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Essential Newborn Care

14 min read

References:

  1. Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (2nd ed., pp. 222–261), not fully adapted as of yet
  2. Lecturer (V)

Also known as Unang Yakap (First Embrace), these are four core principles of immediate care of the newborn.

  1. Immediate and Thorough Drying
  2. Early Skin-to-skin Contact
  3. Properly-timed Cord Clamping
  4. Non-separation of Newborn from Mother for Early Breastfeeding
  5. (add.) Eyecare and Immunization Procedures
  6. (add.) Rooming-in

It is a simply, step-by-step, time-bound and cost-effective newborn care protocol developed by the Philippine Department of Health that adopts international evidence-based standards set by the World Health Organization that can improve neonatal as well as maternal care by directly addressing Millennium Development Goal (MDG) 4: Reduce Child Mortality.

  1. For preparation, prepare
    1. Three pairs of surgical gloves, two for the obstetrician and one pair for the pediatrician.
    2. Two warm blankets/towels
    3. Bonnet
    4. Cord care set: clamp, scissors
    5. Erythromycin ointment for eye care
    6. Vitamin K and Hepatitis B shots
  2. Perform handwashing following the prescribed 1, 2, 3, 4, and 5 counts for each movement.
  3. Double gloving: put on two sets of sterile gloves.

Prohibitions

  1. Do not suction unless the mouth/nose is blocked with secretions or other materials.
  2. Do not ventilate unless the baby is floppy/limp and not breathing.
  3. Do not place the newborn on a cold or wet surface.
  4. Do not bathe the newborn earlier than six hours of life.
  5. Do not separate the newborn from the mother as long as the newborn does not exhibit danger signs of respiratory distress and the mother does not need urgent medical stabilization. If the newborn must be separated from the mother, put him/her on a warm and safe surface close to the mother.
  6. Do not do footprinting as the stamp pad may be a source of infection; the use of an ankle band is sufficient.
  7. Do not wipe off vernix caseosa, if present, as it helps prevent heat loss.
  8. Do not manipulate (e.g., routine suctioning) if the newborn is crying and breathing normally to prevent trauma or infection.
  9. Do not milk the cord toward the newborn.
  10. Do not touch the newborn while it is on the maternal abdomen unless there is a medical indication.
  11. Do not give glucose water, formula, or other prelacteal feedings.
  12. Do not give bottles or pacifiers.
  13. Do not throw away the colostrum.
  14. Do not wash away the eye antimicrobial.
  15. Do not touch the cord stump unnecessarily.
  16. Do not apply any substances or medicine to the cord stump.
  17. Do not bandage the cord stump or abdomen.

Essential Intrapartal and Newborn Care (EINC)

A mandated series of steps in the care of the newborn during and immediately after delivery. The ENC (December, 2009) attempted to answer the Millennium Development Goals 4 and 5 (Maternal and Child Mortality, respectively). The goal is to decrease mortality rates by 40%. This was achieved for mothers, but only 20% for neonates. To push neonatal health further, the previously established ENC was updated to the EINC (May, 2012) to further improve outcomes of pregnancy.

In Pre-Pregnant and Childbearing-Age Women

  1. Healthy Lifestyle: exercise and the avoidance of alcohol (Low IQ; cognitive impairment) and smoking (Vasoconstriction; SGA, IUGR). Even residues of these can affect a pregnancy even after cessation.
  2. Health Teachings:
    • Prevention of venereal diseases (STDs), family planning, and conception.
    • Nutritional requirements: (inc.)
ComponentAmount
Calories2,000/day
Iron30 mg/day
SaltIodized, not Rock Salt

In Pregnant Women

Exercises and avoidance of smoking and alcohol are still practiced during pregnancy.

