Equipment Demonstration: National Neonatology Forum

EQUIPMENT
DEMONSTRATION
NATIONAL NEONATOLOGY FORUM

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1. RADIANT WARMER
OBJECTIVE : Upon completion of this section the participant should

1. know the parts of a warmer
2. be able to demonstrate the working of the warmer.
3. know the dangers associated with its usage and should be
able to manage minor equipments maintenance.
PARTS : Bassinet
- Quartz rod
- Skin probe
- Air probe
- Control panel
- Heater output
WORKING : i) Connect to mains
ii) For prewarming keep heater output to maximum.
iii) Place baby
iv) Connect probe
v) Read temperature on display
vi) Adjust heater output
- If below 360C- High
- If between 36-36.50C-Medium
- If between 36.5-37.50C-Low
- If >37.50C-Remove baby/Switch off warmer.
vii) Measure temperature 1/ 2 hourly X 2 hours & then 2
hourly.
CLEANING & DISINFECTION
- Glutaraldehyde 2 %
- Soap/detergent } Once daily
DOS & DONTS : i) Check temperature ½ hourly/2 hourly

ii) Ensure warm feet
iii) Ensure probe is connected
iv) Do not leave baby unattended.
v) Ensure side walls are fastened up
vi) Ensure adequate clothing in case of electricity failure
TROUBLE SHOOTING
i) Check fuse
ii) Check plug
iii) Check cords
SIDE EFFECTS & DANGERS
• Increased insensible water loss
• Fluid intake must be tailored to meet demands
• Hyperthermia
• Hypothermia
MAINTENACE i) Calibration
ii) Annual maintenance Contract

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2. PHOTOTHERAPY UNIT
OBJECTIVE : Upon completion this section the participant should

1. know the parts of a phototherapy unit.
2. be able of understand the functioning and demonstrate the
working of a phototherapy unit
3. be able to place a baby under phototherapy unit
PARTS : Tubes - Number -6
- Color -Blue/White
- Watt -20
- Irradiance -4-8 uw/cm2/nm (minimum)
- Duration -3 months
- Wavelength -420-460nm
- Distance <45 cms
WORKING : i) Connect to mains.
ii) Switch on the unit & check that all tube lights are
working
iii) Place baby naked only with the napkin on
iv) Cover the eyes
v) Change position frequently
vi) Increase fluid intake
Breast feed frequently
Spoon/Gavage – Inc. by 20 ml/kg/day
vii) Provide continuous phototherapy
CLEANING : - Glutaraldehyde 2%
o Soap/Detergent
DOS & DONTS : i) Cover eyes
ii) Check temperature- prevent hypo/hyperthermia
iii) Check weight daily
iv) Frequent breast feeding/increasing allowance for fluid
v) Reassess frequently
TROUBLE SHOOTING
i) Check fuse
ii) Check plug
iii) Check Cord
iv) Change tube if flickering or ends are blackened
INEFFECTIVE PHOTOTHERAPY
i) Baby covered
ii) Some tubes not working
iii) Flickering light
iv) Tube ends have black circles
SIDE EFFECTS AND DANGERS
i) Hyperthermia/Hypothermia
ii) Increased insensible water loss
iii) Tailor fluid intake to meet demands

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MAINTENANCE
i) Change tubes - if ends black or
- every three minutes
ii) Check flux (if possible )
iv) Annual Maintenance contract

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3. SUCTION MACHINE
1. Know the parts of a suction machine

2. Know how to use a suction machine and
3. Know its sterilization
PARTS :
o Suction Catheter
o Suction tubing
o Suction bottles
TYPE :
o De Lee’s suction trap
o Foot operated
o Electric ( if available )
WORKING : i) Connect to mains
ii) Switch on the unit and occlude distal end to check the
pressure. Ensure it does not exceed 100 mm of Hg
iii) Use disposable suction catheters
iv) Connect to suction tubing
v) Perform suction gently
vi) Switch off the suction machine
vii)
i) Wash suction bottle with soap & water
ii) Change bottle solution every day
DOs & DONTs : i) Suction gently

ii) Do not do vigorous & deep suction
iii) Use only disposable suction catheters
iv) Check adequacy of suction pressure
TROUBLESHOOTING
i) Check fuse
ii) Check cord
iii) Check earthing
iv) Check for leakages in the bottle/tubing
SIDE EFFECTS & DANGERS

i) Local trauma
ii) Bradycardia
iii) Apnea
iv) Infection
MAINTENANCE
i) Check for adequacy of suction pressure
ii) Change tubing if leaky or broken
iii) Annual maintenance Contract

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4. BAG & MASK
1. know the parts of a bag & types of masks

2. be able to demonstrate the use of a bag
3. know how to clean a bag & mask
PARTS :
i) Body of the bag
ii) Oxygen inlet
iii) Air inlet
iv) Safety valve/pressure release valve.
v) Patient outlet
vi) Valve assembly
WORKING : i) Assemble bag

ii) Check bag
iii) Connect to oxygen source
iv) Attach the reservoir
v) Fix appropriate size mask
vi) Apply mask on manikin Ensure adequate seal
vii) Perform PPV-Check for chest rise
INDICATION : i) Apnea or gasping respiration

ii) HR<100/min
iii) Central cyanosis despite free flow oxygen
CONTRA INDICATION:
i) Congenital diaphragmatic hernia
ii) Meconium stained liquor
iii)
i) Wash with soap and water daily
ii) Soak in glutaraldehyde 2% for 6 hrs once a week
iii) Clean mask with spirit between patient use
DOs & DONTs : i) Check bag prior to use

iv) Choose appropriate size mask
v) Use enough pressure to obtain easy chest rise
vi) Do not perform overzealous PPV
vii) Check for adequacy of ventilation
Chest rise, Increase in HR, Improvement in color
Appearance of spontaneous respiratory effort
viii) Check and maintain adequate seal

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TROUBLE SHOOTING
i) Change bag
ii) Check for oxygen source
iii) Remedial actions for no chest rise
MAINTENANCE
i) Clean and disinfect as per protocol
ii) Replace if damaged or leaky

