ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)

 The EINC practices are evidenced-based standards for safe and quality of birthing mothers and their
newborns, within the 48 hours of Intrapartum period (labor and delivery) and a week of life for the
newborn.
 This was developed and field tested by international and local experts, EINC practices reflect current
knowledge. EINC distinguishes the necessary practices in the delivery and care for the newborn and
the mother, from the unnecessary. In December, 2009, the Secretary of the Department of Health,
Francisco Duque signed Administrative Order 2009-0025,which mandates implementation of the
EINC Protocol in both public and private hospitals. Likewise, the Unang Yakap was launched.
 The EINC Practices During Intrapartum Period

1. Continuous maternal support, by a companion of her choice, during labor and delivery.
2. Mobility during labor – the mother is still mobile, within reason, during this stage
3. Position of choice during labor and delivery
4. on-drug pain relief, before offering labor anesthesia
5. Spontaneous pushing in a semi-upright positions
6. Episiotomy will not be done, unless necessary
7. Active management of the third stage of labor
8. Monitoring the progress of labor using the partograph

Recommended EINC Practices for Newborn Care are Time-bound Interventions at the Time of Birth
1. Immediate and thorough drying of the newborn

 Ensure quality provision of time bound interventions.

 Within the first 30 seconds dry and provide warmth the newborn to prevent hypothermia
 Put on gloves(double gloves)
 Use clean and dry cloth to thoroughly dry newborn by wiping the eyes, face, head, front, back, arms
and legs.
 Remove wet cloth – cover baby with another clean and warm cloth.
 Do not wipe off vernix caseosa if present. The vernix is protective barrier to bacteria such as E coli
and Group B strep.
 Do a quick check to newborn’s breathing6. Do not separate the baby from the mother –if newborns
must be separated from the mother put baby on a warm surface in a safe close to the mother.
 Do not put the newborn on a cold or wet surface8. Use radiant warmer or heat source if resuscitation
is required
 Do not bathe the newborn earlier than6hoursoflife.Washing expose the baby on hypothermia.
Washing also remove the crawling reflex.

 Partial and incomplete drying gives risks to hypothermia which can lead to:
i. Infection
ii. coagulation defects (group of conditions in which there is a problem with the body's blood clotting
process. These disorders can lead to heavy and prolonged bleeding after an injury or bleeding may
also begin on its own.)
iii. Acidosis (condition in which there is too much acid in the body fluids)
iv. delayed fetal to newborn circulatory adjustment
v. hyaline membrane disease(also called respiratory distress syndrome(RDS), is a condition that causes
babies to need extra oxygen andhelpbreathing. HMD is one of the most common problems seen in
prematurebabies.)
vi. brain hemorrhage

2. Early skin-to-skin contact between mother and the newborn

 Place the newborn on prone position unto the mother’s abdomenor chest, skin-to-skin.
 Cover the newborn’s back with a blanket and head with bonnet
 Place the identification band on the ankle.
 Do not separate the newborn from the mother as long as the newborn does not exhibit severe chest
in drawing, gasping or apnea and the mother does not need urgent stabilization.

❑ Skin-to-skin contact is generally perceived to be an intervention for the provision of warmth and bonding.
Appreciated contributions are to the following:
 Immuno –protection of the newborn
 Colonization with maternal skin flora
 Stimulation of the mucosa-associated with the lymphoidtissuesystem
 Ingestion of colostrum
  Overall success of breastfeeding. (Studies show that delayed breastfeeding has a greater risk of
death due to infection)
 Protection from hypoglycemia. (90 minutes after birth, blood glucose levels are significantly higher)

3. Properly-timed cord clamping and cutting

i. Remove first set of gloves prior to cord clamping.

ii. Clamp the cord aseptically and cut the cord after the pulsations have stopped between 1 to 3 minutes after
birth to allow for transfusion of blood from the placenta to the newborn. 3. Do not milk the cord towards the
newborn.
a. Put the clamp tightly around the cord 2 cm and 5 cm from the abdomen of newborn.
b. cut between the clamp with sterile instrument.
c. observe for oozing of blood
d. after clamping, give oxytocin to the mother.
Note: Clamp and cut the cord immediately only if the babyrequireshelp with breathing. Delayed cord
clamping is found to:
 increase the newborn’s iron reserve
 reduces the incidence of Iron deficiency
 Anemiaininfancy

4. Non separation of the mother and the newborn for early breastfeeding initiation
i. Within 90 minutes of age, facilitate the newborn’s early initiation to breastfeeding and transfer of
colostrum.
ii. Leave the newborn on the mother’s chest in skin-to-skin contact.
iii. Health workers should not touch the newborn unless thereismedical indication.
iv. Counsel mother on positioning infant and attachment tobreast.Ifattachment is not good, reassess.
Suggest mother toassist babytowards the breast.
v. Advise mother not to throw away colostrum.
vi. Advise mother to start feeding once the newbornshowsfeeding cues like opening the mouth, licking
androoting.
vii. Encourage the Kangaroo Mother Care. Kangaroo mother care provides the newborn with low birth
weight or preterm babies with benefits of incubator care. Once baby is stable, kangaroo mother care
can begin.

