UNIT 1 ESSENTIAL NEWBORN CARE

Structure
1.0 Objectives
1.1 Introduction
1.2 Principles e f Newborn Care
1.3 Care at Birth
1:3.1 Provision of Warmth
1.3.2 Cord. Skin and Eye Care
1.4 Neonatal Resuscitation
1.4.1 Physiology of Asphyxia
1.4.2 Preparatior~for Delivery
1.4.3 Assessment at Birth
1.4.4 Initial Steps
1.4.5 Assisted Ventilation
1.4.6 Chest Compression
1.4.7 Endotracheal Intubation
1.4.8 Use of Drugs
1.4.9 Role of Apgar Scoring
1.5 Postnatal care
1.5.1 ldentificat~onof At Risk Neonates
1.5.2 Maintenance of Body Temperature
1.53 Promotion of Breastfeeding
1 .5.4 Prevention of Infection
1.5.5 Danger Signs in Newborn
1 .5.6 Immunization Advice
1.5.7 Weight Changes after Birth
1.6 Common Neonatal Problems
1.7 Special Neonatal Situations
1.8 Let Us Sum Up
1.9 Answers to Check Your Progress

1.0 OBJECTIVES
After completing this unit, you should be able to:
outline the steps in the immediate care at birth;
explain the steps in the resuscitation of an asphyxiated newborn;
identify neonates at risk for special care;
evaluate a normal newborn baby and identify a sick neonate;
describe the common neonatal problems; and.
discuss the management of asymptomatic babies born to mothers with Hepatitis B,
Tuberculosis, HIV and Syphilis.

1 . INTRODUCTION
~ e o n a f adeaths
l i.e. deaths during first 2 8 days of life account for more than 60 percent of
all deaths during infancy. Therefore, a reduction in neonatal mortality is essential to have a
Care of Newborn and significant decline in infant mortality rate. Moreover, most of the deaths during neonatal
Young Infant
period are preventable.
In this unit you shall appriase yourself of care of the newborn at birth which is primarily
aimed at helping the newborn to adapt to the extra uterine environment. The physiological
adaptation includes initiating respiration and oxygenation of arterial blood, temperature
adaptation and initiating feeding. The present unit will discuss the prevention of
maladaptation at birth which can lead to asphyxia and hypothermia which are associated
with fatal consequences.

We shall also review some of the continuing adaptive changes that take place in the
newborn especially during the first week of life. It is important to understand that these
phenomena are often mistaken for an illness and the newborn is unnecessarily treated.
However, the line dividing normal from the abnormal is often a fine one and we need to be
careful not to miss when the newborn's condition shifts from the normal to the abnormal
situation

PRINCIPLES OF NEWBORN CARE

The basic principles of care at birth are same irrespective of the place of the birth and the
person attending to birth (medical or paramedical personnel). The aims of neonatal care at
birth include the following:

Estabiishment of respiration
Prevention of hypothermia
Establishment of breast feeding
Prevention of infection
Identification of at risk neonate

1.3 CARE AT BIRTH

The umbilical cord should be clamped as soon as the neonate is completely delivered.
Early and immediate clamping of the cord is indicated in babies with severe birth asphyxia,
cord around the neck and rhesus iso-immunization. Efforts are directed to prevent
hypothermia and attention is focused on the airways, so that they are cleared off any
secretions and kept patent. Baby is dried and kept with the mother using skin-to-skin
contact. Clearing of the upper airway can be provided as necessary by wiping the baby's
mouth and nose. This is called routine care (Fig. 1. I). However if liquor is meconium
stained, baby is preterm or not crying or breathing ineffectively or he is limp baby will
need initial steps and resuscitation (as described in sub-section 1.4 of this unit).

1.3.1 Provision of Warmth

Hypothermia (body temperature < 36OC) can occur within the first few minutes after birth
if preventive steps are not taken.

Effect of Hypothermia on the Newborn

Hypothermia results in increased oxygen consumption (for generating more body heat) and
hypoxemia, increased glucose consumption (glucose is the fuel burnt by the body for
generating heat) and hypoglycemia as well as metabolic acidosis. Hypoxemia and
hypoglycemia can result in death of the newborn. Amongst survivors it can lead to
permanent impairment of the brain resulting in developmental handicaps.