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5. WEIGHING MACHINE
OBJECTIVE : Upon completion of this section the participant should be
1. Know how to calibrate the weighing machine

2. Be able to demonstrate the use of the weighing machine
3. Be able to classify newborns by weights as
NBW/LBW/VLBW & ELBW
PARTS : i) Pan or baby tray

ii) Weight scale dial
iii) Machine proper
WORKING : i) Wipe clean the weighing pan

ii) Check for and adjust zero error
iii) Calibrate using a known weight
iv) Place baby with sheet
v) Note weight (a)
vi) Remove baby
vii) Weigh the sheet above (b)
viii) Subtract b from a (a-b)
ix) Record weight
CLEANING AND DISINFECTION

i) Clean with soap and water
ii) Wipe with spirit swab b/w patient use
DOs & DONTs : i) Always look for and adjust zero error
iii) Always calibrate using a known weight
iv) Weigh baby naked with a just a nappy
v) Remove excessive clothing
vi) Do not stack up linen or other objects on the weighing
pan when not in use
vii) Record weight only when needle is stationary & not
oscillating.
TROUBLESHOOTING:
i) Place on a flat firm surface
ii) Calibrate before each use
iii) Record zero error if it can not be corrected and account
for it
MAINTENANCE :
i) Calibration
ii) Annual maintenance contract

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6. PULSE OXIMETER
OBJECTIVE:-
Upon completion of this section the participant should

• Know the parts of Pulse Oximeter.
• Know how to use a Pulse Oximeter.
• Be able to demonstrate the working of the pulse oximeter
• Know how to interpret the Pulse Oximeter readings.
• Be able to take care of its daily maintenance and minor troubleshooting
• Know how to clean it.
PARTS:-
→ Numeric display (LED).

→ Graphic display (LED).
→ SpO2 alarm limits, high / low setting button.
→ Pulse rate alarm limits, high / low setting button.
→ Display contrast adjusts slide.
→ Power / Stand by button.
→ Carrying handle
→ Sensor Connector.
→ Pulse Beep volume button.
→ Alarm volume button.
→ Alarm silence button.
WORKING:
→ Connect to Main.
→ Use the mode switches in the oximeter real panel to set the language, averaging mode,
patient mode, patient’s pulsatile value display and EMI line frequency.
→ If you change the switch settings while the oximeter is on, the new settings do not take
effect until you power OFF then ON again.
CLEANING AND DISINFECTION:
→ To clean the display panel, use a cotton swab moistened with 70% isopropyl alcohol
and gently wipe the panel.
→ To clean the outer surface of the oximeter, use a soft cloth dampened with a mild soap
and water solution or one of the following solutions :
) 70% Isopropyl OR ethyl alcohol.

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) Quaternary ammonia
) 3 volume % hydrogen peroxide in water
) 100 : 1 bleach solution
) Cidex plus activator.
DO’S & DONT’S:
¾ Do not autoclave, pressure sterilize OR gas sterilize.

¾ Do not soak or immerse the monitor in liquid.
¾ When cleaning the display area do not use abrasive cleaning compounds OR other
materials that could damage the screen.
¾ Do not use petroleum based solutions, acetone solutions OR other harsh solvents to
clean the oximeter.
TROUBLE SHOOTING:-
) Check fuse.
) Check Plug.
) Check Battery
) Check for internal failure.
) Check for disconnected OR failed Speaker.
) Check for sensor failure.
SIDE EFFECTS & DANGERS :-
/ Failure of operation.
/ Explosion hazard in presence of any flammable anesthetis mixture.
/ Electrical shock hazard.
/ Patient conditions such as reddening, blistering, skin discolouration etc. Because
of the sensor placement.
Maintenance
; Cleaning the Oximeter as necessary.

; Recharging the battery as necessary.
; Replacing the fuses in power module as necessary.

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PULSE OXIMETER
Display monitor
Oxygen saturation
in percent
Heart
rate
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Plethysmograph
Patient
sensor
HOW DOES IT WORK

A sensor device consisting of two light sources (red and infrared) and a photo detector is
placed over a pulsating arteriolar bed (e.g. on the finger, toe, ear) opposite each other. Light
moves through the tissue and is absorbed by the pulsatile arteriolar bed of the intervening
tissue bed. The light passing through the tissue bed after absorption is measured by the photo
detector and displayed as the plethysmograph as well as a numeric value in percent. This value
is a ratio of the oxygenated to deoxygenated hemoglobin.
WHAT IT MEASURES
Blood is made up of plasma and cells (red and white blood cells, platelets,etc.). Oxygen is both
dissolved in the plasma and bound to hemoglobin. Hemoglobin is within the red blood cells
and oxygen bound to it absorbs infrared light whereas deoxygenated or reduced hemoglobin
absorbs red light. The pulse oximetry reading reflects the amount of hemoglobin
SATURATED with oxygen at the time of measurement.
WHAT IT DISPLAYS
Most machines display a waveform (plethysmograph), a bar or a light sensor which indicates
that the machine is picking up an adequate pulse. The machine is expected to read accurately
over a 70- 100% saturation range. The basic model of pulse oximeter shows the pulse rate,
SpO2 numeric value and the waveform.

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DRAWBACKS
• Unreliable readings in hypothermia, hypotension, vasoconstriction and motion artifacts.
• Abnormal hemoglobins are not accounted for like CO poisoning and meth-
hemoglobinemia.
• Does not work well in bright ambient light.
PRECAUTIONS
• Don’t apply the probe tightly
• Rotate the site of probe applications as delicate neonatal skin tends to get compressed
and there could be perfusion problem.
• Clean the probe with only clean cotton swab with distilled water (ideally one probe is
for one baby only).

