2006;
Rabe H, et al. 2004;
McDonald SJ, et al. 2008;
Hutton EK, et al. 2007;
Kugelman A, et al. 2007
Van Rheenen PF, et al. 2006
Van Rheenen PF & Brabin BJ. 2006
Properly Timed Cord Clamping
• After the umbilical pulsations have stopped
remove first set of gloves
Properly Timed Cord Clamping
• Put plastic clamp at 2
cm from the newborn’s
abdomen
• Put forceps at 5 cm
from the newborn’s
abdomen
Properly Timed Cord Clamping
• Cut just above the clamp
with sterile instrument
Care of the Cord
• Do not milk the cord towards the baby
• Observe for the oozing of blood. If blood
oozes, place a second tie between the skin
and the clamp
• DRY cord care is currently recommended
• Do not apply any substance onto the cord
• Do not use a binder or “bigkis”
Active Management of the
3rd Stage of Labor
1. Give Oxytocin 10 mg IM to mother
After excluding a second baby
2. Apply gentle traction to the cord
3. Gentle uterine massage
Deliver the placenta
Non-separation of Newborn from
Mother for Early Breastfeeding
• Place the newborn on the
mother’s chest in
skin-to-skin contact
• Cover the baby’s head
with a hat. Cover the
mother and baby with a
warm cloth.
• Initiate breastfeeding
while maintaining skin-toskin contact.
• Place identification band
on ankle.
Non-separation of Newborn from
Mother for Early Breastfeeding
• Never leave the mother
and baby unattended
• Monitor mother & baby
every 15 mins in the first
1-2 hrs. Assess warmth
and breathing.
 Warmth: check to see if
feet are cold to touch
if no thermometer
 Breathing: listen for
grunting, look for chest indrawing and fast breathing
Signs of Readiness to Breastfeed
• When the newborn
shows feeding cues
(ex. opening of
mouth, tonguing,
licking, rooting), make
verbal suggestions to
the mother to
encourage her
newborn to move
toward the breast (ex.
nudging)
A newborn attaching to the breast (latching on)
Initiation of Breastfeeding
• Health workers should not touch the
newborn unless there is a medical indication
• Do not give sugar water, formula or other
prelacteals
• Do not give bottles or pacifiers
• Do not throw away colostrum
• Let the baby feed for as long as it wants on
both breasts
Phil. ENCC
32
Non-separation of Newborn from
Mother for Early Breastfeeding
• Eye care, weighing, bathing, examinations, injections
should be done after the first full breastfeed is completed
• Inform the mother and record all actions
• Postpone bathing until at least 6 hours
Eye Care
Action:
• Wipe the eyes
• Apply an eye antimicrobial within
1 hour of birth:
– 1% silver nitrate drops or
– 2.5% povidone iodine
drops or
– 1% tetracycline ointment
or erythromycin eye
• Do not wash away the eye
drops
antimicrobial
Physical Examination
Injections
Special Situations
What should be done if a baby does not feed
in one hour after birth?
• Help the mother to initiate breastfeeding
within 1 hour, when baby is ready
• If the baby does not feed in 1 hour, examine
the baby
• If healthy, leave the baby with the mother to
try later. Assess in 3 hours, or earlier if the
baby is small.
If the Mother has HIV/AIDS
• Standard precautions MUST be followed as with
ANY other delivery and after care
• Give special counselling to the mother who is HIV
postive regarding choice of feeding
• Her baby can have immediate skin-to-skin contact
as any other mother and baby
• If mother chose replacement feeding, explain the
risks of diarrhea and malnutrition and how to
avoid them
• Teach the mother how to feed baby by cup
Phil. ENCC
38
Harm of Early Bathing
• Washing exposes baby to hypothermia
• The vernix is a protective barrier to bacteria
such as E. coli and Group B Strep
• Washing removes the crawling reflex
[i] Tollin M, Bergsson G, Kai-Larsen Y, Lengqvist J, Sjovall J, Griffiths W, Skulavottir G, Haraldsson A, et al. Vernix Caseosa as a multicomponent defense
system based on polypeptides, lipids and their interactions. Cell Mol Life Sci 2005; 62:2390-2399
[ii] Righard L, Alade M. Effect of delivery room routines on success of first breastfeed. Lancet 1990; 336: 1105-07
PERFORMING THE EINC PROTOCOL
During
Pregnancy
Upon
arrival at
Facility
During
Labor
Prior to
Delivery
At Perineal
Bulging
At least 4 antenatal visits
Iron and folate supplementation
Tetanus Toxoid Vaccine
Prepare a BIRTH PLAN including PhilHealth & Unang Yakap
Identify women in PRETERM LABOR or at risk for PRETERM DELIVERY Inject 1st dose of Antenatal Steroids
History, Physical Exam & BP, HR, RR. Obtain Birth Plan, Identify
Companion of choice, Stabilize if with complications
Encourage woman into a
comfortable position
IV fluid and NPO only when
indicated
Encourage mother to have oral
fluids and light snacks
Use WHO Partograph to
monitor labor
Ensure room temperature at
25-28°C& eliminate air drafts
Arrange all instruments & needs in a
linear fashion
Discuss care in the 1st hours
Prepare NB resuscitation area &
check that equipment is clean,
functional and within easy reach
Perform Proper Handwashing and put on 2 pairs of sterile gloves
NO routine episotomy, NO fundal pressure
Time
Delivery
Mother
Support the perineum with
controlled delivery of the head
Baby
Call out time of birth and sex
Dry, check breathing
First 30 secs
Give Oxytocin IM
After excluding a 2nd baby
1 minute to
3 minutes
Do controlled traction of cord
with counter-traction
Massage the uterus gently
Remove wet cloth for skin-toskin contact
Feel for cord pulsation ,
Clamp, cut cord
Return baby to prone position
Examine birth canal and placenta
Support FIRST FULL BREASTFEED. Monitor DYAD q15 mins
20 minutes
onwards
(until first
breastfeed)
Continue uterine massage;
Monitor every 15 minutes
Do eye care, examine, weigh, measure,
inject Vit K, Hep B vaccine, BCG vaccine
Transport to room TOGETHER
> 6 hours
BREASTFEEDING SUPPORT
Optional: Bathing > 24 hrs
EINC TRAINING VIDEO
Four Core Steps in
Immediate Newborn Care