Why should a newborn become hypothermic at birth, especially when human beings
are homoeothermic? There are several reasons:

1) The birth places (whether at home or a hospital) usually are considerably cooler
(about 24-28OC) than the teniperature of the newborn (37OC). This results in heat
 Essential Newborn Ca
being lost from the naked baby to the cooler environment by radiation. This highlights
the need to keep only the essential equipmentlartjcles in the delivery area.

2) ~ 1 babies
1 are born wet and therefore evaporation of fluid from the skin surface
results in evaporative heat loss.

3) Very often currents of air from fans and open windows result in heat being carried
away from the baby's skin surface by the process of convection.

4) Babies loose some heat to the surface on which they are placed by conduction, and
this increases if they are placed naked.
Do you know how this tremendous heat loss at the time of birth can be prevented?
Simple interventions listed below can achieve the desired result.

I) Receive the baby at birth in dry, warm, clean linenitowel and dry the baby well.
Discard the wet linen immediately and wrap in fresh, clean, dry linen. This procedure
will minimize evaporative heat loss.

2) After drying the baby, place him near a source of warmth. A no[-ma1baby, who is
crying well after birth, can be placed in skin-to-skin contact on the mother's abdomen
and covered with dry cloth. The maternal body heat will provide the extra warmth
required. It also has the added advantage of reassuring the mother of her baby's well
being and initiating breast feeding early.

Whenever skin to skin contact is not feasible, you can provide additional heat by
placing the baby under a source of heat such as a lamp with a 200 watt bulb or a
radiant warmer (in institutional deliveries). These procedures minimize radiant heat
loss from the baby.

3) You must take care that during the birth of a baby there are no fans switched on in the
delivery room or open windows through which air currents blow into the room. These
steps will minimize convective heat losses.

1.3.2 Cord, Skin and Eye Care

Care of Umbilical Cord

The umbilical cord should be clamped and cut soon after the infant is completely
delivered. There should be no undue delay or unnecessary anxiety to clamp the cord.
Put ties tightly around cord at 2cm and 5cm from baby's abdomen, cut between ties
with a sterile blade. OR
Use commercially available Cord Clamp at 2 cm from baby's abdomen
Observe for oozing blood. I f blood oozes, place a second tie between the skin and
first tie.
DO NOT apply any substance or medication to stump.

II DO NOT bind or bandage stump.

Leave stump uncovered
r
t
!
Care of Eyes

i The eyes should be cleaned at biith and once every day using sterile cotton swabs soaked
in sterile water or normal saline. Each eye should be cleaned using a separate swab.
Routine use of local antiseptic drops for prophylaxis is not recommended
Skin Care
Clean the baby off blood, mucus and meconium before presenting to the mother. Bathing
of babies soon after birth is not recommended.

Give Vitamin K lmg intramuscular once and initiate breast feeding soon after
.
birth; preferably within the first hour and let the baby breast feed on demand
*
Care of Newborn and
Young Infant

Birth

30
Second
T
S

t
30
Second

+t Persistent cyanosis

30 HR>100 & Pink

Second
s

Fig 1.1: Neonatal ResuscitationAlgorithm

Birth asphyxia accounts for about 19% of the approximately five million neonatal deaths
that occur each year worldwide (WHO 1995). Of the 26 million infants born in this
country, 3.5% experience asphyxia at birth. Perinatal asphyxia results from conditions that
interfere with maternal transport of oxygen to the placenta, placentaUfetal gas exchange
and transport of oxygen from the placenta to the fetal tissues. It is usually accompanied by
hypercapnia and results in hypoxia and metabolic acidosis. This suggests that outcome of
more than one million new born each year can be improved by using the correct
resuscitation techniques.

Most newly born babies are vigorous at birth and make smooth transition from intra-
uterine lives to extra-uterine environment. About 8% to 10% of babies require some
assistance at birth; however, the absolute number becomes more due to large number of
births in our country. Only about 1 to I .5% needs extensive resuscitative techniques
I
!

including chest compression and medications.

1.4.1 Physiology of asphyxia

Although fetal lungs are expanded in- utero, but alvqli are fluid Nled. At birth, the fluid
in the alveoli is absorbed into lung tissue and is replaced by the air.