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7. INFUSION PUMP (SYRINGE PUMP)
OBJECTIVE :-
• Upon completion of this section the participant should

1. Know the parts of a Syringe Pump.
2. Be able to demonstrate the working of a syringe pump.
3. Be able to set proper rate for fluid administration
4. Be able to settle minor trouble shooting and take care of the apparatus
5. Know the dangers associated with its use.
PARTS :-
→ Syringe barrel clamp
→ Pusher & Push guard.
→ Handle & Assembly bolt.
→ Main connection, fixing button.
→ Swing lock clamp.
→ ON / OFF.
→ Main warning.
→ Screen.
→ Silence Alarm.
→ Bolus OR Prime.
→ Value Selection.
→ Pre Alarm & Alarm Warning.
→ Stop – Infusion stop.
→ Menu
WORKING :
→ Connect to Main.
→ Press on key to turn the pump on.
→ Install syringe loaded with desired amount of fluid with pressure line attached and
primed.
→ Press OK to confirm syringe.
→ Select the flow rate.
→ Connect the Patient.
→ Start the infusion.
→ Check IV site regularly to avoid inadvertent extravasations.
→ To give a BOLUS, press the bolus key and continue pressing till the desired amount has
been infused.
→ Press STOP to stop the infusion.

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CLEANING & DISINFECTION:-
Use a cloth soaked in DETERGENT – DISINFECTANT, previously diluted with water if
required to destroy micro organisms.
DO’S & DONT’S :

¾ Do not place in autoclave or immerse the device.
¾ Disconnect battery before opening device.
¾ Avoid short circuits and excessive temperatures.
TROUBLE SHOOTING:-
) Check continuous display.
) Check indicator lights.
) Check alarm and safety features.
SIDE EFFECTS & DANGERS :-
/ SHORT CIRCUITS & EXCESSIVE TEMPERATURES.
MAINTENANCE :-
; Preventive maintenance is recommended every 3 years .This includes battery
replacement.
Accurate fluid infusion and drug administration is crucial for the optimum
management of critically sick and small neonates. Continuous and controlled intravenous
delivery of fluids and common medications, such as antibiotics, dopamine, phenobarbitone,
aminophylline and others via infusion pump is the preferred mode of therapy in acute care.
This is especially true for drugs with short half lives, so as to maintain a desirable constant
serum concentration and in situations when constant infusion of glucose is needed. Small
babies or those with compromised renal, cardiac or pulmonary function have limited fluid
tolerance and hence it is essential to use infusion pumps so as to prevent inadvertent volume
overload.

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CLINICAL
SKILLS

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1. TEMPRATURE RECORDING & THERMAL CONTROL
OBJECTIVE : Upon completion of this session each participant
i. Should be able to record axillary temperature in a newborn

ii. Should be able to clinically asses hypothermia, cold stress and normal
temperature.
iii. Should be well versed with ways to achieve thermal control during
domiciliary care, institutional care & transport.
RATIONALE : Temperature recording is a simple bedside tool to assess the baby’s

temperature and ascertain the degree of hypothermia
EQUIPMENT & OTHER REQUIREMENTS:
i) Low reading/Normal thermometer

ii) A manikin /newborn
iii) Cotton Swabs
iv) Cotton sheet
v) A wrist watch
vi) Mother or other caregiver to demonstrate kangaroo care
SKILLS:
i) Drying
ii) Wrapping & covering the baby
iii) Recording temperature
iv) Tactile assessment of temperature ( Cold stress assessment)
v) Kangaroo care
PROCEDURE :
i) Drying Dry baby from head to toe, on the back, front, axillae & groin and discard
wet linen.
ii) Wrapping Wrap the baby using a sheet spread the sheet fold one corner on itself-
place baby’s head on the infolded corner so as to cover the head till the
hairline on forehead. Cover over the right shoulder & tuck on left side.
Fold from the foot end & tuck beneath the chin & finally cover over the
left shoulder and tuck on the right side.
iii) Record temperature
i) Place the baby supine or on the side

ii) Ensure dry arm pit
iii) Abduct arm at shoulder. Place the bulb of the thermo meter in the apex
of the axilla

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iv) Hold arm in adduction at shoulder & flexion at the elbow for three
minutes.
v) Remove thermometer & read temperature
iv) Tactile assessment
i) Wash hands
ii)Rub them to dry
iii)
Rub together & warm them
iv)Touch the baby’s soles & palms the dorsum of your hands
v) Now touch the baby’s chest using the dorsum of your hands
vi)If both are warm-normothermic, if periphery is cold but chest is warm –
cold stress, if both are cold – hypothermic baby.
v) Kangaroo Care
i) Ask mother or caretaker to wear a loose shirt or blouse

ii) Unbutton top 2-3 button & slip baby with only the napkin on, into the
shirt.
iii) Ensure skin to skin contact b/w baby & care taker
iv) Tie a belt or string at the belt level prevent the baby from slipping
down
v) Cover the mother baby duo with a woolen shawl or sheet
vi) Encourage frequent breast feeding.

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2. INFECTION PREVENTION
i) Should be able to demonstrate steps of hand washing

ii) Should be able to clean and disinfect newborn care equipment and
environment.
iii) Should be able to provide routine eyes & cord care and be able to
advise mother regarding maternal & baby hygiene.
RATIONALE: Prevention of infection in newborns is easily achievable by simple

measure like hand-washing and keeping baby’s environment clean.
Prevention is much more rewarding as therapy for neonatal sepsis is
not always successful.
i) Soap
ii) Running water
iii) Hand washing chart
iv) Disposable delivery kit
v) Cord tie
vi) Cord stump
vii) Spirit
viii) Sterile Cotton
ix) Sterile blade
x) Manikin
xi) Disinfectant solution
xii) Newborn care equipments
• Bag & mask
• Laryngoscope
• Thermometer
• Oxygen hood
• Skin probe
• Cots/mattresses
• Sheet
• Suction machine
SKILLS : i) Hand Washing

ii) Equipment disinfection
iii) Eye & cord care

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PROCEDURE :
I. Hand washing (Ref to Annexure III pg 60 )
• wet hands
• apply soap
• Rub hands, first palms & fingers
• Then back of hands
• Followed by rubbing of thumbs
• Finally rub finger tips in the palms & lastly
• The wrists
• Keep elbows dependent & wash in the same order
II. Equipment disinfection

i) Resuscitation bag & mask
Face mask( Disinfect daily and sterilize weekly)
• Clean with detergent daily and after each use
• Immerse in 2% gluteraldehyde
• Rinse with clean water and dry with sterile linen (washed and
sun dried)
• Resuscitation bag ( Disinfect daily and sterilize weekly)
• Dismantle parts
• Clean with Detergent
• Immerse in 2 % glutaraldehyde
• Rinse with clean water and dry with sterilize linen
• Reassemble the parts
ii) Laryngoscope
• Wipe blade with 70% isopropyl alcohol after use.
iii) Thermometer
• Ideal to have separate for each baby

