chapter 2 appendix 1 standards for newborn care

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CHAPTER2:APPENDIX1

ESSENTIALNEWBORNCARE

STANDARDSFORNEWBORNCARE

Thisdocumentisintendedtoprovideguidelinestohealthservicemanagers,doctorsandnursesinchargeofneonatalfacilitieswhenplanningandimprovingfacilitiesandservicesfor newborns. The information is based on National Standards and work done inLimpopoProvincebytheLimpopoInitiativeforNewbornCare(LINC)team

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LEVELSOFCAREANDBEDNUMBERS

TheLevelsatwhichNewbornservicesareprovidedaredescribedbelowaswellasthenumberofbedsforsickandsmallnewbornsateachfacility.Thenumberofneonatalbeds1requiredisexpressedasbedsper1000livebirths.Table1showsthenumberofrecommendedbedsfoundinthedocument“HealthPlanforNeonatalCare”producedbythe1997PrioritiesinPerinatalCareConference.

Table1.RecommendedNeonatalBedNumbers.

Levelofcare NationalRecommendation

Practicalnumberused

L I 3 – 4 / 1000 live births 4 / 1000 live births L lI 2 – 3 / 1000 live births 3 / 1000 live births L llI 0.5 – 1 / 1000 live births 0.5 / 1000 live births

Table2.Calculationthenumbers

LevelI:LevelIservicesareprovidedatclinicsanddistricthospitals4levelIbeds/1000births(clinic,hospitalandhomebirths)inthesub-districtAndiflevelIIservicesarenotfullyavailable1levelll(HC)beds/1000birthsinthesub-district–inthedistricthospitalLevelII:LevelIIservicesareprovidedatRegionalhospitals4levelIbeds/1000birthsinthesub-district3Levelllbeds/1000birthsinthedistrictLevelIII:LevelIIIservicesareprovidedatTertiaryhospitals4levelIbeds/1000birthsinthesub–district3levelllbeds/1000birthsinthedistrict,ifthishospitalalsoprovidelevelIIservices0.5levelIIIbeds/1000birthsintheprovinceLevelIVLevelIVservicesareprovidedatCentralHospitalsandincludecomplexsurgeryandinvestigations.Additionalbedmaybeneeded,asthisserviceshouldspanacrossprovincialboundaries.

Everyhospitalhasaneonatalunitornurseryforsickandsmallbabies.Theextentoftheunitdependsonthelevelofcareprovidedandnumberofdeliveriesintheareaserved.Theunitisideallykeptinonearea,butcanbedividedorpartitionedintothefollowinggradesofcare:Kangaroomothercare(KMC),Standardcare(SC),Highcare(HC),andIntensivecare(ICU).Ifyoucannotincludehighcarebedsinyourrenovations,neonatesrequiringhighcaremustbeaccommodatedinthemainHCandICU.Wellnewbornsareroomedinwiththeirmothersandneverentertheneonatalunit/nursery.

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Table3:LevelsofCare

Levelofcare LevelI LevelI LevelII LevelIIIFacility Clinic/health

centreDistricthospital RegionalHospital TertiaryHospital

Noofbeds 1 4/1000birthsinthesub-district

4/1000births/sub-district+2/1000birthsinthedistrict

4/1000births/sub-district+2/1000birthsinthedistrict+0.5/1000birth/province

Neonatalcarethatshouldbedelivered.**Seetable4

RoutinecareInitiatingKMC

RoutinecareKangarooMotherCare(KMC)Standardinpatient(SIC)Highcare(HC)

RoutinecareKangarooMotherCareStandardcareHighCareIntensivecare(Shortterm)

RoutinecareKangarooMotherCareStandardcareHighCareIntensivecare

Ratioofbeds/10*KMC:SIC:HC:ICU

*Approximateratio KMC:SIC:HC4:4:2

KMC:SIC:HC:ICU4:3:2:1

KMC:SIC:HC:ICU2:3:3:2

Table4:Carerequired

Routinecare Standardcare Highcare Intensiveandhighlyspecialisedcare

Categoryofbabyrequiringcare

• MostFullterminfants• Mostlowbirthweightinfants>2kg

Babieswith:• LowApgars• Congenital

abnormalities• LBW1500–1999g• AGestationalage32

–36wks• Birthweight>4000g• Meconiumstaining• Wasting• Possibleinfection• Jaundice

