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MARY ANNE L. ILAO, M.D.,FPPS,DPSNbM 2010
MDG 4: Reduce Child Mortality
Reduce by two thirds, between 1990 and 2015, the child mortality rate:
Reduce Under 5-mortality rate from 80.0 to 26.7 (per 1,000 LB) Reduce Infant mortality rate from 57.0 to 19.0 (per 1,000 LB)
What is the Essential Newborn Care Protocol?
• Series of time bound chronologically ordered, standard procedures that a baby receives from birth • Simple, to-the-point, user-friendly, globally accepted evidence-based protocol to essential newborn care focusing on the 1st week of life • Doable even by a single health worker caring for both mother and newborn
How is the Newborn Care Protocol organized?
• By time bands • With cross references to sections of the WHO PCPNC Manual (2006) • With algorithms that represent clinical pathways
Immediate Essential Newborn Care The First 90 Minutes .
Immediate Essential Newborn Care Time band: 2nd stage of labor • At perineal bulging. • Wash hands with clean water and soap. • Double glove just before delivery. . with presenting part visible Intervention:Prepare for the delivery Action: • Ensure that delivery area is draft-free and room temperature between 25–28oC.
including newborn resuscitation equipment. are available. • Line up materials for delivery according to sequence of use .Preparing to Meet the Baby’s Needs “Good care of the newborn begins with good preparation” • Ensure all delivery equipment and supplies.
Prepare for Delivery • 2 sets of sterile gloves • Two clean and warm towels or cloth • Self inflating bag and mask (normal and small newborn) • Suction device • Sterile cord clamp or ties • Sterile forceps and scissors • Rolled up piece of cloth • Bonnet • Clean dry warm surface .
Broken equipment is dangerous • Equipment must be checked daily and well before a delivery takes place. ENCC 11 . Phil. • Resuscitation equipment should always be close to the delivery area • Health workers must know how to use the equipment.
STANDARD PRECAUTIONS A4 • Always remember the importance of observing precautions to help protect the mother and baby and ourselves from infections with bacteria. viruses including HIV .
Cover the back with a dry blanket. Check the baby’s breathing while drying. • Place the newborn on the mother’s abdomen in skin-to-skin contact. face turned to the side • Call out time of birth. Remove wet cloth.Immediate Essential Newborn Care • Deliver the baby in prone position on the mother’s abdomen. • Dry the newborn thoroughly. .
Action: • Use a clean. front and back of the trunk. • Remove the wet cloth. dry cloth to thoroughly dry the baby by wiping the face. head. • Do a quick check of newborn’s breathing while drying. eyes.Time: WITHIN THE 1ST 30 SECS Intervention: Dry and provide warmth. arms and legs. .
Drying The Newborn •Stimulates the newborn to breathe normally •Minimizes heat loss .
Drying the newborn • During the 1st 30 seconds of drying/stimulation: – Do not suction unless mouth/nose are obstructed with secretions or other material – Do not ventilate unless the baby is floppy and not breathing Phil. ENCC 16 .
Do not remove the vernix!!! .
newborn is breathing or crying Intervention: Skin -to-skin (STS) contact Action: • Avoid any manipulation. • Place the newborn prone on the mother’s abdomen or chest skin-to-skin. • Place identification band on ankle . • Cover newborn’s back with a blanket and head with a bonnet. such as routine suctioning.Time band: If after 30 secs of drying.
Immediate skin-to-skin contact .
Immediate skin-to-skin contact .
Skin-to-Skin Contact • 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 • Contributes to the overall success of breastfeeding .
Skin-to-Skin Contact Effect on Immunoprotection • Colonization with maternal skin flora • Stimulation of the mucosa-associated lymphoid tissue system. • Ingestion of colostrum .
[i] Tunell R. 207-220. Manandhar. Costello and D. Editors. Hypothermia: epidemiology and prevention. . 2000. p.Risks of Hypothermia • Hypothermia can lead to : – Infection – Coagulation defects – Acidosis – Delayed fetal to newborn circulatory adjustment – Hyaline membrane disease – Brain hemorrhage. A. Imperial College Press: London. in Improving Newborn Health in Developing Countries. UK.
C. When the cord pulsations stop Between 1 and 3 minutes Between 30 secs .1 minute in preterms All of the above are appropriate .When should the cord be clamped after birth? A. D. B.
suction and ventilate Action: • Clamp and cut the cord immediately • Call for HELP • Transfer to a warm firm surface • Inform the mother • Start resuscitation protocol .Time band: If after 30 secs of drying. newborn is NOT breathing or is gasping Intervention: Re-position.
• Clamp and cut the cord after cord pulsations have stopped ( at 1 to 3 minutes) .Time Band: 1 – 3 minutes Intervention: Delayed or non-immediate cord clamping Action: • Remove the first set of gloves immediately prior to cord clamping.
• Do not apply any substance to the stump • Do not bind or bandage the stump • Leave the stump uncovered . -Observe for oozing blood.Action: Initial Cord care -Put ties tightly around the cord at 2 cm & 5 cm from the abdomen. -Cut between ties with sterile instrument.
6 .2 (95% CI 0. 0.6) – NNT 7.49 (95% CI 0.8) • Preterms: less infant anemia – RR 0. (4. 0.20.29.Properly timed clamping of the umbilical cord Reduces the risk of anemia in both term and preterm babies • Term babies: less anemia in the newborn 24-48 hrs after birth – RR 0.6) .3.06.81) – NNT 3 (1.5.
