EXPLAIN

Firstly, you need to read and understand the summarized notes on IMMEDIATE NEWBORN
CARE. This section of this unit will highlight the following topics.
a. 4 core steps in Essential Newborn Care

b. Apgar Scoring and Interpretation

c. Vaccines and Medications (BCG, Hepatitis B, Vitamin K, Crede’s prophylaxis)

A. ESSENTIAL NEWBORN CARE (4 CORE STEPS)

The ENC Protocol was developed the Newborn Care Technical Working Group (TWG) that
conducted a systematic search and critical appraisal of foreign and local medical and
allied health literature on practices in the immediate newborn period. An evidence-based
draft was then developed and reviewed by the Department of Health (DOH), United Nations
Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), the Philippine Obstetrical
and Gynecological Society (POGS), the Philippine Society of Newborn Medicine (PSNbM, a
subspecialty society of the Philippine Pediatric Society, PPS), other health professional
organizations/associations, Save the Children, the academe and other stakeholders

Time- Bound Interventions and Purpose

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 TIME BAND: FIRST 30 SECONDS
1. Call out the time of delivery/ birth
2. Thoroughly dry baby for at least 30 seconds
✓ Wiping the baby dry will prevent heat loss by evaporation
✓ Changing the wet towel to a dry towel and performing skin to skin
contact will prevent heat loss by conduction
✓ Exposure of a newborn to a radiant warmer will retain heat by
radiation
✓ Bringing a baby away near air currents, air condition or electric fan
will prevent heat loss by convection
3. Start from the face and head, going down to the trunk and extremities;
Omit the palms in wiping
4. Perform a quick check for breathing
NOTE:
DO NOT ventilate unless the baby is floppy/limp and is not breathing
DO NOT suction uncles the mouth or nose is/ are blocked with secretion or
other materials
TIME BAND: AFTER 30 SECONDS OF THOROUGH DRYING, IF BABY IS NOT
BREATHING OR IS GASPING
1. Re-position, suction, and ventilate
2. Clamp and cut the cord immediately
3. Call for help
4. Transfer to a warm and firm surface
5. Inform the mother that the baby is having difficulty in breathing and that
you will help the baby breath
6. Start resuscitation protocol
NOTE:
If the baby is Non-vigorous (limp/ floppy and not breathing) and
meconium stained
a) Health worker is not skilled in advanced resuscitation
- Clear the mouth
- Start bag/ mask ventilation
- Refer and transport

b) Health worker is skilled in advance resuscitation

- Intubate the baby and provide positive-pressure ventilation
- Refer and transport as necessary
When appropriate and when personnel skilled in advanced
resuscitation (intubation, cardiac massage) are available, refer to
appropriate guidelines
TIME BAND: AFTER 30 SECONDS OF THOROUGH DRYING, IF BABY IS
BREATHING OR CRYING
1. Remove the wet cloth.
2. Place baby in skin-to-skin contact on the mother’s abdomen or chest.
If the baby is crying and breathing normally, avoid any manipulation, such
as routine suctioning, that may cause trauma or introduce any infection

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 3. Place the baby in prone position, then turn the head of the newborn to
one side
4. Cover baby with the dry cloth
5. Cover the baby’s head with a bonnet.
6. Place identification band on the ankle of the newborn
NOTE: The following traditional practices are no longer continued.
DO NOT separate the baby from the mother, as long as the baby is not
exhibiting severe chest indrawing, gasping or apnea, and the mother does
not need any immediate or urgent medical stabilization
DO NOT put the baby on a cold or wet surface
DO NOT wipe the vernix caseosa if present
DO NOT bath the baby earlier than 6 hours of life
DO NOT do foot printing

Palpate the mother’s abdomen to exclude a second baby. If no 2 nd baby,

inject Oxytocin 10 IU IM into the mother’s arm or thigh. If there is a 2 nd
baby, get help. Deliver the 2nd newborn. Manage as in multi-fetal
pregnancy.
TIME BAND: 1-3 MINUTES (DO NON-IMMEDIATE AND PROPERLY/
APPROPRIATELY TIMED CORD CLAMPING)
1. Dispose wet cloth properly.
2. Remove the first set of gloves immediately prior to touching or handling
the cord
3. Palpate umbilical cord to check for pulsations.
4. After pulsations stopped, clamped cord using the plastic clamp or cord tie
2 cm from the base.

5. Place the instrument clamp 5 cm from the base.

6. Cut near plastic clamp (not midway).
7. Check baby’s color and breathing; Check for oozing blood
NOTE:
DO NOT milk the cord towards the baby
DO controlled cord traction with counter traction and gentle uterine
massage

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 TIME BAND: 15-90 MINUTES
1. Leave the newborn on mother’s chest in skin-to-skin contact

2. Observe the newborn. Only when the newborn shows feeding cues (eg.
opening of mouth, tonguing, licking, rooting), make verbal suggestions to
the mother to encourage her newborn to move towards the breast, or
nudging
Counsel on positioning and attachment:
- Make sure that the newborn’s neck is not flexed or twisted
- Make sure the newborn is facing the breast, with the newborn’s nose
opposite her nipple and chin touching the breast.
- Hold the newborn close to her body
- Support the whole newborn’s body not only the neck and shoulder
3. Wait for FULL BREASTFEED to be completed.
4. Administer eye ointment (erythromycin or tetracycline or 2.5% povidone
iodine drops)
DO NOT wash away the eye antimicrobial
TIME BAND: 90 MINUTES – 6 HOURS
1. Do thorough physical examination; Check for birth injuries, malformation or
defects