Babieswith:• LBW<1500g• Gestationalage<32wks

• Encephalopathy• Meconiumaspiration• Septicaemia/meningitis

• Recurrentapnoea• Moderateandsevererespiratorydistress

• Convulsions• Severejaundice

Babieswith:• Aneedforassistedventilation

• ComplexSurgicalproblems

• Persistenthypoglycaemia• Cardiovascularproblems• Multisystemproblems• Problemsrequiringspecialistinterventione.g.ambiguousgenitalia

•

Careprovided • Safe,cleandelivery• Newbornresuscitation• Identification• Apgarscore• VitaminK,eyecare,cordcare

• Thermalsupport• Emergencycare• Assessgrowth• Fullexamination• Breastfeeding• Immunisation• CareofbabyexposedtoHIV,TBandSyphilis

• Educationandfollowupplan

Inadditiontoroutinecare:• ThermalSupport• OxygenSupport• GlucoseMonitoring• IVFluidadministration• Tubefeeding• BilirubinmonitoringandPhototherapy

• Drugadministration

Inadditiontoroutineandstandardcare:• Cardio-respiratorymonitoring

• Oxygentherapy>40%Headbox

• NasalprongCPAP• ShorttermIPPV• Bloodtransfusion• Chestdrains• Exchangebloodtransfusion

Inadditiontootherneonatalcare:• IPPV• TotalparenteralNutrition• Arterialcatheterization• Therapeuticcooling• Advancedneurologicalmonitoring

• UltrasoundandEcho-cardiography

• Sophisticateddiagnosticinvestigation

• Sub-specialistconsultation

• Neonatalsurgicalintervention

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Table5:Newbornfacilities

Levelofcare LevelI(Clinic/CommunityHealthCentre)

LevelI(District) LevelII(Regionalhospital)

LevelIII(Tertiaryhospital)

Facilityrequired Emergencyspacenexttoresuscitation

Asingleneonatalunitwithareasfordifferentlevelsofcare.Theneonatalunitisbestsituatedbetweenthelabourwardandpostnatalward.

Facilitydesign • Theneonatalunitisideallybeinonearea,withacentralnursesstation• Glasspartitionsbygradeofcarewith6–8babiesinanarea• Theareashouldberestrictedtogeneraltraffic.• Adualcorridorratherthanacentralcorridorisideal.• TheKMCunitispartoftheneonatalunitandisideallyinterleadingor

adjacent.Itshouldhaveabathroom,andlounge/diningroomarea.• Allmothersshouldhavelodgerfacilitiesnearby.

Areasrequiredintheunit

Nexttoresuscitation • KMC• Standardcare(SC)• Highcare(HC)• Lodgermothers• Counsellingroom• CentralNurses

station• Utility/storage

areas• Unitmanager’s

office• Staffrestroom• Milkpreparation

area

• KMC• Standardcare(SC)• Highcare(HC)• IntensiveCare(NICU)

• Lodgermothers• Counsellingroom• CentralNursesstation

• Utility&storagerooms

• Unitmanager’soffice

• Staffrestroom• Milkpreparationarea

• DoctorsOffice• Meetingroom• Doctorsovernight

• KMC• Standardcare(SC)• Highcare(HC)• Intensivecare(NICU)

• Lodgermothers• Counsellingroom• Nursesstations• Utility&storagerooms

• Unitmanager’soffice

• Staffrestroom• Milkpreparationarea

• DoctorsOffices• Meetingroom• Doctorsovernight

MinimumSpacerequiredforeachlevelofcare

7.2m2/motherandbaby

• 6m2/babyforSIC• 7.2m2/motherand

babyforKMC• 7.2-10m2/HC

• 6m2/babyfor6IC• 7.2m2/motherandbabyforKMC

• 7.2-10m2/HC• 10-15m2/ICU

• 6m2/babyforSIC• 7.2m2/motherandbabyforKMC

• 7.2-10m2/HC• 10-15m2/ICU

Handwashingsinkswithelboworfootcontrols

1per6Bedsorpercubicle

1per6Bedsorpercubicle

1atentranceofunitPLUS1per6Beds

1atentranceofunitPLUS1per6beds

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Levelofcare LevelI(Clinic/CommunityHealthCentre)

LevelI(District) LevelII(Regionalhospital)

LevelIII(Tertiaryhospital)