• Wipe with alcohol after use
• Store in bottle containing dry cotton
iv) Oxygen hood

• Clean every day or after use each use with detergent
v) Costs and mattresses

- Clean everyday with 3% phenol or 5% Lysol
- Replace mattresses whenever surface covering is broken
vi) Suction apparatus

• Suction bottle should contain 3% phenol or 5% Lysol
• Suction bottle should be cleaned with detergent and changed
daily

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• Change tube connected to bottle daily. Flush with water and dry
• Soak for disinfection in 2 % gluteraldehyde
• Ideally suction for catheter should be for single use
vii)Feeding utensils
• Cup, spoon and paladai should be boiled for at least for 15 min
before use.
• Feeding tubes should be preferably disposable.
III. Care of Cord & eyes
Cord - Keep cord dry

• Clean cord base and keep dry
• Do not apply anything
Eyes Clean eyes from medial to lateral side separate sterile saline
Soaked cotton swabs for each eye.

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3. BREAST FEEDING/ASSISTED FEEDING:

i) Should be able to advise mother on manual expression of breast milk.
ii) Should be able to provide gavage feeds to the baby
iii) Should be able to provide katori spoon feeding to the baby
iv) Should be able to advise mother regarding therapy for retracted nipples.
v) Should be able to allay all fears & anxiety of a lactating mother regarding
adequacy & superiority of breast milk.
RATIONALE: Advantages of breast milk are many fold and this mode of feeding id the
ideal for all neonates.
i) Lactating mother
ii) Katori/cup
iii) Spoon/paladay
iv) 6 fr & 8 fr feeding tubes
v) 10 ml & 5 ml syringes
vi) Adhesive tape
vii) Manikin
viii) Blade
SKILLS:
i) Manual Expression of breast milk
ii) Gavage feeding
iii) Katori spoon feeding
iv) Treatment for retracted nipples
PROCEDURE:
i) Manual expression of Breast Milk

• Ask mother to sit comfortably, lean forward and support the
breast over a bowl using both hands
• Position the thumb and the forefinger at the margin of areola on
both sides & press the breast tissue into the ribcage
• Maintaining the backward pressure start bringing the thumb &
the forefinger of each hand towards the nipple
• Repeat the same several times till not further milk can be
expressed out.
ii) Gavage feeding

• Take 6 fr or 8 fr catheter depending on the gestation and weight
• Measure length from angle of mouth to tragus to xiphisternum

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• Insert the tube from mouth till the desired length has been
introduced
• Check position using a syringe & a stethoscope to auscultate the
gush of air
• Tape the tube & close outer end after removing the syringe
• To instill feed-Take a 10 ml syringe barrel without the plunger
and insert nozzle into the open end of the feeding tube.
• Check abdominal girth at next feeding session & proceed to feed
if no increase in girth. If the girth increases by 2 cm., do a pre-
feed gastric aspirate and analyse the amount and content to
decide about continuing/discontinuing feeds.
iii) Katori spoon feeding

i) Take baby in the lap hold the baby semi upright with head well
supported.
ii) Stimulate the angle of the mouth and rest the spoon with 1-2 ml milk
at the angle of the mouth.
iii) Pour milk slowly into open mouth & watch for swallowing. Gently
stroke behind the ear or on the sole.
iv) Continue feeding in this manner till the desired amount has been fed.
v) Burp the baby
vi) Place in right lateral position with head supported a little higher than
the rest of the body.
iv) Treatment of Retracted nipples
Antenatal
i) Teach mother to roll out nipple between thumb and forefinger several
times a day.
Postnatal
i) Take a 10 ml syringe, cut the nozzle end transversely using a new blade
Take care that the syringe barrel’s cut margin is not ragged.
ii) Insert plunger into the barrel from the cut nozzle end
iii) Place the barrel’s open end on the areola including the nipple in the
barrel & pull back the plunger as far as possible.
iv) Repeat this several times & follow putting the baby to the breast to
encourage suckling.
4. ASSESSING CFT & VENOUS ACCESS:
i) Should be able to assess perfusion by using CFT method

ii) Should be able to catheterize the umbilical vein

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iii) Should be able to demonstrate peripheral venous access on an
improvised model.
RATIONALE i) CFT-CFT is simple sign to assess perfusion (BP of the

baby) of a baby. A CFT of >3 seconds denotes poor peripheral
perfusion. This can also be prolonged in hypothermia due to
peripheral vaso constriction. If the baby is hypothermic, CFT
should be reassessed after temperature improvement.
ii) Umbilical. Venous access – It is a quick IV access for infusing
volume expanders & drugs during resuscitation.
iii) IV access: To provide parental fluids & medications
i) Stop watch/wrist watch

ii) Umbilical cord 1 ft
iii) Blade
iv) Forceps
v) Normal saline
vi) 2ml/5ml syringe
vii) 5fr. Feeding tube or umbilical venous cannula.
viii) Straw, Splint , Tongue depressor
ix) Polythene sheet
x) Spirit
xi) Iodine
xii) Gloves
xiii) Soap & Water
xiv) Sticking tape
xv) Splint
SKILLS :
i) CFT assessment
ii) Umbilical venous cannulation on a cord stump.
iii) Peripheral IV access on an improvised model.
PROCEDURE :
i) CFT assessment
• Wash and dry hands
• Press the forehead or sternum using index finger /thumb for 5
sec, release and look at the blanched area for return of color.
Note the time taken for return of color. Note the time taken for
return of the color. Normal CFT is upto 3 sec
• CFT>3 secs indicates poor perfusion, however in presence of
hypothermia interpretation may be fallacious.