During Labor and Delivery

1. enemas
2. shavings
3. fluid and food intake restriction
4. routine insertion of intravenous fluids
5. fundal pressure

Unnecessary Interventions in Newborn Care

1. routine suctioning
2. early bathing
3. routine separation from the mother
4. foot printing
5. application of various substances tothecord
6. giving pre-lacteals or artificial milk formulaorotherbreast-milk substitute.

CARE OF THE NEWBORN

The 8 Priorities of the Newborn in the First Day of Life

1. Initiation and maintenance of respiration

Alerts:
 second stage of labor initiate airway - initiation of airway is a crucial adjustment amongnewborn- most
neonatal deaths within the first 24-48 hours is primarilythe inability to initiate airway
 lung function begins only after birth
How
A. Removal of secretions by proper suctioning
B. Proper suctioning of a catheter
 - place baby’s heads to side to facilitate drainage- suction nose first because neonates are nasal obligates
- suction for 5-10 seconds and should be gentleandquickbecause prolong deep suctioning may result tohypoxia,
bradycardia(caused by vagal nerve stimulation) andlaryngospasm
C. If not effective, requires effective laryngoscopy to open theairway. Afterdeep suctioning, an endotracheal tube
can be inserted and oxygencanbeadministered by positive pressure bag and mask with 100%oxygenat40-60b/min.

Alerts:
 No smoking sign to prevent combustion - Always humidify to prevent drying of mucosa - Mask should cover
nose and mouth
 Overdosage of oxygen may lead to scaring of retina which mayleadtoblindness called RETROLENTAL
FIBROPLASIA (retinopathy of prematurity)
 When meconium stained, never administer oxygen becausepressurewill force meconium to the alveolar sac
and cause atelectasis.

2. Establishment of extra uterine circulation

Alerts:
 Circulation is initiated by pulmonary ventilation and is completedbycutting of cord
The Fetal Circulation
 Blood flow in the unborn baby follows this pathway:
o Oxygen and nutrients fromthe mother's bloodaretransferred across the placenta to the fetus
throughtheumbilical cord.
o This enriched blood flows through the umbilical veintowardthe baby’s liver. There it moves through a
shunt calledtheductus venosus.
o This allows some of the blood to go to the liver. Butmostofthis highly oxygenated blood flows to a
large vessel calledthe inferior vena cava and then into the right atriumoftheheart.
Here is what happens inside the fetal heart:
 When oxygenated blood from the mother enters the right side of the heart, it flows into the upper chamber
(the right atrium). Most of the blood flows across to the left atrium through a shunt called the foramenovale.
 From the left atrium, blood moves down in to the lower chamber of the heart (the left ventricle). It's then
pumped into the first part of the large artery coming from the heart (the ascending aorta).
 From the aorta, the oxygen-rich blood is sent to the brain and to the heart muscle itself. Blood is also sent to
the lower body
 Blood returning to the heart from the fetal body contains carbon dioxide and waste products as it enters the
right atrium. It flows down in to the right ventricle, where it normally would be sent to the lungs to be
oxygenated. Instead, it bypasses the lungs and flows through the ductus arteriosus into the descending
aorta, which connects to the umbilical arteries. From there, blood flows back into the placenta. There the
carbon dioxide and waste products are released into the mother's circulatory system. Oxygen and nutrients
from the mother's blood are transferred across the placenta. Then the cycle starts again.

3. Control of body temperature

 The goal in temperature regulation is to maintain it not lessthan97.7degrees farenheit (36.5 celcius)
 Maintenance of temperature is important for pretermandSGAbecause it may lead to hypothermia or cold
stress.

