Download - Einc Newborn Mar 2011
Essential Newborn Care:
From Evidence to Practice
Essential Intra-Partum and
Newborn Care Scale-Up Program
DOH/WHO
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• 1988-1998: 40%
• 1998-2008: 20%
• Neonatal mortality hasn’t improved
Under Five MR
Neonatal MR
•DHS 88, 93, 98, 03, 08
<5 year old and Neonatal Mortality
The Philippines is one of 42 countries
that account for90% of global
under-five mortality
Most could have lived
82,000 Filipino children die annually
Under Five Year Old Deaths, 2008
Source: Child Health Epidemiology Reference Group (CHERG)
Global, Regional and National Causes of Child Mortality: a systematic analysis. The Lancet May 2010; 375: 1969-1987
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3 out of 4 newborn deaths occur in the 1st week of life
Day of Life
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NDHS 2003, special tabulations
Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate
postpartum period
Neonatal Mortality is high
for Rich and Poor, NDHS 2003
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Poorest 2nd 3rd 4th Least Poor
Preventive Interventions
Breastfeeding 13%
Insecticide-treated materials 7%
Complementary Feeding 6%
Zinc 4%
Clean delivery 4%
Hib Vaccine 4%
Water sanitation, hygiene 3%
Antenatal Steroids 3%
Newborn temperature management 2%
Vitamin A 2%
Tetanus Toxoid 2%
Nevirapine and replacement feeding 2%
Antibiotics for premature rupture of membranes 1%
Measles vaccine 1%
Antimalarial intermittent preventive treatment in pregnancy
<1% The Lancet Child Survival Series.
Lancet 2003; 362: 65–71
What Can We Do to Save Newborn Lives?
Baguio General Hospital, 1970’s
Period I: •Neonates were not rooming-in with their mother
•The hospital allowed formula
•Many cases of neonatal sepsis
Clavano, J TropPed, 1982
Period II: •Neonates roomed-in with their mother
•The hospital strongly promoted breastfeeding policy
•89% reduction of neonates with clinical signs of sepsis
Delaying Initiation of breastfeeding increases risk of infection-related death
Nepal 2008 N = 22,838 breastfed babies
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Rel
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Hours after Birth
Mullany LC, et al. JNutr, 2008; 138(3):599-603.
Delaying Initiation of breastfeeding increases risk of infection-related death Ghana 2004 N = 10,947 breastfed infants
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Random Clinical Control Trial of Low Birth Weight Hospitalized Neonates comparing type of feeding
vs. percentage with serious illness
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Raw ExpressedBF + Formula
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The extent of neonatal death and
sepsis in the Philippines
+ FPS 2006, § Sobel, Silvestre, Mantaring 2009 * Sobel, Oliveros, Nyunt-U 2009
Nationwide home deliveries by non-
health professionals
Nationwide
Hospitals
Newborn Sepsis § Not Studied 6%
Newborn Mortality * 16.8/1000
Live Births
16.0/1000
Live Births
Maternal Mortality 162/100,000 + 234/100,000§
Essential Newborn
Care Protocol was
developed to address these
issues
What Immediate Newborn Care
Practices Save Lives?
Antenatal Steroids: The Evidence
Overall reduction in neonatal death RR 0.69 (95% CI 0.58 – 0.81)
Reduction in RDS RR 0.66 (95% CI 0.59 to 0.73)
Reduction in cerebroventricular hemorrhage RR 0.54 (95% CI 0.43 to 0.69)
Reduction in sepsis in the first 48 hours of life RR 0.56 (95% CI 0.38 to 0.85)
Does not increase risk of death, chorioamnionitis or puerperal sepsis in the mother
Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3.
Antenatal Steroids Betamethasone
12 mg IM q 24 hrs x 2 doses May be the preferred drug – less PVL
Dexamethasone 6 mg IM q 12 hrs x 4 doses
Have dexamethasone available in the E-cart
No additional benefit to using higher or more frequent doses
Prednisone, methylprednisolone, cortisol are unreliable
Antenatal Steroids
After a baby is born, what should be the first action performed?
• Clamp and cut the cord A
• Dry the baby B
• Suction the baby’s mouth and nose C
• Do foot printing D
After a baby is born, what should be the first action performed?