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ii) Umbilical Venous Cannulation
This activity shall be carried out on the umbilical cord provided to
the participants. Each participant shall perform this activity and
acquire the skill.
• Wash hands & dry.

• Wear gloves
• Connect syringe to the catheter, flush the catheter with saline &
keep ready
• Take a small piece ( about 10 cm long ) of fresh umbilical cord
in a kidney tray
• Hold or mount cord
• Cut the umbilical cord transversely clean with a sterile blade.
• Identify 2 arteries & 1 vein – the umbilical vein is a thin walled
patulous large opening in contrast to the arteries which are thick
walled and much smaller in caliber. ( In the normal position the
umbilical vein is at 11-12 ‘O’ lock position)
• Insert the saline filled catheter gently into the vein( Black flow of
blood can be appreciated in a live baby by pulling at the plunger
)
• In actual situation the length of the catheter to be inserted is
usually 1-2 cm below the skin till there is a free flow of blood.
• Inject the drug or volume
• Pinch the catheter & remove.
• Press the cord to prevent bleeding.
iii) IV Access:
The training for gaining an intravenous access shall be done on a
model which is provided. Each participant shall carry out this skill
on this given model.
- Select the vein (dorsum of hand/foot )

- Wash hands and dry
- Wear gloves
- Prepare skin- betadine, spirit, let dry between applications
- Hold the limb proximally to make the vein prominent
- Pierce skin distal to the intended ‘site of puncture
- Insert needle into the vein (feeling of give way )
- Ensure free flow; thread the needle further up into the teeth
- Secure the scalp vein needle by adhesive tape
- Secure splint
- Inject fluid/medications
- Check distal limb for adequacy of circulation

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CASE
STUDIES

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CHECKLIST FOR NEWBORN CARE
Cases discussed will be managed on the principle of TABCFMFMCF as detailed here
T.A.B.C. F.M. F.M. C.F.

Hypothermia - Provide heat
Cold Stress - Skin to skin contact, Warmer,
1. Temperature - Assess
Normal - Cover adequately
Hyperthermia - Uncover
Maintained
2. Airway
Compromised - Open and maintain airway
• Position
• Suction
3. Breathing None or gasping - PPV with 100% oxygen

Normal - No intervention
Respiratory distress - Provide oxygen
4. Circulation-CFT
>3 seconds - * Normal saline bolus
* Check temperature
* Check heart rate
5. Fluids - If CFT >3 sec - IV RL/NS 10ml/kg

If stressed baby IV 10% Dextrose 2ml/kg
If circulation not compromised-Normal requirement
( Refer to annex no. 1 Pg. 34 )
6. Medications Pneumonia- IV antibiotics -Ampicillin, Gentamycin

Apnea - IV Aminophyllin
Meningitis- IV antibiotics
Bleeding - Inj Vitamin K 1mg IM
Convulsions – Inj Phenobarbitone, Inj Phenytoin
( Refer to annex. no. 3 Pg. 36 )
7. Feeds - Weight<1200 gm-Gavage feeds

Weight 1200-1800 gms- Katori Spoon feeding
Weight > 1800 gms- Breast feeding
Amount – ( Refer to annex no. 2 Pg. 35 )

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8. Monitoring
i) Temperature - Touch method
- Temperature record 2 hrly
ii) Respiration - Apneic
- Gasping
- Tachypneic – RR
- Retractions +/-
- Grunts +/-
iii) Color - Pink
- Pink with peripheral cyanosis
- Pale
- Cyanosis
iv) Heart rate - Normal
- Tachycardia
- Bradycardia
v) CFT - Normal
- >3 secs
vi) SpO2 - 90-93
- <90
- >93
vi) *Danger signs- Bleeding - Inj Vit K 1 mg IM stat
- Apnea - Tactile stimulation & PPV
- Grunt - Oxygen
- Severe retractions - Oxygen
- abdominal distension - NPO
* Refer immediately without delay
9. Communication
a) For referral i) Inform parents/relatives about baby’s referral
ii) Inform need for referral
iii) Communicate place of referral
iv) Communicate with the higher centre if possible
v) Send a written note about details of birth & care
vi) Send a health worker with the family if possible
vii) Mother to accompany as far as possible
b) For hospitalized neonate in SCNU

i) Inform neonate’s status to family at least twice
daily
ii) Report on temperature, colour, perfusion and
general activity
iii) Report on progress in terms of resolution of RD,
requirement of O2, IVF, IV Antibiotics, Feeding.

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c) For home care
i) Exclusive breast feeding
ii) Maintain temperature- teach tactile assessment
iii) Prevent infection- Cord & eye care
iv) Danger signs- Early care seeking
v) Maternal nutrition, rest supplements & spacing
10. Follow up i) Follow up 2 weekly initially for 2-3 visit

ii) Check weight, mode of feeding, enquire problems
during each visit
iii) Follow up every month thereafter
iv) Immunization advice
v) Complimentary feeding advise

131
Case Study – 1
A 5 days old term baby with a birth weight of 3200 gm is brought to the casualty in the
hospital with yellow palms and soles. The child has a temperature of 360C. The respiratory rate
is 52/min. The CFT is > 3 secs.
How would you triage this neonate?
At the Hospital:
S. Bil – 24 mg/dl
MBG – B Negative
BBG - B Negative
How would you manage this child?

132
Case Study – 2
A 7 day old newborn is brought in with complaints of fast breathing and inability to feed at the
breast. The weight today is 2250 gm as against 2450 at birth. The temperature is 360C
respiratory rate is 80/min with moderate retractions and grunt but no cyanosis.
What is your diagnosis?
How will you manage the baby?

133
Case Study – 3
A, 35 weeks gestation baby weighing 2550 gms at birth was feeding well at the breast and on
day 5 developed discharge from the umbilicus followed the refusal of feeds and lethargy the
next day. He vomited twice, had a feeble cry and on way to the hospital had a convulsion.
At the hospital-
Weight - 2400 gm
Temperature - 370C
Clinical exam - Drowsy
RR-56/mim, no retractions, no grunt
CFT-5 secs.
Abdominal distention and poor bowel sound with a normal fontanel.
What is your diagnosis?

How will you manage this baby?