  1. Prenatal checkups are utilized to track the progress of gestation. The minimum recommended is four visits (DOH), at least once per trimester, and one at the final month of pregnancy.
  2. Dieting requirements:
ComponentAmount
Calories2,300 to 2,500/day
Iron60 mg/day
Folic Acid400 mcg/day
Calcium1,200 mg/day
Protein60 mg/day
Vitamin A10,000 IU 2nd Trimester
Elemental Iodine250 mg (1 cap)/pregnancy; can relieve need for iodized salt
Increased fiber and fluidPrevent constipation
Phosphorus700 mg/day
  1. Exercises:
    • Walking (best)
    • Pelvic Rocking: the assumption of a squatting position, and rocking the pelvis forward and backwards. This relieves back pain.
    • Tailor Sitting: The assumption of Indian seating on a non-slip mat, and stretching of the perineal tissues. This makes the perineum supple (elastic, stretchy) to prevent easy laceration.
    • Squatting: with support from a sturdy surface; this strengthens perineal muscles.
    • Kegel’s Exercise: strengthens the perineal (pelvic floor) muscles.
  2. Antenatal Steroids: the administration of steroids for pregnant women with (a) history of premature birth, (b) risk of preterm birth (hypertension, diabetes mellitus, anemia), (c) history of vaginal bleeding during pregnancy, and (d) actual preterm labor. These steroids are given from the 24th to 28th week to promote surfactant production (fetal lung maturity).
    • Dexamethasone: 6 mg IM every 12 hours for four doses.
    • Betamethasone (Celestone): 12 mg IM every 24 hours for two doses. In emergent cases, this is used because of its higher dosage.

For patients with history of premature labor, risk of premature labor, or history of bleeding, the patient can complete the dosage. Otherwise, in actual premature labor, one dose is enough.

In the Labor Room

  1. Admit the patient when they reach the active phase (4 cm dilatation or 2-3 contractions every 10 minutes), with her companion of choice (COC) to provide continuous maternal support.
  2. Positioning: any upright position (sitting, fowlers, standing, squatting, walking), as long as the bag of water has not ruptured, whichever the patient deems more comfortable. This utilizes gravity to promote cervical effacement and dilatation. Once ruptured, the woman is placed on a left lateral (side-lying) position.
  3. End of NPO Status: the woman can continue consuming food and fluids. This provides the energy for maternal pushing. Eating can be done until about half of the active phase; 6 cm, with easy-to-digest foods.
  4. End of IV Infusion, including oxytocin incorporation. IV fluids were also used to provide glucose, but with the continuation of eating and drinking, these are discontinued. Oxytocic drugs also produce the risk for atony.
  5. Perform IE to monitor the progress of labor. This is done less than five times to reduce the risk of infection. The standard for frequency is every four hours, at most every two hours.
  6. Empty the bladder. A distended bladder may obstruct fetal descent; an empty bladder promotes fetal descent.
  7. No more shaving: there was no significant difference between unshaved and shaved women during labor.
  8. No more enema, due to its tendency to increase blood pressure.
  9. Partography is used in order to monitor the progress of labor.

In the Delivery Room

Prior to the transfer to the delivery room, prepare the environment.

  • Set the temperature (25°C to 28°C).
  • Eliminate air drafts.
  • The AC unit is closed just before the baby is delivered to avoid hypothermia.

Safe Delivery Techniques

  • Maintain the semi-upright position, with the COC present (continue providing maternal support). This position utilizes gravity (again) to aid in delivery, and make bearing down easier as the natural motion is to draw the chin to the chest.
  • Perform Ritgen’s Maneuver to support the perineum during crowning, preventing lacerations.
  • Check for cord coil once the head and neck are exposed. If present, the cord is clamped and cut.
  • Oxytocin IM is given one minute after the baby is out (after initiation of early skin-to-skin contact).
  • Perform the four newborn protocols.

Procedures Not Routinely or Not Performed

  • Amniotomy: only performed when indicated, primarily in prolonged labor and delivery, decided by the doctor.
  • Episiotomy: only performed when indicated, when the head is deemed likely to cause laceration of the perineum as decided by the doctor.
  • Coached pushing: not done to avoid the valsalva maneuver. However, pushing is not allowed if cervical effacement and dilatation have not been completed.
  • Fundal pushing can produce lacerations.
  • Brandt-Andrew’s Maneuver: not used; rather, controlled cord traction with counter traction is used to express the placenta.
  • Cord Milking, which may result in neonatal circulatory overload.
  • Methergine IM

Chronological Arrangement of EINC Deliveries

  1. Gloves: 2 pairs, both worn at the same time to first deliver the baby, then to clamp and cut the cord.
  2. Towels: 2 pieces, one on the lower abdomen of the mother for catching and drying the baby. The second towel is used to wrap the back of the baby (ensure skin-to-skin contact)
    • Pat the baby dry, rather than rubbing. This maintains the vernix caseosa, which is a thermoregulatory and bacteriostatic medium.
  3. Bonnet: 1 piece, placed on the head of the baby to maintain heat after drying.
  4. Oxytocin IM in syringe ready for injection to the mother. This is given one minute after the baby is out, coinciding with the end time of drying and early skin-to-skin contact.
    • The WHO promotes the use of two precautions prior to administration of oxytocin: check for uterine contraction and the possible presence of a second baby.
    • Oxytocin can increase blood pressure. It must be less than 140/90 for administration. Notify the physician if this threshold is crossed.
  5. Cord dressing materials: cord clamp, kelly, bandage scissors.
    • Remove the last worn pair of gloves used for delivering the baby.
    • Clamping and cutting is done after pulsations have stopped, at a maximum of three minutes.
    • The cord clamp is placed first, 2 cm from the base of the umbilicus, then the kelly clamp 5 cm from the base (3 cm from the cord clamp). It is cut 1 cm from the cord clamp, in between the two clamps.
    • Once cut, the umbilicus is air-dried. It dries and falls off by itself in 7 to 10 days.

Evolution of Cord Care

  1. Previously, daily cord care was done with 70% alcohol b.i.d. to enhance drying of the umbilical cord. However, this method kept the cord moist with the 30% water the remains after alcohol evaporates, which promotes infection.
  2. Then, betadine 10% was used. However, this caused skin irritation and scratching by the newborn.
  3. After the ENC arrived, room-temperature pre-boiled water was used to clean the umbilical cord. However, this retained the original issue of retention of moisture of the cord, which promoted infection.
  4. In EINC, nothing is applied to the cord to let it dry by itself.
  1. Empty kidney basin used for disposable items such as needles and syringes.
  2. Kidney basin with 5% chlorine solution to disinfect the scissors and kelly used during cord dressing.
    • It is after this period that the placenta is delivered in AMTSL (Active Management of the Third Stage of Labor). This period starts immediately after oxytocin is administered.
    • The CCTCT (controlled cord traction with counter traction) technique is used for delivering the placenta. Again, the Brandt-Andrew’s Maneuver is no longer done, as this may continue to irritate lacerations if present. In CCTCT, (a) press down on the lower abdomen (counter-traction), then (b) pull on the cord with a straight line of force.
    • After expulsion, the completeness of the placenta is checked. The normal 15 to 20 cotyledons are found on the maternal side of the placenta. The perineal area of the mother is quickly cleaned.
  3. Empty space; time for breastfeeding. This period lasts for the first 90 minutes after delivery, following the last step of the four newborn protocols.
    • Signs of the readiness for feeding: (1) mouth-opening (sucking reflex), (2) kicking, and (3) grasping. With these signs, the mother is instructed to bring the child to her chest, and let the baby find the nipple for feeding.
      • To do so, the baby’s head is placed between the breasts and the baby’s head is turned towards the areola and nipple. The head of the baby may turn with the rooting reflex that functions to locate and find the nipple. This reflex is incited by touching the corner of the mouth, after which the head turns towards the side of the corner stimulatd.
      • Despite the baby’s blurry and limited vision (~9 inches), the baby is able to see the nipple and grasps (grasping reflex) the nipple, which the newborn brings to its mouth.
  4. Eye prophylaxis with erythromycin (ophthalmic ointment) is done after successful breastfeeding. This is applied from the inner canthus to the outer canthus. It is done to prevent blindness from sexually-transmissible diseases the child may obtain after traversing the birth canal. This condition is known as ophthalmia neonatorum, often due to Neisseria gonorrhea.
  5. Vitamin K: an anticoagulant applied to the vastus lateralis to make up for the lack of normal flora (E. Coli) in the intestinal environment, which is contributory in the synthesis of Vitamin K. The normal flora develops naturally with contact with the mother.
  6. Hepatitis B Vaccine: 0.5 mL IM at the vastus lateralis to protect against hepatitis B. If screening shows the presence of HBV in mothers, then Hepatitis B immunoglobulin is also used.
  7. BCG Vaccine: 0.05 mL ID on the upper right deltoid.