• Clamp and cut the cord A
• Dry the baby B
• Suction the baby’s mouth and nose C
• Do foot printing D
A Minute-by-Minute Assessment of Newborn Care within the First Hour of
Life in Philippine Hospitals (2009)
Sobel, Silvestre, Mantaring, Oliveros, 2009
Intervention Percentage and
Median Time WHO Standard
Drying 97% at 1 min 100% Immediately
Put on cold surface 12% None
Not dried 2.5% None
Head not dried 6.2% None
Every Newborn Has Needs
To breathe normally
To be warm
To be protected
To be fed
Providing Warmth: Check the Environment
Check temperature of the delivery room
Ideal temp: 25 – 28°C
Check for air drafts
Turn air conditioner off at time of delivery
Immediate Thorough Drying Immediate drying: Stimulates Breathing
Prevents hypothermia
Hypothermia can lead to Infection
Coagulation defects
Acidosis
Delayed fetal to newborn circulatory adjustment
Hyaline membrane disease
Brain hemorrhage Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London,
UK. p. 207-220; TollinM,etal.. Cell Mol Life Sci 2005
Drying should be the first action,
IMMEDIATELY for a full 30 seconds
unless the infant is both floppy/limp and apneic
Resuscitation action of 26 infants with apnea:
Sobel, Silvestre, Mantaring, Oliveros, 2009
Action N (%)
Suctioning 24 (92.3%)
Bag and Mask 12 (46.1%) at 120 seconds
Slapping back 7 (26.9%)
Intubation 2 (7.7%) at 3 and 6 min
Chest compressions/ Epi 2 (7.7%) at 4 min
Drying *** 1 (3.8%)
Immediate Thorough Drying
Dry the newborn thoroughly for at least 30 seconds
Follow an organized sequence Wipe eyes, face, head
Front and back
Arms and legs
Wipe gently, do not wipe off the vernix
Remove the wet cloth, replace with a dry one
Immediate Thorough Drying
Do a quick check of breathing while drying 90% of newborns breathe normally after birth
If a baby is not breathing; Stimulate by drying thoroughly
Do not slap the baby
Do not shake the baby
Do not rub the baby vigorously
Immediate Thorough Drying Do not ventilate unless
the baby is floppy/limp and not breathing
Do not suction unless the mouth/nose are blocked by secretions
Unnecessary Suctioning
Of the 455 who were already breathing
94.9% suctioned once
84.0% suctioned more than once
Those trained in neonatal resuscitation were 2.5 (1.1-5.7) and in pediatric resuscitation 2.2 (0.96-5.2) times more likely to unnecessarily suction babies who were already breathing.
Sobel, Silvestre, Mantaring, Oliveros, 2009
During drying and stimulation of the baby, your rapid assessment shows that the baby is crying.
What is your next action?
• Suction the baby’s mouth and nose A
• Clamp and cut the cord B
• Do skin-to-skin contact C
• Do early latching on D
During drying and stimulation of the baby, your rapid assessment shows that the baby is crying.
What is your next action?
• Suction the baby’s mouth and nose A
• Clamp and cut the cord B
• Do skin-to-skin contact C
• Do early latching on D
A Minute-by-Minute Assessment of Newborn Care within the First Hour of
Life in Philippine Hospitals (2009)
Sobel, Silvestre, Mantaring, Oliveros, 2009
Intervention Percentage and
Median Time WHO Standard
Immediate Skin-to-Skin Contact
9.6% at 5 min >90% (except those needing
resuscitation)
Skin-to-Skin Contact Generally perceived to be an intervention for
provision of warmth and bonding
Less well appreciated are its contributions to
Overall success of breastfeeding/colostrum feeding
Stimulation of the mucosa-associated lymphoid tissue system
Protection from hypoglycemia
Colonization with maternal skin flora
Moore E, et al. Cochrane Rev. 2007 Jul 18;(3). Anderson GC, et al. Cochrane Rev 2003;(2).
Brandtzaeg P. Ann N Y AcadSci 2002;964:13–45
Early Skin-to-Skin Contact If newborn is breathing
or crying: Position the newborn
prone on the mother’s abdomen or chest
Cover the newborn’s back with a dry blanket
Cover the newborn’s head with a bonnet
Use a warm cover if room temp <25°C
When should the cord be clamped after birth?
• When the cord pulsations stop A
• Between 1 and 3 minutes B • Between 30 secs - 1 minute in
preterms C
• All of the above are appropriate D
When should the cord be clamped after birth?
• When the cord pulsations stop A
• Between 1 and 3 minutes B • Between 30 secs - 1 minute in
preterms C
• All of the above are appropriate D
A Minute-by-Minute Assessment of Newborn Care within the First Hour of
Life in Philippine Hospitals (2009)
Sobel, Silvestre, Mantaring, Oliveros, 2009
Intervention Percentage and
Median Time WHO Standard
Cord Clamp 12 sec
99% in < 1 min Until pulsations stop
(1-3 mins)
Properly-Timed Cord Clamping Term babies: less anemia in the newborn
24-48 hrs after birth RR 0.2 (95% CI 0.06, 0.6) NNT 7 (4.5 - 20.8)
Preterms: less infant anemia RR 0.49 (95% CI 0.3, 0.81) NNT 3 (1.6 - 29.6)
Preterms: less intraventricular hemorrhage RR 0.59 (95% CI 0.35, 0.92) NNT 2 (1.4 – 9.8)
No significant impact on incidence of Post-Partum Hemorrhage
1) CerianiCernadas ,et al.
2006;
2) Rabe H, et al. 2004;
3) McDonald SJ, et al. 2008;
4) Hutton EK, et al. 2007;
5) Kugelman A, et al. 2007
6) Van Rheenen PF, et al.