2004.9.Properly timed clamping of the umbilical cord Preterms: less intraventricular hemorrhage RR 0.59 (95% CI 0. 2006 Van Rheenen PF & Brabin BJ.et al. 2008. et al. 0. et al.35.4 . et al. Kugelman A. 2006 .Rabe H. et al. 2007 Van Rheenen PF. McDonald SJ.8) No significant impact on incidence of Post-partum hemorhage Ceriani Cernadas . 2007. et al.92) NNT 2 (1. Hutton EK. 2006.
et al. coli and Group B Strep • Washing removes the crawling reflex [i] Tollin M. Lancet 1990. Griffiths W. 62:2390-2399 [ii] Righard L. 336: 1105-07 . Cell Mol Life Sci 2005. Lengqvist J. Skulavottir G. Haraldsson A. Bergsson G. Vernix Caseosa as a multicomponent defense system based on polypeptides.Washing should be delayed until after 6 hours • Washing exposes to hypothermia • The vernix is a protective barrier to bacteria such as E. Sjovall J. Kai-Larsen Y. lipids and their interactions. Alade M. Effect of delivery room routines on success of first breastfeed.
Time: WITHIN 90 min of age Intervention: Provide breastfeeding support for initiation of breastfeeding Action: • Leave the baby on the mother’s chest in skin-to-skin contact. • Place identification tag / bracelet on the baby’s ankle . • Observe the newborn.
Maintain skin-to-skin contact .uninterrupted for at least 90 minutes after birth and until the first thorough breastfeed is complete .
treatments and procedures in the labor record • Monitor every 15 minutes: Baby • Breathing • warmth .Monitor the mother and baby during the first hour after complete delivery of the placenta • Never leave the woman and newborn alone • Keep the mother and baby in the delivery room • Record findings.
. • Rest period may take from a few minutes to 30 or 40 minutes before the baby shows feeding cues.SKIN TO SKIN CONTACT & INITIATION OF BREASTFEEDING • To begin with the baby will want to rest.
g. rooting). make verbal suggestions to the mother to encourage her newborn to move toward the breast e.g. .SIGNS OF READINESS TO BREASTFEED • Only once the newborn shows feeding cues (e. tonguing. licking. opening of mouth. nudging.
Help the mother and baby into a comfortable position .
counsel the mother on breastfeeding . • If the mother is HIV-positive. • Do not give bottles or pacifiers. • Do not throw away colostrum.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.
immunizations.The first breast feed – Check attachment and positioning when the baby is feeding – Let the baby feed for as long as he wants on both breasts – Keep the mother and baby together for as long as possible after delivery – Delay tasks such as weighing. until after the first feed . etc.
prepare formula for the mother for the first few feeds . – Her baby can have immediate skin-to-skin contact – Breastfeeding can begin when the baby is ready after delivery – Do not give the baby any other food or drink – Good attachment and positioning are vital – If replacement feeding.HIV and Immediate Newborn Care • If the mother has HIV/AIDS: – universal precautions must be followed as with any other delivery and after care.
Time: WITHIN 90 min of age Intervention: Do 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 drops • Do not wash away the eye antimicrobial .
Essential Newborn Care FROM 90 Min – 6 HRS .II.
• Inject a single dose of Vitamin K 1 mg IM. • Record.Time: FROM 90 Min – 6 HRS Intervention: Give Vitamin K prophylaxis and Hepatitis B and BCG vaccinations at birth Action: • Wash hands. • Inject Hepatitis B vaccine IM and BCG intradermally. .
malformations or defects Action: • Thoroughly examine the baby. • Weigh the baby and record.Time: WITHIN 90 min of age Interventions: • Examine the baby • Check for birth injuries. • Look for possible birth injury and/or malformation .
Dry it thoroughly with clean cloth. . Keep cord stump loosely covered with clean clothes. . . .Put nothing on the stump.Time: WITHIN 90 min of age Interventions: Cord care Action: Wash hands before and after cord care.Fold diaper below stump.If stump is soiled. wash it with clean water and soap.
Time: WITHIN 90 min of age Interventions: Provide additional care for a small baby or twin Action: • If the newborn is delivered 2 months earlier or weighs <1500 grams. refer to a hospital .
Time: WITHIN 90 min of age Interventions: Provide additional care for a small baby or twin Action: • If the newborn is delivered 1 month early of is visibly small (1501 – 2499g) .Special support for breastfeeding .Discharge planning .KMC .
Routine suctioning Early bathing/washing Foot printing Giving sugar water. 4. formula or other prelacteals and use of bottles and pacifiers 5. 2. 3.Unneccesary Procedures Not routinely recommended for all neonates 1. Application of alcohol. medicines and other susbstances on the cord stump and bandaging the cord stump or abdomen .
step-by-step • Some time-bound but doable even by a single health worker caring for both mother and newborn . performed methodically.SUMMARY Essential Newborn Care Protocol • Essential interventions in the first 90 minutes of life and up to 7 days of life • Emphasizes a core sequence of actions.
Check breathing while drying. Cover the back with a dry blanket. • Remove wet cloth. ENCC .Immediate Newborn Care First 90 Minutes of Life • Call out time of birth. • Deliver the baby prone on the mother’s abdomen • Dry the newborn thoroughly. Phil. • Position the newborn on the mother’s abdomen in skin-to-skin contact.
• Clamp and cut the cord when pulsations have stopped ( 1-3 minutes) • Place the newborn on the mother’s chest in skin-to-skin contact • Cover the baby’s head with a hat. • Do eye care Phil. • Place identification band on ankle. Cover the mother and baby with a warm cloth. • Initiate breastfeeding while maintaining skin-to-skin contact. ENCC .• Remove first set of gloves.
2009 .• Pocket guide to the PCPNC Manual (WHO 2006) • DOH issued Administrative Order 2009-0025on Dec.2009 : Adopting New Policies and Protocol On ENC • Launched on Dec 7. 1.
Together. we can DoH it… before 2015 .
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