4. Intake of adequate nourishment

Alerts: Breastfeed immediately for NSD and after 4 hours for CS(colostrum is present on the 3rd trimester)
Physiology of Breastmilk Production
 Decrease in level of estrogen and progestin, stimulates theanteriorpituitary gland that stimulates the
prolactin of the acinar cells(alveoli)to produce the foremilk stored in lactiferous tubules.
Advantages of Breastfeeding
 very economical
 always available
 promotes bonding
 helps in rapid involution
 decrease incidence of breast cancer
 breast fed babies has higher IQ - it contains antibody (IgA) lactobacillus bifidus that interfereattackof
pathogenic bacteria in GIT - Contains macrophages (store in plastic container, good for
6monthswhenstored in freezer)
Disadvantages of Breastmilk and Cow’s Milk
 Both has no iron
 possibility of transfer of HIV, Hepatitis B - Father cannot feed or bond as well
Stages of Breastmilk
 i. Colostrum
 available 2-4 days after delivery Contents:
 low fats
 low carbohydrates
 high protein
 high immunoglobulin
 high minerals
 high fat-soluble vitamins
ii. Transitional – covering 4-14 days
Contents:
 high lactose
 high minerals
 high water soluble vitamins
iii. Mature milk – 14 days and above
Contents:
 high fats (linoleic acid responsible for integrity of skin and development of skin)
 high carbohydrates ( lactose, easily digested, responsible for sour milksmelling odor of stool)
 low protein (lactalbumin
iv. Cow’s Milk
Contents:
 high fats
 low carbohydrates (add sugar)
 high protein (casein) has a curd that is hard to digest - high minerals, has traumatic effect on
kidneys of baby
 high phosphorous that may cause inverse proportion with calcium

5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Development care that balances rest and stimulation for mental development

E. Health Teachings
1. Proper Hygiene
- importance of handwashing
- removal of caked colostrum 2. Position
- upright sitting avoid tension to properly empty breast milk 3. Stimulate and evaluate feeding
reflexes
A. Rooting
- touch side of lips or cheek and baby will turn to the stimulus Purpose: to look for food
- disappear at 6 weeks because baby can already focus
b. Sucking
- by touching the middle of lips then baby will suck - Purpose: take in food
- disappear at 6 months
- easily disappear when not stimulated c. Swallowing
- food touches posterior portion of tongue automatically swallowed- never disappear cough, gag and
sneeze reflex d. Extrusion/protrusion reflex
- food touches anterior portion of tongue and tongue automatically
extruded/protruded - Purpose: prevent from poisoning, helps protect babies
fromchokingoraspirating food and other foreign objects and helps themtolatchontoa
nipple. - disappear by 4 months because baby can
already spit out
4. Correct Attachment to Breastfeeding
a. lower lip turned upward
b. more areola above the mouth
c. chin touches the breast
d. mouth wide open
5. To prevent from crack nipples and initiate proper productionof oxytocin- begin 2-3 minutes per breast
- increase 1 minute per day each breast until you reach 10 minuteseachbreast or 20 minutes per feeding 6. For proper emptying

and continuous milk production per feeding- feed baby on the last breast that you fed him
Problems Experienced in Breastfeeding
 A. Engorgement
- feeling of tension and fullness of breast (3rd to 4th day after birth) - before feeding – warm compress
- cold compress after feeding
of milk B. Sore Nipple
- it fades as the infant begins effective sucking and empties thebreasts

- cracked, wet and painful nipple

- exposure to air is the management or 20 watt bulb - avoid wearing plastic liner bra, instead wear cotton bra
C. Mastitis
- inflammation of breast
- causative factor: Staphylococcus aureus - improper breast emptying
- unhealthy sexual practices
- breastfeed on unaffected breast - express your breast on affected side - take antibiotic
- increase 500 calories when breastfeeding - involution of breast is 4 weeks
Contraindications in Breastfeeding
Maternal Conditions
- HIV, Hepa B, Cytomegalo virus, comadin/warfarin sulfate intakeNewborn Conditions
- erythroblastosis fetalis
- hydrops fetalis
- phenylketonuria (PKU) (PKU is treated with phenylalanine (Phe) restriction. Breastfeeding infants with PKU is challenging in part because Phe intakeis
difficult to
determine precisely) - galactosemia
- tay-sachs disease
5. Establishment of Waste-Elimination

A. Stages of Stools
1. Meconium
- physiologic stool
- blackish green
- sticky
- tar like
- odorless (because of sterile intestines)
- no bacteria
- passed within 24-36 hours
- failure to pass meconium suspect GIT obstruction a. Hirschsprung’s
b. imperforate anus
c. meconium lieu (cystic fibrosis)
2. Transitional
- become green, loose and slimy that may appear tobeaslightdiarrhea to the untrained eye

3. Breastfed stool
- golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring almost nearly every
feeding

4. Bottle-fed stool
- light yellow, formed, hard with a typical offensive odor seldompassed 2-3 times a day
B. Indication of Stool Changes

- light stool: jaundice baby

- bright green: phototherapy
- mucous mixed with stool: allergy
- clay colored: obstruction to bile duct
- chalk clay/ whitish clay: barium enema - black stool: GIT hemorrhage
- black flecked: anal fissure
- currant jelly: intussusception
- ribbon like: Hirschsprung’s (disease is a condition that affects thelargeintestine (colon) and causes problems with passing stool. Theconditionis present at birth

muscles of the baby's colon.