Temperature ~24oC ~24oC ~24oC ~24oCHeating/cooling Heaters Air-conditioning Air-conditioning Air-conditioningLighting Daylight

WhitefluorescentlightWhite/offwhitewalls

DaylightWhitefluorescentWhite/offwhitewalls

DaylightWhitefluorescentWhite/off-whitewalls

DaylightWhitefluorescentWhite/offwhitewalls

Electricalpoints KMC4/bedIC4-6/bedHC6–8/bed

KMC4/bedIC4-6/bedHC6–8/bedICU12/bed

KMC4/bedIC4-6/bedHC6–8/bedICU12/bed

Oxygenpoints 1O2pointper/1000deliveries/year,plus1

1perKMC/SCbeds2perHCbeds

1perKMC/SCbeds2perHCbeds

1perKMC/SCbeds2perHC/ICUbeds

Airpoints 1perHCbed 1perHCbed 1perHCandICUbedSuctionpoints 1per2ICbeds

1perHCbed1per2ICbeds1perHC/ICUbeds

1per2ICbeds1perHC/ICUbeds

3.EQUIPMENT

Theequipmentrequiredisoutlinedinthetable.Buygoodqualityequipmentandensureadequatein-servicetrainingonitsuseaswellasanefficientsystemofrepairingequipment.

Equipment MaternityserviceClinic,Labourward,Theatreandpostnatalward

LevelINeonatalUnit LevelIINeonatalUnit LevelIIINeonatalUnit

Incubators,bassinettes,andgeneralneonatalequipmentClosedincubator

1perSCbed 1perSCbed 1perSCbed

Bassinette(Washable)

4per1000deliveries

1perSCbed

Transportincubator 1per3labourwardbeds2permaternitytheatre

Overheadservoincubator

0 1perHCbed 1perHC/ICUbed 1perHC/ICUbed

HeatShield

0 1perHCbed 1perHC/ICUbed 1perHC/ICUbed

Phototherapyunits 1/Healthcentre1/6postnatalbeds

1per2NNUbeds 1per2NNUbeds 1per2ICandHCbeds

Transcutaneousbilirubinmeter

1/Healthcentre1/Postnatalward

1perNNU

1forKMCandSC1forHCandICU

1forKMCandIC1forHCandICU

Electronicscale 1perclinic1per6labourwardbeds1per12postnatalwardbeds

1perNeonatalunitcubicle



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EquipmentforrespiratorysupportandoxygentherapyVentilators(Complete)

0 1–2forshorttermventilation

1perICUbed

NasalCPAP(Complete)

1perHCbed

1perHCbed 1perHCbed

Headboxes 1perClinic1forLabourWard1forPostnatalWard

1perICandHCbed

1perICandHCbed 1perICandHCbed

Pulseoximeters* 1perHealthCentre1forLabourward1forpostnatalward

1perHCbeds1per2SCbeds

1perHCbeds1per2SCbeds

1perHC/ICUbeds1per2SCbeds

Oxygenblender 1perHCbed 1perHCbed 1perHCbedOxygenanalyser 1per2HCbed 1per2HCbed 1per2HCbedApnoeamonitors 1per2HCbed 1per2HCbed 1per2HCbedTrans-illuminationlight

1 1perHCunit1perICUunit

1perHCunit1perICUunit

Chestdrainkit

1 1 2

FluidcontrollersandcardiacmonitorsIntravenousinfusioncontrollers

1perNNUbed 1perNNUbed 1perNNUbed

Multi-parametermonitors

1perHCbed 1perHC/ICUbed 1perHC/ICUbed

BPmonitor–portable

1 1 1

Syringepumps

1perICUbed 1perICUbed

Mobilesuctionapparatus

1perclinic

1perNeonatalunit 1per6beds 1per6beds

MobileXRay 1inthehospital 1intheunit 1intheunitUltrasoundmachine 1mobilewithinfant

probeavailabletotheneonatalunit

1intheunitwithneonatalprobes,includingecho-cardiography

Bloodgasanalyser 1inlargehospitals 1inthehospital 1intheunit

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ResuscitationequipmentResuscitaire 1perclinic

1perlabourwardbed2pertheatre1perpostnatalward

1perunit 1perunit 1perunit

Self-inflatingneonatalbagandmaskandmasks(sizes00,0,1)

2perresuscitaire2peradvancedresuscitationtrolley

2peradvancedresuscitationtrolley



Suctioncatheters Size103peradvancedresuscitationtrolley3ateachlabourwardbed

Size103peradvancedresuscitationtrolley3ateachlabourwardbed



AdvancedResuscitationtrolley

1perhealthcentre1per6labourwardbeds

1perunit 1per6HC/ICbeds 1per6HC/ICbeds

Neopuff

1perICUunit 1perICUunit

Laryngoscopehandleandstraightmillerbladesize00,0,1,sparebatteries

1perhealthcentre1per6labourwardbeds




Endotrachealtubes 4sizes2.5,3.0,3.5and4,0perresuscitationtrolley

4sizes2.5,3.0,3.5and4,0perresuscitationtrolley



Introducer 1peradvancedresuscitationtrolley




Mcgillsforceps 1peradvancedresuscitationtrolley




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Consumables Oxygentubing* 2peroxygenpoint 2peroxygenpoint 2peroxygenpoint 2peroxygenpointNasalprongs* 2neonataland

pretermperclinic2neonatal/pretermperoxygenpoint

2neonatal/pretermperoxygenpoint



Venturi’s* 1fullsetperoxygenpoint

1fullsetperoxygenpointinSC/HC

1fullsetperoxygenpointinSC/HC

1fullsetperoxygenpointinSC

CPAPcircuit 4circuits/machineavailableforreuse

4circuits/machineavailableforreuse


Ventilatorcircuits 4circuits/machineavailableforreuse



Neonatalsaturationprobes

2permachineavailableforreuse




Neonatalincubatortemperatureprobes

1spareperservoincubator



Infusionsets 5x60dpmset 60dpmorCorrectsetforinfusioncontroller

60dpmorCorrectsetforinfusioncontroller

60dpmorCorrectsetforinfusioncontroller

IVcannulas 5x24and22G Many24and22G Many24and22G Many24and22GDial–a–flow 5perclinic

5inlabourward,andpostnatalward

Infusioncontrollersarepreferable



ConsumablesforbilicheckIVfluids • 10%Neonatolyte,

• NSaline,• 10%dextrose• 5%dextrose

• 10%Neonatolyte,• NSaline,• 10%dextrose• 5%dextrose



Feedingequipment Breastpumps Notrecommendedinclinicsandhospitalsastheyaredifficulttocleanandsterilise.Express

milkbyhandintoacupEquipmentforflashheattreatingmilk2platestove,aluminiumpots

1per12beds 1per12beds 1per12beds

200mland50mlfeedingcup

4per10deliveries 8perbed 8perbed 8perbed

Disinfection Autoclaveatclinic Autoclave Autoclaveandgassteriliser

Autoclaveandgassteriliser

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1. STAFFING,SKILLS,GUIDELINESANDTRAINING

NurseriesatLevelIIandIIIhospitalsandlargerLevelIhospitalsneedpermanentnursingstaffwhoseonlydutyisthecareofillneonates.ProfessionalnursesatlevelIIandIIIfacilitiesshouldbetrainedinNeonatalIntensiveCare.

Table7.Staffrequirements:skills,guidelinesandtraining

Level I (Clinic / Community Health Centre)

Level I (District) Level II (Regional hospital)

Level III (Tertiary hospital)

Medical Staff Medical officer Medical officer / full time Paediatrician

MO’s / Registrars Paediatricians and Neonatologist

Nursing staff requirements

Professional nurses with midwifery training, EN / ENAs

Permanent nurses (Professional nurses and EN / ENA)

Permanent nurses PN with Neonatal (NICU) training

Permanent nurses PN with Neonatal (NICU) training

Nurses per shift

1 PN per 6 babies in SIC 1 PN per 3 HC babies 1 Nurse per 6 KMC

1 PN per 3 HC / ICU babies 1 PN per 6 beds 1 Nurse per 3 HC babies 1 Nurse per 6 babies SIC, KMC

1 PN per 2 ICU 1 PN per 3 HC babies 1 nurse per 3 ICU / HC babies 1 nurse per 6 babies SIC, KMC

Skills required • Resuscitation of newborn • Examination of newborn • Routine care • Observation • Measure blood glucose