2006
7) Van Rheenen PF & Brabin
BJ. 2006
Properly-Timed Cord Clamping
When preparing for delivery, don 2 pairs of gloves after thorough handwashing
Remove the first set of gloves
Palpate the umbilical cord
After cord pulsations have stopped, clamp the cord using a sterile plastic clamp or tie at 2 cm from the umbilical base
Properly-Timed Cord Clamping
Clamp again at 5 cm from the base
Cut the cord close to the plastic clamp
BABY
3cm 2cm
Properly-Timed Cord-Clamping Do not milk the cord
towards the baby
After the 1st clamp, you may “strip” the cord of blood before applying the 2nd clamp
Cut the cord close to the plastic clamp so that there is no need for a 2nd trim
Care of the Cord Do not use a binder or “bigkis”
Do not apply any substance onto the cord
Observe for the oozing of blood. If blood oozes, place a second tie between the skin and the clamp
Washing the Baby in the First 6 Hours is Protective.
TRUE FALSE
Washing the Baby in the First 6 Hours is Protective.
TRUE FALSE
Early Washing Can Lead To: Hypothermia which can lead to
Infection, coagulation defects, acidosis, delayed fetal to newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage
Infection The vernix is a protective barrier to bacteria such as
E.coli and Group B Strep; so is maternal bacterial colonization
No crawling reflex
Tunell R., Cell Mol Life Sci 2005; 62:2390-99; Righard L, Alade M. Lancet 1990; 336: 1105-07.
A Minute-by-Minute Assessment of Newborn Care within the First Hour of
Life in Philippine Hospitals (2009)
Sobel, Silvestre, Mantaring, Oliveros, 2009
Intervention Percentage and
Median Time WHO Standard
Wash 84% at 8 min >6 hours
Temp taken before 17% All
What is the approximate capacity of a
newborn’s stomach?
A
B C
D
What is the approximate capacity of a
newborn’s stomach?
A
B C
D
How long after birth is a newborn ready to breastfeed?
•immediately A
•5-10 minutes B
•10-20 minutes C
•20-60 minutes D
How long after birth is a newborn ready to breastfeed?
•immediately A
•5-10 minutes B
•10-20 minutes C
•20-60 minutes D
Non-separation of Newborn from Mother for Early Breastfeeding
Weighing, bathing, eye care, examinations, injections should be done after the first full breastfeed is completed
Postpone bathing until at least 6 hours
A Minute-by-Minute Assessment of Newborn Care within the First Hour of
Life in Philippine Hospitals (2009)
Sobel, Silvestre, Mantaring, Oliveros, 2009
Intervention Percentage and
Median Time WHO Standard
Breast feed 69.3% at10min Within 1 hour (but when baby shows signs)
Separatedfrom mother 92.9% at12 min >1 hour
Weigh 100% at 13 min > 1 hour
Exam 75.7% at 17 min > 1 hour
Hepatitis B Vaccine 69.4% at 20 min >1 hour
Nursery 52% at 19 min Never
Rooming in 83% (155 min) Immediately with mother
Non-separation of Newborn from
Mother
Never leave the mother and baby unattended
Monitor mother and baby q15 minutes in the first 1-2 hrs. Assess breathing and warmth
Breathing: listen for grunting, look for chest in-drawing and fast breathing
Warmth: check to see if feet are cold to touch if no thermometer
Early and Appropriate
Breastfeeding Initiation
Leave the newborn between the mother’s breasts in continuous skin-to-skin contact
The baby may want to rest for 20-30 mins and even up to 120 minutes before showing signs of readiness to feed
Early and Appropriate Breastfeeding Initiation
Health workers should not touch the newborn unless there is a medical indication
Do not give sugar water, formula or other prelacteals
Do not give bottles or pacifiers
Do not throw away colostrum
Let the baby feed for as long as he/she wants on both breasts
Help the mother and baby into a comfortable position
Observe the newborn
Once the newborn shows feeding cues, ask the mother to encourage her newborn to move toward the breast
Early and Appropriate Breastfeeding Initiation
After delivery, mother is moved onto a stretcher with her baby and transported to Recovery Room, mother-baby ward or private room
Breastfeeding support is continued
Support Continued and Exclusive Breastfeeding
Counsel on positioning
Newborn’s neck is not flexed or twisted
Newborn is facing the breast
Newborn is close to mother’s body
Newborn’s whole body is supported
Support Continued and Exclusive Breastfeeding
Counsel on attachment and suckling Mouth wide open
Lower lip turned outwards
Baby’s chin touching breast
Suckling is slow, deep with some pauses
Support Continued and Exclusive Breastfeeding
Proper Breastfeeding Hold
Look for a quiet place
Find most relaxed position for mother
Provide adequate back support
Support feet
Do not hunch shoulders
Do not “scissor” the breast
Underarm Hold
Football hold
Baby is held like a clutch bag
Nose further away from the breast
Baby’s trunk is secure beside mother’s trunk
Side-Lying Position
Side-Lying Position
E.O. 51 and its rIRR: The DON’Ts
Gifts of any sort Samples or products covered under the Milk Code Posters, other promotional materials or direct
promotions of products covered under the code within your Health Facility, Community, Barangays, Events, etc.
Sponsorships without permission from FDA Endorsements of products covered by the Milk Code
DO NOT REQUEST or ACCEPT from Milk Companies or their representatives: