Monday, August 24, 2020

Essential Intrapartum Newborn Care

NCM 107

EINC

- A package of evidence based practices recommended by DOH, Philippine Health

Insurance Corporation (Philhealth), and WHO; as the standard of care in all births by
skilled attendance in all government and private settings

- It is a basic component in DOH’s maternal new born and child health and nutrition
strategy

- The EINC practices newborn care constitute, a series of time bound, chronologically
ordered standard procedures that a baby receives at birth

- At the heart of the protocol are 4 time bound interventions; immediate crying, skin-
sin contact, clamping of the chord after 1 - 3 minutes, non separation of the baby
from mother, and breastfeeding initiation

• In advance, prepare decontamination solution by mixing 1 part 5% chlorine bleach

to 9 parts water to mark 0.5% chlorine solution. Change chlorine solution at the
beginning of each day or whenever solution is very contaminated or cloudy

• Prior to Woman’s Transfer to the DR

- Ensure that mother is in her position of choice while in labor

We allow mother freedom of movement to distract mother from discomfort of

labor, release muscle tension, and give mother a sense of control over her labor

If mother stays in bed, we encourage her to assume the left lateral recumbent
position, or the left sims position; this position displays the uterus from the
inferior vena cava, thus preventing supine hypotensive syndrome or inferior vena
cava compression syndrome

Improves fraternal hemodynamics

- Ask mother if she wishes to eat/drink or void

For normal, low risk births, their is no need for restriction of food except where
intervention is anticipated

A diet of easy to digest foods and fluids when in labor is recommended

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- Communicate with the mother

Inform her of the progress of labor, give reassurance and encouragement

• Woman Already in the DR

- PREPARING FOR DELIVERY
Check temperature in DR area to be 25-26 degrees celsius; eliminate air draft

• Use a non mercury thermometer

• Make sure that the delivery area is draft free by hanging a piece of tissue
paper, eliminate draft if present

• Turn of fans and/or aircon units

Ask mother if she is comfortable in the semi-upright position (the default

position of delivery table)

• Upright position during delivery promotes more efficient uterine contractions,

improve fetal alignment, and needs less interventions such as less
episiotomies

• Episiotomy: a surgical insition made over the perineum to prevent laceration

Prepare a clear, clean newborn resuscitation area. Check the equipment if clean,
functional, and within easy reach

• Do this by clearing a flat, firm surface and checking the resuscitation

equipment including bag, mask, a suction device, or what is i reach, clean,
and functional

Ensure woman’s privacy

Remove all jewelry then wash hands observing the WHO 1-2-3-4-5 procedure

1. Wet hands with water

2. Apply enough soap to cover all hand surfaces

3. Rub hands palm-to-palm, right palm over left dorsal, interlace fingers, and
vice versa, palm-to-palm with fingers interlaced, back of fingers to opposing
palms with fingers interlock, rotational rubbing of left and right palms and
vice versa, rotational rubbing backwards and forwards with fingers

4. Rinse hands with water

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5. Dry thoroughly with a single use towel

Arrange materials/supplies in a linear sequence:

1. Gloves, dry linen, bonnet, oxytocin injection (uterotonic agent that promotes
uterine contractions, thus preventing bleeding)

2. Plastic clamp, instrument clamp, scissors, 2 kidney basins (pour

decontamination solution to one of your kidney basins and other kidney
basin will serve as a reservoir and container for placenta)

3. After the 1st breastfeed - eye ointment, stethoscope to symbolize physical

examination, vitamin K, hepatitis B and BC vaccine (plus cotton balls, etc)

immunizations
Clean the perineum with antiseptic solution

Wash hands and put on 2 pairs of sterile gloves aseptically (if same worker
handles perineum and cord)

- AT THE TIME OF DELIVERY

Encourage the women to push as desired

Drape the clean, dry linen over the mother’s abdomen or arms in preparation for
drying the baby

Apply perineal support and do controlled delivery of the head

Call out time of birth and sex of baby

Inform the mother of outcome

- Perineal Support and Controlled Delivery of the Head

Keep on hand on the head as it advances during contractions while the other
hand supports the perineum

During the delivery of the head, encourage the woman to stop pushing and
breath rapidly with mouth open

- FIRST 30 SECONDS
Thoroughly dry baby for at least 30 seconds, starting from the face and head,
going down to the trunk and extremities while performing a quick check for
breathing

- 1 - 3 MINUTES

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Remove the wet cloth

Place baby in skin-to-skin contact on the mother’s abdomen or chest

Cover baby with the dry cloth and the baby’s head with a bonnet

- AFTER
Excluding a second baby by palpating the abdomen in preparation for giving
OXYTOCIN

The circulating nurse gives IM oxytocin within one minute of baby’s birth

The immediate newborn care nurse removes first set of gloves and
decontaminate then properly (in 0.5% chlorine solution for at least 10 minutes)

Palpate umbilical cord to check for pulsations

After pulsation stops, clamp cord using the plastic clamp 2 cm from the base

Place the instrument clamp 5 cm from the base

Cut near plastic clamp (not midway)

Perform the remaining steps of the Active Management of the Third Stage of
Labor (AMTSL):

• Wait for strong uterine contractions then applied controlled cord traction and
counter traction on the uterus, continuing until placenta is delivered

• Massage the uterus until it is firm

Inspect the vagina and perineum for lacerations/tears, as necessary

Active Management of the Third Stage of Labor (AMTSL)

1. Administration of 10 IU oxytocin IM within one minute of delivery of the baby

2. Controlled cord traction with counter traction (CCT with CT) on the uterus

3. Uterine massage

If lacerations/ tears/ or episiotomy is present, repair is done

Prepare sterile syringe with needle (lidocaine hydrochloride), tissue/thumb

forces, scissors, sterile gauze and suture (chromic 2/0 catgut)