and treat hypoglycaemia • Commence IV infusion • Monitor and maintain

baby’s temperature • Assess breast feeding • Administer oxygen and

monitor • Kangaroo Mother Care

• As for level clinc + : • administer parenteral

antibiotics • nasogastric feeding • provide phototherapy

and monitor bilirubin • Perform lumbar

punctures, U&E, Ca, Mg, FBC

• Nasal Prong CPAP

• As for District Hospital +

• chest drains • caridorespiratory

monitoring • Initiate IPPV

• As for regional hospital +

• Ventilator support • Ultrasound examination • Total parenteral nutrition • Exchange transfusions • Care of neonates with

surgical problems

Professional nurse competency required

Midwifery Neonatal resuscitation Routine Newborn Care

Midwifery Neonatal resuscitation Routine Newborn Care Basic newborn training

Midwifery Neonatal resuscitation Routine Newborn Care Basic newborn care Neonatal Intensive care

Midwifery Neonatal resuscitation Routine Newborn Care Basic newborn care Neonatal Intensive care

In-service training or self study courses recommended

Routine newborn care (LINC) Helping Babies Breathe PMTCT Lactation management PEP2 – Primary newborn care

Routine newborn care Helping Babies Breathe MSSN(LINC) PMTCT Lactation management PEP2 – Newborn Care

RNC (LINC) Helping Babies Breathe MSSN (LINC) NRP or equivalent PMTCT Lactation management PEP2 – Newborn care

RNC (LINC) Helping Babies Breathe MSSN (LINC) NRP or equivalent PMTCT Lactation management PEP – Newborn care

2 PEP =Perinatal Education Programme, MSSN = Management of Sick and Small Newborns, RNC = Routine Newborn Care, NRP = Neonatal Resuscitation Programme, PMTCT = Prevention of Mother to Child Transmission

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PROTOCOLSANDPOLICIES

Newbornprotocolsandpoliciesneedtobeinplaceateachhospital.Reviewandadoptpoliciesandprotocolsforyourservice.Thefollowingguidelinesarerecommended.

• EssentialNewbornCareCharts:Managementofthesickandsmallnewbornsinhospital.• EssentialNewbornCareCharts:RoutineNewbornCare• LimpopoGuidelinesforNewbornCare• StandardTreatmentGuidelinesandEssentialDrugListforSouthAfrica:HospitalLevelPaediatrics

REFERRALSReferralpoliciesneedfrequentreview.AsservicesatLevelIIhospitalsdevelop,morebabieswithsevereproblemscanbetransferredforhighcareandNeonatalIntensivecare.Therearestillsomeservicesthatareonlyavailableatthetertiaryorquaternarylevelsandreferralshouldbeexpeditedwithoutunnecessarilygoingviaallthelevels.Goodcommunicationisessentialforreferralservicestoworkwellandforequityofcare.Thefollowingmustexist.

• Telephonesatallfacilities.• Districthospitalsandclinicstohaveaccesstoambulanceswithportableincubatorsandportableoxygento

transportillneonates.• Regionalandtertiaryhospitalstohaveaccesstoambulanceswithadvancedneonatalcareincludingportable

incubators,IVflowcontrollers,pulseoximetersandventilators

NEWBORNRECORDS.AuniformnewbornadmissionrecordasthatdevelopedforLimpopoProvince:

• Ensuresthatthereisadequateperinatalinformation• Facilitatesthemanagementofpatients• Diminishesmissedopportunities• Makestransferofpatientsmoreefficient.

MONITORINGANDEVALUATION

Regularmonitoringandevaluationoftheneonatalserviceinvolvesthefollowing

• CorrectdocumentationofbirthsandperinataldeathsinthematernityregisterandtheninDHISandPPIP• ReviewofperinataldeathsusingthePPIPformat,assessingobstetriccause,neonatalcauseofdeathand

avoidablefactors• CompleterecordingofNeonatalAdmissionsintheNeonatalAdmissionRegister,andNeonatalDeathsin

theNeonatalDeathRegister• MonthlysummaryofNeonataladmissionandDeaths• Meetingswithin24hoursofadeathwiththerelevantroleplayerstodeterminethecauseofdeath• Monthlyneonatalandperinatalimprovementmeetingstodiscussprogresswithimprovements,new

improvements,goodandadverseoutcomes.• DocumentationofBirthDefectsinMonthlySummaryFormandNotification

chapter 2 appendix 1 standards for newborn care

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