Esstential new born care

NEW BORN CARE
By Jemberu Nigussie
28/05/2021 By Jemberu N. 1

New Born Care
• ENC is basic care provided to support survival and wellbeing of
the newborn.
• It includes immediate care at birth, care during the first day and
up to 28 days.
• Majority of babies born healthy and at term
• Most newborns require only simple supportive care at birth and
after delivery.
• Care during first hours, days and weeks of life determine
whether they remain healthy in the future life.
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By Jemberu N.
28/05/2021

Four basic needs of ALL newborns
»To breath normally
»To be protected
»To be warm
»To be fed
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By Jemberu N.
28/05/2021

Universal Precautions & cleanliness
• Wash hands.
• Wear gloves.
• Protect yourself from blood and other body fluids
during deliveries.
• Practice safe sharps disposal.
• Practice safe waste disposal.
• Deal with contaminated laundry.
• Sterilize and clean contaminated equipment.
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By Jemberu N.
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Essential Newborn Care
Essential newborn care comprises of the following
actions:
1. Immediate care
2. Neonatal examinations
3. Identifying ‘high – risk’ infants
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By Jemberu N.
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ENC #2
1. Immediate care - at Birth
– Clearing the airway
– APGAR score
– Care of the cord
– Body temperature maintenance /KMC
– Care of the skin
– Breast feeding initiation and establishment
– Care of the eyes
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By Jemberu N.
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Steps of essential newborn care
• First remember the “three cleans”:
– clean hands
– clean surface and
– clean equipments
Step 1: Deliver the baby onto the mother’s abdomen or a dry
warm surface close to the mother.
– Continue to support and reassure the mother.
– Tell her the sex of the baby and congratulate her.
– Put identity label on the baby
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By Jemberu N.
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Steps of ENC #2
 Step 2: Dry the baby’s body with a dry warm towel as you try to stimulate
breathing.
– Dry the baby well, including the head, immediately and then discard the
wet cloth.
– Wipe the baby’s eyes.
– Rub up and down the baby’s back.
– Then wrap the baby with another dry cloth and cover the head.
– Drying often provides sufficient stimulation for breathing to start in
mildly depressed newborn babies.
– Do not remove the vernix
• protects the skin and may help prevent infection.
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By Jemberu N.
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Steps of ENC #3
Step 3: Assess breathing and color
• As you dry the baby, check if the baby is:
– Breathing normally- symmetrical chest mov’t
– Having trouble breathing
– Breathing less than 30 breaths per minute, or
– Not breathing at all.
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By Jemberu N.
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Steps of ENC #4
 Clearing the Airway
 Establishment and maintenance of breathing is important
immediately after birth, everything else is secondary
 Mucus and other secretions should be cleared from the
airways.
 Positioning the baby with his head low may help in
drainage of secretions
 Gentle suction to remove mucus and amniotic fluid also
helps to clear the airway
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By Jemberu N.
28/05/2021

Steps of ENC #5
 If natural breathing fails to establish within a minute of
birth (RR <30 breaths, gasping or not breathing at all),
resuscitation is necessary
– Suction and
– Assisted respiration
• Application of oxygen mask
• Intubation
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By Jemberu N.
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Steps of ENC #6
 All labor wards should be equipped with resuscitation
equipment including oxygen
– Start resuscitation immediately- within one minute of
birth.
 You can perform the steps described above simultaneously.
 If there is gasping or no breathing at all even after 20
minutes of effective resuscitation, stop ventilation
By Jemberu N. 12
28/05/2021

Steps of ENC #7
 Step 4: Cord care
• Tie the cord two fingers’ length from the baby’s abdomen and make
another tie two fingers from the first one.
• Cut the cord between the first and second tie
• Use a small piece of cloth or gauze to cover the part of the cord you
are cutting so no blood splashes on you or on others.
• Be careful not to injure the baby.
– Either cut away from the baby or place your hand between the
cutting instrument and the baby.
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By Jemberu N.
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Steps of ENC #8
• In a normal neonate: Cut and tie the cord when it stops pulsating
or wait for 3–7 minutes before cutting the cord (only if no need
of resuscitation).
The advantage is that the baby derives about 10 ml of
extra blood, if the cord is cut after pulsation ceases
• If the baby needs resuscitation (RR <30 breaths, gasping or not
breathing at all):
– Quickly clamp or tie and cut the cord, leaving a stump at least
10 cm long for now
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By Jemberu N.
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Steps of ENC #9
 Do NOT apply anything on the stump; keep the
cord clean and dry.
 Inspect the cord for bleeding 2 hours after ligation
 Inspect for discharge or infection till healing
occurs.
 The cord should be kept as dry as possible
 It dries up and separates by aseptic necrosis within
5 – 10 days
By Jemberu N. 15
28/05/2021