Flush perineum, clean the mother and apply perineal pad/napkin/cloth

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Check the baby’s color and breathing; check that mother is comfortable, uterus
contracted

Dispose of the placenta in a leak-proof container or plastic bag

Decontaminate (soaked in 0.5% chlorine solution) instruments before cleaning,

decontaminate 2nd pair of gloves before disposal. Decontamination lasts for at
least 10 minutes
decontaminate for at least to min .

before cleaning
Advise mother to maintain skin-to-skin contact. Baby should be prone on
mother’s chest/in between he breasts with head turn to one side

- 15 - 90 minutes
Advise mother to observe for feeding cues and cite examples for feeding cues

Support mother, instruct her on positioning and attachment

Wait for FULL BREASTFEED to be completed

Observe the baby only when the baby shows feeding cues such as opening the
mouth, tongue licking rooting

When baby is ready, tell mother to make sure that baby’s neck is not flexed or
twisted

Make sure the baby is facing the breast with the baby’s nose opposite her nipple
and chin touching the breast

Hold the baby’s body close to her body to support baby’s whole body and not
just her neck and shoulder

Wait until baby’s mouth is open wide and move the baby unto her breast, aiming
the lower lip well below her nipple

Look for signs of good attachment and suckling:

• Mouth wide open

• Lower lip turned outwards

• Baby’s chin touching breast

• And slow and deep suckling with some pauses

Breastfeed is a learned behavior for both baby and mother

Baby will make several attempts to breastfeed before being successful

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Health workers should avoid interpreting this process like manipulating the
infants body

- AFTER
After complete breastfeed, administer eye ointment, do thorough physical
examination, do vitamin K, hepatitis B, and BCG injections

Different Dosages:

- Vitamin K
• Dosage: 0.1 ml

• Route: IM

• Site: anterolateral aspect of the left thigh-vastus lateralis muscle

- Hepatitis B
• Dosage: 0.5 ml

• Route: IM

• Site: Anterolateral aspect of the right thigh - vastus lateralis muscle

- BCG
• Dosage: 0.5 ml

• Route: Intradermal

• Site: Right Deltoid

Crede’s Prophylaxis

• Serves as prophylaxis for gonorrheal conjunctivitis

• Erythromycin ointment is more commonly used today

• Instill or squeeze along the lower eyelid from the inner canthus outward

Explain to mother that you will be injecting vitamin k

• Vitamin K is given to all newborns to prevent bleeding due to deficient clotting

factor of vitamin K

Hepatitis B Vaccine

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• Given to prevent her baby from catching an infection of the liver that can cause
cancer later in life

BCG Vaccine

• To prevent serious infections due to TB

Vital Measurements

Weigh in kilograms (N: 2.5 - 3.5 kg)

Take temperature per rectum to check for potency of the anus, or for imperforate
anus

ANTROPROMETRIC MEASUREMENTS

To measure your baby’s head circumference, a nurse will wrap a flexible

measuring tape around the broadest part of your baby’s forehead, just above the
ears and at the midpoint of the back of the head (N: 33 - 35 cm)

The chest circumference is measured at the level of the nipple (N: 30 - 33 cm)

The abdominal circumference is measured just above the level of the umbilicus
(N: 29 - 33 cm)

Measure the length from the heel in recumbent position to the vertex of the head
(N; 45 - 55 cm)

Advised OPTIONAL/DELAYED bathing

Advise breastfeeding per demand and about Danger Signs for early referral

In the first hour, check baby’s breathing and color and check mother’s vital signs and
massage uterus every 15 minutes

In the second hour, check mother-baby dyad every 30 minutes to 1 hour

Complete all records

ESSENTIAL NEWBORN CARE

1. Immediate and thorough drying of the newborn

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

3. Properly-timed cord clamping and cutting

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4. Non-separation of the newborn from the mother for early breastfeeding initiation
and rooming-in (for colostrum)

Extra Notes:
- Do not give oxytocin if their is another baby because oxytocin initiates uterine
contraction

- Check vagina or palpate uterus

- If room temp is not in 25-28 degrees celsius, the baby will not be able to cope with
the temperature

- In injections, use a 1cc syringe with 26 gauge needle

- For newborns: injection site is always in VASTUS LATERALIS

- Hospitals are mandated to have a wall thermometer where it is constantly monitored

to be between 25 - 28 degrees celsius

- NAAY ORIENTATION BEFORE MAG RD

- Episiotomy is not a recommended practice for EINC procedure. However, dili

malikayan inig first time mother

- Placentas has a designated disposal procedure and policy

- Roles in DR:

• Delivery handling nurse: assist midwife, doctor, or obstetrician

• Delivery circulating nurse

• Rotating nurse

- Baby does not feel any pain during cutting the cord because it doesn’t have any
nerves. It only contains blood vessels which are 2 arteries, 1 vein

- Perform traction in the presence of uterine contractions and pull in direction of

vaginal opening

- Use ovum forceps to remove placenta

- If ever nang lagum ang baby, i diretso na sa resuscitating area para mag
interventions, araw na i skin-to-skin contact

- If abnormalities are present, report immediately to pediatrician

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- Baby’s head is malleable

- In cutting the cord, wait within 1 - 3 minutes to wait for the pulsations to stop. If you
cut the cord without waiting for the pulsations to stop, there will be flushing of blood
and there will be a possibility of iron-deficiency anemia. Wait to allow enough blood
to go into the baby

if dili ipa stop ang pulsations ,

dingo og ago
mag