“Five Cleans” at the time of

Delivery
 Newborn Death

The most vulnerable time for both the mother and newborn is
during birth and in the hours and days immediately after
childbirth.

Each year, millions of newborns die as a result of birth asphyxia,

infections, and complications of preterm birth.

It is estimated that 30-40% of infections resulting in neonatal

sepsis deaths are transmitted at the time of childbirth

In addition many neonatal deaths due to tetanus and other

infections are acquired postnatally.

BMC Public Health 2011, 11(Suppl 3):S11

 Newborn Death

 The unhealed umbilical cord is an important portal for local

and invasive infections during this period

 It is rapidly colonised by bacteria from the maternal genital tract

and then from the environment

 Localised umbilical infection (omphalitis) can spread to the

abdominal wall, the peritoneum, or through the umbilical or portal
vessels leading to systemic sepsis.

if it is untreated, has a high case-fatality rate.

BMC Public Health 2011, 11(Suppl 3):S11

 Infant Mortality Rate - India
The present level of IMR (Infant Mortality Rate) (32 infant deaths
per thousand live births, for the year 2018) is about one-fourth
as compared to 1971 (129 infant deaths per thousand live births).

In the last ten years, IMR has witnessed a decline of about 35%
in rural areas and about 32% in urban areas.

https://censusindia.gov.in/vital_statistics/SRS_Bulletins/SRS%20Bulletin_2018.pdf
 Infant Mortality Rate - India

Despite the decline in IMR over the last decades:

one in every 31 infants die within first year of their life at the
National level (irrespective of rural urban);

one in every 28 infants in rural areas and

one in every 43 infants in urban areas still die within one year of
life.

https://censusindia.gov.in/vital_statistics/SRS_Bulletins/SRS%20Bulletin_2018.pdf
 Essential Newborn Care
The WHO has outlined a set of practices called “essential newborn
care”, to prevent neonatal morbidity and mortality.

It is the care provided to the neonate after birth within the

delivery room by skilled personnel.

These include :
o hygiene during delivery;
o keeping the neonate warm;
o early initiation and exclusive breastfeeding;
o care of the eyes;
o care during illness; and
o immunization and care of low-birth-weight neonates.

WHO South-East Asia Journal of Public Health | April 2017 | 6(1)

 Essential Newborn Care

https://www.who.int/pmnch/media/publications/aonsectionIII_3.pdf?ua=1
 Essential Newborn Care
 Skilled care during labour and childbirth with prompt management of
complications alone can prevent about 50% of newborn mortality.

 Continuation of adequate newborn care in the postnatal period can

prevent 75% of current newborn deaths.

Hindawi; International Journal of Pediatrics Volume 2020, Article ID 3647309, 8 pages

 Need of Clean Practice at Birth

Reasons for high incidence of cord infections in the developing

world include:
 delivery under unhygienic conditions,
 unhygienic cutting of the cord,
 application of unclean substances to the cord stump, and
 covering the stump with unclean fabric

Clean practices at birth and in the postnatal period could prevent

many needless deaths.

Proper essential care of a newborn is significantly important for

survival, growth, and development of a newborn.

Both maternal puerperal and neonatal umbilical cord infections are

preventable.

It can be reduced by promoting clean delivery and clean cord

care practices along with discouraging harmful practices.

Journal of Perinatology (2009) 29, 673–679 ; BMC Public Health 2011, 11(Suppl 3):S11
 WHO recommends “Five cleans”

WHO recommends “five cleans” to maintain hygiene during

delivery:

1) clean surface,
2) clean hands of attendant,
3) clean cord,
4) clean cord tie without dressing and
5) clean and dry wrapping of the baby.

WHO South-East Asia Journal of Public Health | April 2017 | 6(1)

“Five cleans”
 “Five cleans”

BMC Public Health 2011, 11(Suppl 3):S11

 “Five cleans”
 Hand-washing with soap results in a large reduction in hand
contamination.

 Birth attendant and maternal hand washing have been associated with
reductions in neonatal mortality

 Many populations commonly rub potentially harmful substances on the

umbilical cord or skin despite WHO recommendations for dry cord care

 It is well known that application of substances like ghee (clarified

butter) to the umbilical cord is a risk factor for neonatal tetanus

 No dressing was applied to the stump of the cord.

 Chlorhexidine, a broad-spectrum topical antiseptic, has residual effect

for up to 72 hours and may be a useful adjunct to basic clean practices in
home.

WHO South-East Asia Journal of Public Health | April 2017 | 6(1) ; BMC Public Health 2011, 11(Suppl 3):S11
 “Five cleans”
 To maintain these “cleans”, kits for safe home delivery are
manufactured and distributed free of charge.

 Encouragingly, in nearly 70% of the home deliveries, a new blade

was used to cut the umbilical cord.

 Women who had at least one antenatal visit may have received
counselling about the “cleans” during delivery and therefore
practised clean cord care.

WHO South-East Asia Journal of Public Health | April 2017 | 6(1)

 Evidence for the effect of clean birth practices
Place of birth

o Most studies of clean birth practices are carried out in populations with
high rates of home birth.

o Four studies reported a reduced risk of neonatal tetanus associated

with facility delivery.

Hand washing of birth attendant with soap before birth

o One large cohort study (n=23,662 with 713 deaths) reported lower
neonatal mortality associated with reported birth attendant hand-
washing with soap and water.

o No cases of neonatal tetanus were documented in this study

population.

o Also reported reductions in the incidence of cord infection associated

with birth attendant hand-washing
BMC Public Health 2011, 11(Suppl 3):S11
 Evidence for the effect of clean birth practices
Cutting of the umbilical cord using a clean implement

o observational studies were identified which examined the association

of using a clean implement (a new/ boiled/ sterile blade or scissors) to
cut the cord with neonatal sepsis or tetanus.

o Two case-control studies and one cohort study reported strong

evidence of lower neonatal tetanus mortality associated with use of
clean cord cutting tools

Chlorhexidine applied to the cord postnatally

o In a RCT, chlorhexidine cleansing of the cord in rural Nepal reduced

all-cause neonatal mortality and sepsis-specific neonatal mortality
if applied within the first 24 hours

BMC Public Health 2011, 11(Suppl 3):S11

 Evidence for the effect of clean birth practices

Avoidance of harmful postnatal cord applications

Evidence from case-control studies supports an association between

neonatal tetanus and applications of

o cow dung or ash to the cord ,

o traditional applications (mustard oil, ghee or surma) to the cord,
o shea butter and ghee (in particular cow’s milk ghee)

BMC Public Health 2011, 11(Suppl 3):S11

 WHO Recommendation on First Bathing
Bathing should be delayed until 24 hours after birth.

If this is not possible due to cultural reasons, bathing should be delayed for at
least six hours.

Appropriate clothing of the baby for ambient temperature is recommended. This

allows time for the infant to maternal–infant bonding and early breastfeeding.

WHO and the Neonatal Skin Care Evidence-Based Clinical Practice

Guideline recommend leaving residual vernix intact on the skin and allowing it to
wear off with normal care and handling.

Vernix on the baby’s skin

Bathing The Baby