134
ANNEXURES

135
Annexure 1. Guidelines for fluid requirement in neonates
Guidelines for fluid requirements

* First day 60-80ml/kg/day
* Daily increment 15ml/kg till 150 ml/Kg
Fluid requirement (ml/kg)
Birth weight
Day of life
> 1500 g < 1500 g
1 60 80
2 75 95
3 90 110
4 105 125
5 120 140
6 135 150
7 onwards 150 150

136
Annexure 2. Guide lines for feeding of LBW neonates
Feeding schedule
* Begin at 60-80 ml/kg/day

increase by 15 ml/kg every day
maximum of 180-200 ml/kg/day
* First feed at 2hrs of age then every 2 hrly
Guidelines for the methods of providing fluids and feeding

_______________________________________________
Age Categories of neonates
_______________________________________________
Birth weight ( gm ) < 1200 1200-1800 >1800

Gestation ( wks ) <30 30-34 >34
Condition______________________________________________________________
Initial Intravenous fluids Gavage Breast feeding

Try gavage feeds, If unsatisfactory,
If not sick katori-spoon
feeds
After 1-3 days Gavage Katori-spoon Breastfeed
Later (1-3 week) Katori-spoon Breastfeed Breastfeed
After some more Breastfeed Breastfeed Breastfeed

time

137
Annexure 3.
DRUG CHART
DRUG DOSE ROUTE
Ampicillin < 7 days 50 mg/kgdose, q 12 hr IV

> 7 days 50 mg/kg/dose, q 8 hr
Gentamycin Sepsis/ pneumonia IV

2.5 mg/kg/dose, q 12 hr
or 5 mg/kg/dose, q 24 hr IV
Meningitis:
< 7 days 2.5mg/kg/dose , q 12 hr
> 7 days 2.5 mg/kg/dose, q 8 hr
Amikacin < 7 Days 7.5 ml/kg/dose, q 12 hr IV
Cefotaxime < 7 days 50 mg/kg/dose, q 12 hr IV

> 7 days 50 mg/kg/dose, q 8 hr
Chaloramphenicol 12 mg/kg/dose q 12 hr IV
Aminophylline 5 mg/kg loading, IV

then 2 mg/kg/dose q 8-12 hr
Vitamin K 1 mg IM
Phenobarbitone 20 mg/kg loading over 10-15 min Loading IV

then 3-4 mg/kg q 24 hr Then IV, IM
or Oral
Phenytoin 15-20 mg/kg loading over 10-15 min IV
then 5 mg/kg q 24hr
Dopamine/Dobutamine 5-20 micro g/kg/min IV

continuous

138
Annexure 4. NEWBORN HISTORY AND EXAMINATION
Baby of _____________________________ (Mother’ name ) Age ______ Sex___
Date of birth_______________ Time______
Maternal history
Age _____ Para ________ Gravida ________
Previous Obstetric History
Present pregnancy LMP ___/___/_____ Expected date of delivery ___/____/______
Present gestation in weeks ________
Antenatal History
Antenatal check ups : Yes/No If yes where _______________ Number _____________
BP ___/____ mmHg Urine examination: Albumin + / - tetanus toxoid: ____ doses
Blood group ___________ Any other investigation _____________________________
Family history of mother: _____________________________________________________
Labor Presentation: Vertex / Breech / Transverse Spontaneous/induced
APH Placenta previa PROM Duration: _______ (hours)
Amniotic fluid : Clear/meconium stained
Drugs in labour
Delivery mode : Normal Vaginal/Forceps/Vacuum/Caesaran
Indication, if not normal vaginal ______________________________________________
Anesthesia: General / Spinal

139
Baby
Resuscitation required None/ Initial steps / Free Flow oxygen / PPV / CC /
Medications
Apgar scores 1 min. _______ 5 min. ________ 10 min. __________
Presenting Complaints:
1. ___________________________
2. ___________________________
3. ___________________________
General Examination
I. General condition : Alertness/Sensorium – Normal / Drowsy / Comatosed

Activity & Cry: Good / weak / Poor
II. Vital signs :
1 Temperature ______oC (axillary) Peripheries warm/cool
2 Respiration rate _____ (per minute) Retraction Grunt Apnea
3 Heart rate _____ (per minute) All pulses palpable Yes/ No.
4. BP/Perfusion : Capillary refill time (CFT) ___ seconds
III. Anthropometry
Weight _____ (gms) Head circumference ______ (cms) Length _________(cms)
Gestation: Term/Preterm/Post term
IV. Position on intrauterine growth chart: AGA/SGA/LGA
V. Congenital malformations (Head to toe examination) :

________________________________________________________________________
________________________________________________________________________
VI. Other features Cyanosis Icterus Seizures Fontanel: Level / Bulging

140
Systemic Examination
Diagnosis
Single or multiple/Gestation in wk/Wt in gms/ AGAor SGA/ Sex/ add

problems
Management Plan
1. ____________________________________
2. ____________________________________
3. ____________________________________
4. ____________________________________
5. ____________________________________
6. ____________________________________

141
Annexure 5. CHECKLIST FOR NEWBORN CARE
Cases discussed will be managed on the principle of TABCFMFMCF as detailed here
T.A.B.C. F.M. F.M. C.F.