Look for possible birth injuries:

✓ Bump on one or both side of the head, bruises or swelling of the
buttocks, abnormal positions of the legs. (after breech presentation)
If present:
- Explain to parents that this does not hurt the newborn and will most likely
disappear in a week or two and does not need special treatment
- Gently handle the limb that is not moving
- Do not force legs into a different position

✓ asymmetrical arm movement or arm does not move. (Erb’s palsy)

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 - this can be caused by the trauma to the cervical nerves

Look for malformations:

✓ Cleft lip or palate

✓ Club foot (talipes disorders)

- Odd looking, unusual appearance

- Open tissue on head, back or abdomen

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 2. Administer Vit. K over right vastus lateralis
3. Administer hepatitis B vaccine over Left vastus lateralis
4. Administer BCG injections over right upper arm
5. Advise OPTIONAL / DELAYED bathing of baby (and was able to explain the
rationale).
6. Record and Document

B. ASSESSMENT OF NEWBORN WELL-BEING: (APGAR SCORING)

Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score
determines how well the baby tolerated the birthing process. The 5-minute score tells the
health care provider how well the baby is doing outside the mother's womb.
In rare cases, the test will be done 10 minutes after birth.
Virginia Apgar, MD (1909-1974) introduced the Apgar score in 1952.

SIGN 2 1 0
ACTIVITY SOME flexion of
WELL flexed Absent, Flaccid
(muscle tone) extremities
PULSE
>100bpm Slow (<100bpm) Absent
(cardiac rate)
Sneezes, coughs,
GRIMACE
pulls away, Grimace NO response
(reflex irritability)
withdrawal of foot
Body normal
APPEARANCE pigment, except Blue (cyanotic),
Normal skin color
(skin color) extremities pale all over
(acrocyanosis)
Slow, irregular, WEAK
RESPIRATIONS Good, STRONG CRY Absent
CRY
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 FIGURE 1. Apgar Scoring Tool

SCORING:

SCORE: SCORE: SCORE:

7 – 10 4–6 0–3
STATUS:
STATUS: moderately STATUS:
healthy; good depressed/ fair
severely depressed
condition condition but
guarded; close
monitoring needed;
Non separation with more diagnostic test
to identify problem oxygenation and
mother and resuscitation
continue SSC, BF
stimulation and
oxygenation

FREQUENCY:

After APGAR scoring, it has to be followed by physical examination.

Acrocyanosis – reason of imperfect score, bluish color of extremities and pinkish body
which is a natural occurrence as the peripheral circulation is still adjusting, However
observe for its persistence as it may indicate presence of cardiac anomalies.

***(APPEARANCE) is the LEAST important score among the others as this is caused by
acrocyanosis.

The Apgar score is repeated every additional 5 minutes, until a minimum score of 7 is
reached.

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 VACCINES and MEDICATIONS (BCG, Hepa B, Vitamin K, Crede’s prophylaxis)

MINIMUM NUMBER
VACCINE AGE at 1st OF DOSE ROUTE SITE REASON
DOSE DOSES
BCG given at
earliest possible
age protects the
Right
(BCG) Bacillus Birth or any possibility of TB
0.05 deltoid
Calmette- time after 1 dose ID meningitis and
mL region of
Guérin birth other TB
the arm
infections in
which infants are
prone

4 doses
An early start of
(BIRTH Hepatitis B
DOSE or vaccine reduces
B0 PLUS the chance of
Hep B1, Upper being infected
B2, B3) outer and becoming a
portion carrier.
Hepatitis B (B1 to be 0.5
At birth IM of the Prevents liver
Vaccine given at mL
thigh, cirrhosis and liver
6 weeks, Vastus cancer which are
then B2 Lateralis more likely to
at 10 develop if
weeks infected with
and B3 Hepatitis B early
at 14 in life.
weeks)

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 DRUGS FUNCTION DOSAGE and ROUTE

VITAMIN K Prevent and treat Prophylaxis:

hemorrhagic disease in
(Phytonadione, 1.0 mg= 0.1ml
newborn
AquaMEPHYTON)
Preterm <1.5kg = 0.5mg
• to catalyze the synthesis
of prothrombin in the liver IM, Vastus lateralis (lateral
by intestinal flora anterior thigh)
• promotes the synthesis of Minimum gauge: 25, 5/8-
Prothrombin
inch needle
• needed in the formation
of: AVOID: Dorso gluteal –
factor II (prothrombin), sciatica
factor VII (proconvertin), USE gluteal when the child
is walking for 1 year
factor IX (plasma
already
thromboplastin component),

factor X (Stuart-Prower
factor)

CREDE’s PROPHYLAXIS Prevents opthalmia Lower conjunctival sac

neonatorum(Gonorrhea, from inner to outer canthus
* after a complete
Chlamydia)
breastfeeding
can be delayed
1. erythromycin
2. tetracycline
3. 2.5% povidone iodine
drops

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