(congenital) as a result of missing nerve cellsinthe
of
- steatorrhea: fatty, bulky, foul smelling – suspect malabsorptionacase

cystic fibrosis or celiac disease

ASSESSESMENT FOR WELL-BEING
A. APGAR Scoring
Special Considerations
- taken on first minute, shows the general conditionof baby
- taken again after 5 minutes, to determine baby’s capabilitytoadapt/adjust extra uterinely
APGAR SCORING CHART

Score

Criteria 0 1 2 Heart Rate Absent Less than 100 More than 100Respiratory Effort Absent Slow irregular weak

cry Good strong cryMuscle Tone Flaccid extremities Some flexion Well flexed Reflex irritability No response

Grimace Cough or sneezeColor Blue/pale Acrocyanosis (body and

Pink
extremities blue)
Interpretation of APGAR Result

0-3 = severely depressed, need CPR, admission to NICU4-6 = moderately depressed, additional suction and
oxygen administration7-10 = good/healthy
Cardio Pulmonary Resuscitation
Airway (clear airway)
1. shake, no response call for help
2. place flat on bed
3. head tilt – chin lift maneuver
- contraindicated to spinal cord injury
- over extension may occlude airway
Breathing (Ventilating the lungs 4. check for breathlessness
5. administer 2 rescue breaths Circulation (by cardiac compression) 6. check for pulselessness
7. do CPR (when breathless and pulse less)
B. RESPIRATION EVALUATION

Criteria Score 1 2
 0

Chest movement Synchronize Lag on respiration See saw

d

Intercoastal No Just visible Marked

retractionpressure retractions
inside the (air
chest)

Xiphoid (lower None Just visible Marked

partsternum) of the
retraction

Nares dilatation None Minimal Marked

Expiratory grunt Stethoscope Naked ear

None

Interpretation of Result:
0-3 = Normal, no respiratory distress syndrome 4-6 = Moderate RDS
7- 10 = Severe RDS
C. ASSESSMENT OF GESTATIONAL AGEBallard and Dobowitz Clinical Criteria

Gestational Age (weeks)

Findings Less than 36 37-38 39 and up Sole creases Anterior transverse crease
Occasional creases in 2/3 Sole coveredwithcreases
only
Breast nodule (dm.) 2 mm. 4 mm or 3-5mm. 7mm.-7.5mm. Scalp hair Fine and fuzzy Fine and fuzzy Coarse and
silkyEar lobe Pliable Some Thick Testes /Scrotum Testes and scrotum in
Intermediate Testes
lower canal, scrotum is
pendulous,(hangingdown
small with rugae(rugae are a series of ridges
loosely) scrotumfull withextensive rugae
produced by folding of
Pre term Babies: - 28-32 weeks
- frog leg or lax position - hypotonic muscle tone - scarf sign (elbow passes the midline) - square window wrist ( 90
degrees angle) - heel to ear sign
- abundant lanugo
- prominent labia minora and clitoris
Post term Babies:
- more than 42 weeks
- old man’s face
desquamation(peeling of neonate skin characterizedbyextremedryness that begin from sole and palmwithin 24hours)
D. Measurements

1. Upon receiving
 - take anthropometric measurement
2. The take anthropometric measurements a. length – 19.5-21 inches/ 47.5 – 53. 75 cmaverageof 50cmb. head circumference –
33 – 35 cm average of 34 cm/ 13-14inches
c. chest circumference – 31 – 33 cm average of 32 cm/ 12-13inches
d. abdominal circumference – 31-33 cmaverage of 32cm/12-13inches
3. Bathing Baby
- delay for 6 hours
- cleanse and spread vernix
babies of HIV positive mothers are given full bath tolessentransmission of infection

- insulator
- bacteriostatic
- full bath is safety given when cord falls
4. Dressing the Umbilical Cord
- check for 3 vessels ( 2 arteries and 1 vein) - AVA (2 vessel cord suspect kidney malformation) - 8 inches if
anticipating IV or BT
- check for the cord q 15 minutes for the first 6 hours - Omphalagia is bleeding of the cord - cord turns black on the third
day
- falls by 7th – 10th day
- failure to fall is umbilical granulation (silver nitrate) - use saline to clean
5. Credes prophylaxis
purpose: prevent opthalmia neonatorum( use erythromycinophthalmic ointment)

6. Administration of Vit. K
- Action: prevent hemorrhage
- related to physiologic hypoprotrombinemia - give Aquamephyton, phytomenadione, konakoib (.5-1.5mg, IM)
7. Weight taking
Normal weight: 2500-3500 grams
Arbitrary Lower limit: 2500 grams (the smallest possible quantity, minimum)Low birth weight: below 2500 grams Large
for gestational age: more than 4.2 kgs at 40 weeks AOGPhysiological weight loss: 5-10 percent occurs fewdays
afterbirth
E. Physical Examination anddeviationsfromthe Normal

A. Important Considerations
a.