Hypothermia - Provide heat
Cold Stress - Skin to skin contact, Warmer,
1. Temperature - Assess
Normal - Cover adequately
Hyperthermia - Uncover
Maintained
2. Airway
Compromised - Open and maintain airway
• Position
• Suction
3. Breathing None or gasping - PPV with 100% oxygen

Respiratory distress - Provide oxygen
4. Circulation-CFT
>3 seconds - * Normal saline bolus
* Check temperature
* Check heart rate
5. Fluids - If CFT >3 sec - IV RL/NS 10ml/kg

If stressed baby IV 10% Dextrose 2ml/kg
If circulation not compromised-Normal requirement
( Refer to annex no. 1 Pg. 34 )
6. Medications Pneumonia- IV antibiotics -Ampicillin, Gentamycin

Apnea - IV Aminophyllin
Meningitis- IV antibiotics
Bleeding - Inj Vitamin K 1mg IM
Convulsions – Inj Phenobarbitone, Inj Phenytoin
( Refer to annex. no. 3 Pg. 36 )
7. Feeds - Weight<1200 gm-Gavage feeds

Weight 1200-1800 gms- Katori Spoon feeding
Weight > 1800 gms- Breast feeding
Amount – ( Refer to annex no. 2 Pg. 35 )

142
8. Monitoring
i) Temperature - Touch method
- Temperature record 2 hrly
ii) Respiration - Apneic
- Gasping
- Tachypneic – RR
- Retractions +/-
- Grunts +/-
iii) Color - Pink
- Pink with peripheral cyanosis
- Pale
- Cyanosis
iv) Heart rate - Normal
- Tachycardia
- Bradycardia
v) CFT - Normal
- >3 secs
vi) SpO2 - 90-93
- <90
- >93
vi) *Danger signs- Bleeding - Inj Vit K 1 mg IM stat
- Apnea - Tactile stimulation & PPV
- Grunt - Oxygen
- Severe retractions - Oxygen
- abdominal distension - NPO
* Refer immediately without delay
9. Communication
a) For referral i) Inform parents/relatives about baby’s referral
ii) Inform need for referral
iii) Communicate place of referral
iv) Communicate with the higher centre if possible
v) Send a written note about details of birth & care
vi) Send a health worker with the family if possible
vii) Mother to accompany as far as possible
b) For hospitalized neonate in SCNU

i) Inform neonate’s status to family at least twice
daily
ii) Report on temperature, colour, perfusion and
general activity
iii) Report on progress in terms of resolution of RD,
requirement of O2, IVF, IV Antibiotics, Feeding.

143
c) For home care
i) Exclusive breast feeding
ii) Maintain temperature- teach tactile assessment
iii) Prevent infection- Cord & eye care
iv) Danger signs- Early care seeking
v) Maternal nutrition, rest supplements & spacing
10. Follow up i) Follow up 2 weekly initially for 2-3 visit

ii) Check weight, mode of feeding, enquire problems
during each visit
iii) Follow up every month thereafter
iv) Immunization advice
v) Complimentary feeding advise

144
Annexure 6.
Schedule of immunization
________________________________________________________________________
Age Vaccine
0-7 days BCG, OPV, HBV

6 weeks OPV, DPT, HBV
9 months Measles
15 months MMR
18 months OPV, DPT,
School entry (4-5 years) OPV, DPT
10 years dT (every 5 years)
________________________________________________________________________

145
Annexure 7.
CHART FOR PHOTOTHERAPY as per AAP Guidelines 2004

146
Annexure 8.
CHART FOR EXCHANGE TRANSFUSION as per AAP

Guidelines 2004

147
Annexure 9.
KRAMMER’s Rule for assessment of cutaneous levels of Jaundice
12
15
18-20

148
Annexure 10.
Flow diagram for management of neonate with seizures

Neonate with seizures:
Identify and characterize the seizure
Secure airway and optimize breathing, circulation and temperature
Start O2 if seizures are continues
Secure IV access and take samples for baseline investigations including sugar, hematocrit,
sepsis screen and calcium, magnesium, electrolytes where feasible
If blood sugar < 40 mg/dl, give 2 – 4 ml/kg 10% dextrose
If seizures continue
IV phenobartone 20 mg/kg over 20 min
If no control
Rpt phenobarbitone 10 mg/kg till a total of 40 mg/kg
If seizures continue
Give phenytoin 20 mg/kg over 20 min
After control of seizures initiate maintenance doses

149
Annexure 11.
Volume of packed RBC transfusion calculation
Weight in Kg x Blood Volume per Kg x ( Desired PCV – Observed PCV)

Hematocrit of blood to be given
Average blood volume of newborn is 80 ml/kg. The hematocrit of Packed RBCs is 70 and
whole blood is around 50
Example: In infant weighing 1.5 kg is on ventilator, needs 40% oxygen and has a haematocrit
of 30. The volume of packed cells required to be transfused will be
1.5 x 80 x (40 – 30) = 17 ml

70
The maximum transfusion should be 10-15 ml/kg. Volumes larger than 15 ml/kg are to be
divided. The transfusion should be given over as period of 3-4 hrs.
Exchange transfusion with packed RBC is preferred when there is severe anemia and large
volume is required to correct anemia. This would help to prevent CHF due to circulatory
overload.
Stockberg Formula to calculate the volume of Packed cell needed for correction of anemia by
Exchange Transfusion.
Weight in Kg x Blood volume (ml/kg) x (Desired PCV – Observed PCV)

Hematocrit of the blood to be given – HCTW
HCTW = ( initial PCV + Desired PCV) /2

150
Annexure 12.
How to give Dopamine

1 ml of commercially available contains 40 mg of dopamine. In a baby weighing 2.5 kg if we
want to start dopamine at a rate of 10ug/kg/min:
= 10 x 2.5 = 25 ug/min = 25 x 60 = 1500 ug / hour = 1500 x 24 = 36000 ug / day
= 36 mg of dopamine in 24 hours
It means if we add 0.9 ml of dopamine in 24 ml of fluid and give @ rate of 1 ml/ hr with
syringe pump or 1 microdrops per min (which is virtually impossible) with the micro drip set,
we will give dopamine @ 10 ug/kg/min
Increment
If we want to increase dopamine to15 ug/kg/min then give the same fluid @ 1.5 ml/ hr
The above method is to give a separate infusion of Dopamine, however it could also be
added to 24 hours fluid as explained below:
e.g. 2.5 kg neonate in shock with a fluid requirement of 100 ml/kg/day, has received 2 fluid
boluses of 10 ml/kg of normal saline, without any improvement. Plan is
Total Fluid needed for this baby in 24 hours = 100 x 2.5 = 250 ml /day
Fluid to be given every 8 hours = 85 ml. Let us learn how much dopamine to be added in 8
hours fluid i.e. 85 ml to be given at a rate of 10 ug/kg/min
Amount of dopamine required in one minute = 10 x 2.5 = 25 ug
Amount of dopamine required in one hour = 25 x 60 = 1500 ug
Amount of dopamine required in 8 hours = 1500 x 8 = 12000 ug = 12.0 mg
1 ml of available dopamine preparation = 40 mg of dopamine
To make 12 mg of dopamine we need 0.3 ml, add this volume to 85 ml of fluid and give over 8
hours at a rate of 10 ml/hour or at a rate of 10 micro drops /min with a burette set, which will
deliver dopamine at a rate of 10 ug/kg/min

151
Annexure 13.
Partial exchange transfusion

• Peripheral vein or peripheral (radial) artery for bloodletting and peripheral
vein for pushing in.
• Volume to be = Blood volume X (observed – desired hematocrit)
Exchange Observed hematocrit
Desired hematocrit = 55%

Blood volume is estimated to be 80 – 90 ml/kg in term babies and 90 – 100
ml/kg in preterm babies. As a rough guide, the total volume of blood
exchanged is 15-20 ml/kg.
Example: An full term IUGR baby with a weight of 1.5 kg with an observed
hematocrit of 75. To do a partial exchange transfusion the volume needed is:
Blood Volume = 80 x 1.5 = 120 ml
Observed Hematocrit = 75
Desired Hematocrit = 55
Volume to be exchanged = 120 x (75 – 55) = 32 ml

75

152
14. Sample Referral Note
Date __________ Time _________
Address _____________________________________________________________
______________________________________________________________
Name _____________ Mother’s Name____________ Father’s Name __________
DOB ______________ TOB ___________ Sex __ Mother’s Blood Gp:
Birth Details
Mode of Delivery _____________ Place of Delivery ________________________
Time of 1st Cry ____________ Apgar 1 min ___ 5 min ___ 10 min ___
Resuscitation details Initial steps / Free flow oxygen / Bag & Mask Ventilation / Chest
compressions/ Medications
Duration of: O2 ______, Bag & Mask Vent. _______, Chest compression ________
Birth weight _______ grams
Clinical course
Feeding well Yes / No, Breast feeds Yes / No, Spoon Feeds Yes / No
Type of feeds EBM / Formula / Any other milk Diluted milk Yes / No
Passage of Urine Yes / No Stool Yes / No
Reason for transfer LBW / Respiratory distress/ Not feeding well/ Convulsions/ Jaundice/
Malformation/ Any other
Examination Findings
Jaundice Yes / No Any congenital malformations _________________________
Soles Warm/Cold, Trunk Warm/Cold Temperature ______ oC
Heart Rate ____ / min Resp Rate ____ / min Chest Retractions Yes / No
Central Cyanosis Yes / No CFT < 3 sec / > 3 sec

153
Receiving oxygen Yes / No With Nasal canula / Face mask / Oxyhood
SaO2 ____% Dextrostix ______ mg%
Time of Last Feed ________am/pm
Investigations with date

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Treatment Given
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Place to which being referred ____________________________________________________
Mode of transport ____________________ Accompanying person ______________________
Name and Phone number of person at Referral Hospital _______________________________

____________________________________________________________________________
Signatures, Name, Date and Time

154
ANNEXURE 15. IU Growth Chart
L
F
Term LFD D
A
Preterm LFD F
Term AFD D
Preterm AFD
S
Term SFD F
D
Preterm SFD

155
ANNEXURE 16.
Expanded New Ballard Score for Gestation assessment

156

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EQUIPMENT

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion of this section the participant should

DOS & DONTS : i) Check temperature ½ hourly/2 hourly

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion this section the participant should

NATIONAL NEONATOLOGY FORUM

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion of this section the participant should

1. Know the parts of a suction machine

DOs & DONTs : i) Suction gently

SIDE EFFECTS & DANGERS

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion of this section the participant should

1. know the parts of a bag & types of masks

WORKING : i) Assemble bag

INDICATION : i) Apnea or gasping respiration

DOs & DONTs : i) Check bag prior to use

NATIONAL NEONATOLOGY FORUM

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion of this section the participant should be

1. Know how to calibrate the weighing machine

PARTS : i) Pan or baby tray

WORKING : i) Wipe clean the weighing pan

CLEANING AND DISINFECTION

NATIONAL NEONATOLOGY FORUM

Upon completion of this section the participant should

→ Numeric display (LED).

CLEANING AND DISINFECTION:

NATIONAL NEONATOLOGY FORUM

DO’S & DONT’S:

¾ Do not autoclave, pressure sterilize OR gas sterilize.

; Cleaning the Oximeter as necessary.

NATIONAL NEONATOLOGY FORUM

HOW DOES IT WORK

NATIONAL NEONATOLOGY FORUM

NATIONAL NEONATOLOGY FORUM

• Upon completion of this section the participant should

NATIONAL NEONATOLOGY FORUM

DO’S & DONT’S :

NATIONAL NEONATOLOGY FORUM

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion of this session each participant

i. Should be able to record axillary temperature in a newborn

RATIONALE : Temperature recording is a simple bedside tool to assess the baby’s

EQUIPMENT & OTHER REQUIREMENTS:

i) Low reading/Normal thermometer

iii) Record temperature

i) Place the baby supine or on the side

NATIONAL NEONATOLOGY FORUM

iv) Tactile assessment

i) Ask mother or caretaker to wear a loose shirt or blouse

NATIONAL NEONATOLOGY FORUM

OBJECTIVE : Upon completion of this session each participant

i) Should be able to demonstrate steps of hand washing

RATIONALE: Prevention of infection in newborns is easily achievable by simple

EQUIPMENT & OTHER REQUIREMENTS:

SKILLS : i) Hand Washing

NATIONAL NEONATOLOGY FORUM

II. Equipment disinfection

• Ideal to have separate for each baby

iv) Oxygen hood

v) Costs and mattresses

Baby of _________________________ (Mother’ name ) Age Sex_

Date of birth_________ Time

Age _ Para Gravida ____

Present pregnancy LMP _/_/___ Expected date of delivery _//__

Antenatal check ups : Yes/No If yes where ___ Number _

BP _/ mmHg Urine examination: Albumin + / - tetanus toxoid: __ doses