Steps of ENC #10
Figure 1: Tying and cutting the cord.
By Jemberu N. 16
28/05/2021

Steps of ENC #11
Step 5: Maintaining the body temperature (KMC)
Receive the baby in a dry, warm, clean towel.
Dry the baby well
Discard the wet towel Immediately and
Wrap/cover the baby (except for the face and upper
chest) in a fresh, warm, clean and dry towel.
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Steps of ENC #12
 The baby should be kept wrapped during the assessment
and suction ventilation applied (if required)
 Place the baby near a source of warmth.
 A normal baby can be placed in skin-to-skin contact with
the mother's abdomen and covered with a dry cloth.
– The warmth of the mother passes easily to the baby and
helps stabilize the baby’s temperature.
By Jemberu N. 18
28/05/2021

Steps of ENC #13
– Put the baby on the mother’s chest, between the
breasts, for skin-to-skin warmth.
– Cover both mother and baby together with a
warm cloth or blanket and initiate breastfeeding.
– The first skin-to-skin contact should last
uninterrupted for at least one hour after birth or
until after the first breastfeed.
By Jemberu N. 19
28/05/2021

By Jemberu N.
• Skin-to-skin on mother’s chest “frog like”
• Turn babies head to side
• Continuous 24/7 & share between family members
Kangaroo Position demo
28/05/2021

Steps of ENC #14
 additional heat can be provided by placing the baby under a
source of heat such as
– a lamp with a 200 Watt bulb or
– under a radiant warmer
 Practices such as separating the baby from the mother for the
first 12 – 24 hours of life are harmful
– Pre term and low birth babies lose heat more easily through
their skin as they have less subcutaneous fat for insulation
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Steps of ENC #15
Ensure that during and after the delivery, no fans
are running in the delivery room, and no
windows are open through which air currents
blow into the room
By Jemberu N. 22
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Steps of ENC #16
• Warm chain: steps to keep the newborn warm
– Warm the delivery room.
– Immediate drying.
– Skin-to-skin contact at birth.
– Breastfeeding.
– Postpone bathing and weighing.
– Appropriate clothing/bedding.
– Mother and baby together.
– Warm transportation for a baby that needs referral.
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Steps of ENC #17
Step 6: Initiate breast feeding
• If everything is normal, the mother should immediately
start breastfeeding within 1 hr of birth.
• For optimal breastfeeding:
– Help the mother begin breastfeeding within the first
hour of birth.
– Make sure the baby has a good position, attachment,
and is sucking well.
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By Jemberu N.
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Steps of ENC #18
– Do not limit the length of time the baby feeds;
early and unlimited breastfeeding gives the
newborn:
• energy to stay warm,
• nutrition to grow and
• antibodies to fight infection.
By Jemberu N. 25
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Steps of ENC #19
• Supplementary feeds are not necessary, not even water
• The regular milk comes on the third to sixth day after
birth
• The baby should be allowed to breast feed whenever it
wants
– ‘feeding on demand’ helps the baby to gain weight
• Advise the mother to avoid bottle feeding
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Steps of ENC #20
Step 7: Give eye care.
• The eyes should be cleaned
– at birth and once every day using sterile cotton swabs
soaked in sterile water or normal saline.
– From inner to the outer side
– Each eye should be cleaned using a separate swab.
• The routine use of local antiseptic drops for prophylaxis is
not recommended.
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Steps of ENC #21
Figure 3: Applying tetracycline eye ointment
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By Jemberu N.
Give tetracycline 1% eye ointment within one hour of birth
after breastfeeding.
protects the baby from serious eye infection and blindness
28/05/2021

Steps of ENC #22
• Steps for giving eye care:
First, wash your hands
Hold one eye open and apply a rice grain size of TTC
1% eye ointment along the inside of the lower eyelid.
Make sure not to let the medicine dropper or tube touch
the baby’s eye or anything else.
Repeat this step to put medication into the other eye.
Wash your hands again.
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Step 8 Apply Chlorohexidine on the cord.
•Applying Chlorhexidine daily for seven days is
efficacious broad spectrum topical antiseptic agents
active against aerobic and anaerobic organism. It
reduces neonatal bacteria colonization, risk of
omphalitis and neonatal mortality. Never apply
Chlorhexidine to the eye
28/05/2021 By Jemberu N. 30

Steps of ENC #23
Step 9: Give the baby vitamin K, 1 mg IM on the
outside of the upper thigh.
– Use sterile technique
– With the other hand stretch the skin on either side of
the injection site and
– Inject the needle straight into the outside of the baby’s
upper thigh (perpendicular to the skin).
– Then press the plunger to inject the medicine.
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Steps of ENC #24
Step 10: Weigh the baby.
–Weigh the baby within the first hour after birth
or after the first breastfeed.
–If the baby weighs less than 1,500 gm, refer
urgently to NICU.
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NOTES
Place newborn identification band on the wrist or ankle.
Don't forget to record what is done to the newborn.
Give BCG and OPV0 before discharge.
Delay bathing of the baby for 24 hours after birth.
Advise mother to apply Chlorohexidine on the cord daily
for 7 days and NEVER apply to the eyes.
Provide postnatal visits at 6 - 24 hours, 3 days,7 days and
immunization visit at 6 weeks
5/28/2021 Jemberu Nigussie (MSc). 33

Care of the skin
• Clean the blood, mucus and meconium on the newborn's body
• The baby should not be bathed during the first day after birth
– Fear of hypothermia
• After 24 hours, the baby can have the first sponge bath, if the
temperature is established.
• When the baby is given a bath, bathing should be done;
– quickly
– in a warm room,
– using warm water.
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By Jemberu N.
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Skin care #2
• Low birth weight infants should not be given a bath
– Blood, meconium and some of the vernix will have been
wiped off during drying at birth.
– The remaining vernix does not need to be removed as it is
harmless
– If cultural tradition demands bathing, this should not be
carried out before 6 hours after birth, and preferably on the
second or third day of life as long as the baby is healthy
and its temperature normal
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By Jemberu N.
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APGAR scoring: The APGAR score is a commonly-used method to
quantitatively evaluate the newborn's adjustment for extra uterine
environment and need for continuing treatment.
• The score is based on observation of:
–A-appearance/color/: Indicative of peripheral tissue
oxygenation
–P-Pulse/heart rate/ : < 100-indicative of severe asphyxia
–G-Grimace/Response to stimuli/: The neonate response
–A-activity/Muscle tone/: Degree of flexion and resistance
offered by the neonate when to extend his extremity
–R-respiratory effort: Index of adequate ventilation

APGAR score
• Taken at 1 minute and again at 5min
• If APGAR scoring is omitted, it is considered as
negligence
• It provides an immediate estimate of the physical
condition of the baby
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28/05/2021 By Jemberu Nigussie 38

• Points are assigned according to each of five categories.
• Usually evaluated at 1 and 5-minutes after birth.
• N.B. A 1min APGAR score might signals the need for
immediate resuscitation and the 5, 10, 15 and 20 min
scores indicate the probability of successful resuscitating
the infant.
• Done by assigning points from 0 to 2 for each
categories.

Sign 0 1 2
- Heart rate Absent Slow <100 Over 100
Respiratory Absent Weakly Strong cry
-Muscle tone Flaccid Some flexion
of extremities
Well flexed
-Reflex
response
No response Grimace Cough or
sneeze, Cry
* Color Blue, pale Body pink
extremity blue
Completely
pink

Key for scoring
• ≥ 7/10 –Absence of difficulty in adjusting to life
• 6/10 mild asphyxiated = needs follow up
• 4-5/10-Modertely asphyxiated = Needs clearing of the
airway and supplementary oxygen.
• 0-3-severely asphyxiated/ in distress /=needs immediate
resuscitation.
• Note: Most newborn infants with low APGAR scores will
be fine, once they are supported and resuscitated. A 5 min
score of 0-3 correlates with a 50% neonatal mortality rate.

• NB: now a days the APGAR score is not what
determines the need for resuscitation; “respiration
(existence of asphyxia) = rr<30bpm” because the
APGAR score is affected by the degree of:
– Physiologic immaturity.
– Infection.
– Congenital malformations.
– Maternal sedation or analgesia.
– Neuromuscular disorders.

Neonatal resuscitation
• Most babies require basic essential newborn care at and
after delivery. Only few need extra support and
resuscitation.
• Risk factors are poor predictors of birth asphyxia.
Therefore preparation for neonatal resuscitation for any
delivery is the key to save lives.
• Hypothermia is one of the major problems which
contribute for death and poor response for resuscitation so
we have to keep the environment warm during transport
and resuscitation.

Drying and keeping the baby warm
• The initial step of neonatal resuscitation are drying and
stimulating the baby if there is no meconium (suck the mouth
and the nose if there is meconium).
• Immediately, after drying and stimulating, assess the baby for
Breathing? If the baby is not crying, cyanosed, gasping or not
breathing at all, stimulate the baby by rubbing the back, soles,
palm and suck the mouth and the nose. If no response
immediately cut the cord and take the baby to the area where
you can start resuscitation.

Airway
• Keep the baby’s head in slight extension position to open the airway.
Breathing
 Start bag and mask ventilation with room air. Don’t waste time checking
pulse and respiratory rate.
 Choosing mask size which fits over nose and mouth. Size 1 for normal
weight baby, size 0 for small (less than 2.5 kg) baby
• Ventilation with bag and mask at 40 - 60 breaths/minute (count breath to
squeeze then -two-three while releasing the bag)
• Make sure the chest moves up with each press on the bag. While ventilating
a neonate with bag mask, pull the jaw forward towards the mask with the
third finger of the hand holding the mask.

• If the baby is not responding after one minute of bag
and mask ventilation, consider improved ventilation.
• If you don’t see a good chest rise the most important
reasons could be inappropriate technique, try
repositioning and with good sealing.
• If secretions blocking the airways , clear the airway,
check if the ambu bag is working increased pressure
on the bag.

Circulation
• Start chest compressions if HR <60/min after one minute of improved
ventilation with adequate chest movements.
• Ninety compressions Coordinated with 30 breaths /min (3 compressions
and one breath: one-and two-and-three-and-breath).
• Place thumbs just below the line connecting the nipples on the sternum.
• Compress 1/3 to 1/2 the AP diameter of the chest
• If the infant has begun breathing and the heart rate is >100 slowly
discontinue ventilation.
• If the baby is not breathing spontaneously and the heart rate is between
60- 100/min continue ventilating the baby and stop chest compression.

Drugs
• If the heart rate remains below 60 beats per minute,
continue chest compression and epinephrine should be
given.
• Dose of epinephrine therapy in neonates is 0.01 to 0.03
mg per kg of a 1:10,000 concentration, or 0.1 to 0.3 mL
per kg ( to prepare 1:10,000 mix 1ml of epinephrine with
9ml saline of 1:1000 adrenaline).
• Emergency volume expansion may be accomplished with
a normal saline or ringer lactate 10 ml /kg

Post resuscitation stabilization
• Continue monitoring, keep the newborn warm and prevent
hypoglycemia and immediately transfer the newborn to
neonatal ward.
Cessation of resuscitation
If after 20 minutes of resuscitation the baby is:
Not breathing and heart rate is absent: consider stopping
efforts.
Explain to the mother that the baby has died, and give to
her to hold if she wishes

Care after successful resuscitation:
• Leave the newborn skin-to-skin with the mother
• Encourage breast-feeding within one hour of birth.
–Observe suckling: good suckling is a sign of good
recovery.
• Give and follow the age related vaccination

Special Care of the Newborn
• Special care for ‘Sick’ Infants.
• Recognition and Management of Birth
Asphyxia/Birth Injury.
• Recognition and Management of Infection.
• Special Care for the LBW Infant.
• Skin-to-Skin/Kangaroo Care.
• Close Observation for Signs of Infection and/or
Feeding Difficulties.

Neonatal examinations
1. First examination
• Made soon after birth and preferably in the delivery room
• This examination is:
– To ascertain that the baby has not suffered injuries
during the birth process
– To detect malformations especially those requiring
urgent treatment and
– To check for danger signs
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By Jemberu N.
28/05/2021

Neonatal examinations #2
2. Second Examination
• This should be made preferably within 24 hours
after birth
• This examination should form the first stage of a
continual process of health care surveillance
• It is a detailed systematic examination from head
to foot, conducted in good light
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By Jemberu N.
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Preparation for discharge
Provide immunization
Discuss on follow up and appointment schedule
Counsel the mother
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By Jemberu N.
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Follow-up
• Schedule postnatal visit within first week on day 3
and day 7 of delivery. Also visit on day 14, 21 and
28 if baby is LBW.
• Assess for growth and development and signs of
illnesses
• Health education of parents
• Assess at least once every month for 3 months and
subsequently 3 monthly till 1 year.
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By Jemberu N.
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SUMMARY
• Basic care to support survival & wellbeing is ENC
• Ventilation must be initiated within 1st min of life
• Help to initiate breast feeding within 1st hr of birth
• Identify and refer neonates requiring special care
• Take all precautions to prevent infection, hypothermia
and counsel mother for the same
• Counsel mother for Danger signs, immunization &
follow-up
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By Jemberu N.
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