A tuberculin syringe is used (1-mL, 5/8" needle with 26-25 gauge) for Vit. K, HBV, and BCG administration

  1. Stethoscope for assessment
  2. Tape measure for anthropometric measurement:
MeasurementNormal Range
Head Circumference (above the brow)33 to 35 cm
Chest Circumference (nipple line)31 to 33 cm
Abdominal Circumference (above the umbilicus)31 to 33 cm
Birth Length (cephalocaudal)47 to 54 cm
Birth Weight2,500 to 3,400 (max of 4,000) grams

Newborn Protocols (Principles of Unang Yakap)

  1. Immediate Drying of the newborn within 30 seconds. This prevents hypothermia with the poor thermoregulation of the baby.
  2. Skin-to-skin Contact within the next 30 seconds (1 minute total) to promote bonding, promote heat regulation, and promote transfer of skin flora (protects against infection, particularly streptococcal and staphylococcal infection). This prevents hypoglycemia (energy stores are used to keep the baby warm) and infection.
  3. Properly Timed (Delayed) Cord Clamping and Cutting within three minutes (until cord pulsations stop). This prevents anemia of the baby (allow more blood to enter fetal circulation before pulsations stop). Do not milk the cord, as this may result in circulatory overload, which can delay the closure of the foramen ovale.
  4. Rooming-in and Early Initiation of Breastfeeding (for the first 90 minutes): the mother and newborn is kept in the same room to promote the initiation of breastfeeding and bonding.

First Three Minutes

  1. Call out the time of birth.
  2. Towel-dry the body of the baby with the first towel for about 30 seconds. Rubbing with adequate force stimulates breathing. Perform a rapid assessment for breathing as you dry the baby. Remove the wet cloth.
  3. Initiate skin-to-skin contact by placing the baby prone on the mother’s abdomen or between her breasts. Place the bonnet on the baby’s head and use the second linen to keep the infant warm.
  4. Perform cord care. The methodology outlined below prevents anemia, and protects preterms from intraventricular hemorrhages.
    • Remove the first set of gloves before handling the cord.
    • Do not cut the cord immediately. Allow the cord pulsations to stop without milking the cord, which usually takes 1 to 3 minutes.
    • Clamp the cord two centimeters from the base, and again five centimeters from the base.
    • Cut the cord between the two clamps, one centimeter from the first clamp; three centimeters from the base.
  5. Inject 10 IU of oxytocin intramuscularly into the mother’s arm to prevent uterine atony.
  6. While maintaining skin-to-skin contact, check on the mother’s condition and deliver the placenta. Check how heavy the mother’s bleeding is. Examine the perineum, lower vagina, and vulva for tears. Clean the mother and keep her comfortable. The skin-to-skin contact promotes bonding, breastfeeding (and neonatal hypoglycemia) and allows colonization with maternal skin flora.

Thirty to Sixty Minutes

  1. Check the newborn for readiness to breastfeed. This is determined by the licking, rooting, and tagging movements/reflexes. Encourage the mother to nudge the newborn towards the breast for them to seek out the nipple (crawling reflex). Counsel the mother on the proper positioning and nipple attachment of the baby.
  2. After initial feeding, perform eyecare procedures and administer vaccines. Then, let the baby remain in the mother’s arms as she recovers from giving birth. This is part of rooming-in, where the baby stays with the mother as she is brought to the room/ward. Encourage exclusive breastfeeding for six months.
  3. Washing the baby or giving the baby a bath should be done at least six hours after birth.

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