The blood vessels in fetal lungs are markedly constricted. Exposure to oxygen after birth
causes the pulmonary arterioles to relax, permitting a dramatic increase in pulmonary
blood flow. The blood absorbs oxygen from the air in the alveoli, and the oxygen-enriched
blood is pumped into the tissues throughout the body.
 But when a fetushewborn becomes deprived of oxygen, an initial period of rapid Essential Newborn Care
breathing is followed by primary apnea. Primary apnea can be resolved by tactile
stimulation. If oxygen deprivation continues, secondary apnea ensiles. The heart rate
continues to fall, and the blood pressure falls. Secondary apnea cannot be reversed with
stimulation and assisted ventilation must be provided.
When faced with an apneic infant at birth, since it is not possible to distinguish between
primary and secondary apnea, one must assume that apnea in newborn at birth is secondary
apnea and begin assisted ventilation. if there is no response to tactile stimulation given
r twice.

1.4.2 Preparation for Delivery

i At every birth, you should be prepared to resuscitate a newborn because the need for
resuscitation can come as a complete surprise. Three important questions need to be
answered while preparing for resuscitation.

II a)

b)
What risk factors are associated with this pre~nancy?

What personnel should be pre.jent at delivery?

c) What equipment should be made available?

1 Risk Factors

I All babies born to mothers with risk factors have more chances of needing assisted or
advanced resuscitation and these babies also require post-natal care in a specialized center.
If facilities for delivering such mothers are not available arrange for in-utero transportation
of the baby (i.e. mother) to a nearby referral center.

High Risk Factors

Mother with high blood pressure, edema feet, diabetes and severe anemia.
Bleeding in second or third trimester.
Previous fetal or neonatal death.
History of previous premature or low birth weight baby.
Maternal age less than 16 years or more than 35 years.
0 Breech or other abnormal presentation.
Multiple pregnancies e%.
Personnel
Aperson, who has the skill of basic resuscitation, must be present at every birth. The
individual must be a doctor or a nurse who knows the initial steps and technique of
positive pressure ventilation. Person must be present physically and not on call because the
evidence suggests that problem can arise at the time of labor in a number of low risk cases
also.
Equipment

Before delivery one must check the following equipnients, which should be in working
condition:
Source of heat, either radiant warmer or 200-watt bulb
Minimum two clean dry sheets for each newborn
Oxygen supply
Self inflating bag with face mask of three direrent sizes
Laryngoscope with endotracheal tubes of different sizes
Drugs - Epinephrine, N a l o \ o ~ l c .P\lo;.n1;11 s;llitlC
Suction catheters 13 S: I -I 1
Care of Newborn and Tape, scissors
Young l ~ f n n t
Appropriate size gloves
The Principles of Resuscitation
The three cardinal principles of resuscitation are A, B and C
A. Ensure an open AIRWAY through proper position and clearing the passage of any
secretions.
B. To initiate BREATHING by tactile stimulation and PPV when necessary.
C. To maintain CIRCULATION with cardiac compressions and medication.

Newborn babies are wet following birth and heat loss is great. It is therefore important to
maintain body temperature, and hence modifying "ABC" to "TABC" for the neonate
would be more appropriate.

1.4.2 Assessment at birth

Make a quick assessment of the following characteristics

1) Is the amniotic fluid clear of ~neconium?

2) Is the baby breathing or crying?

3) Does the infant have good muscle tone?

4) Is the baby born after full term gestation?

If answer to all above questions is YES, i.e. the infant baby is born at full term, liquor is
clear of me conium, baby is crying well and breathing and has a good muscle tone, this
qualifies for a care which is called ROUTINE CARE.
Steps in ROUTINE CARE are:

I) Provide warmth by skin to s k ~ ncontact

2) Position the baby prone over the chest and abdomen of the mother with head turned to
one side

3) Wipe the mouth with clean cloth or gauze piece

4) Dry the baby

5) Assess the color

However, if skin to skin care is not feasible on mother's abdomen as in Caesarean
section perform these steps under over head servo control warmer.
If the answer to any of the above asked question is 'NO' i.e. the baby
is born pre-term
is not breathing or has gasping respiration
has poor muscle tone or
the liquor is meconium stained proceed to next step in resuscitation called initial steps,
1.4.3 Initial Steps of Resuscitation
Provide warmth
Position clear airway (as necessary)
Dry, stimulate, reposition
Initial steps of resuscitation (perform within 30 seconds)
Provide of warmth by placing the b by under Servo-control overhead radiant
warmer
 Position: Universal position of baby during whole resuscitation is with Neck slight Essential Newborn Care
extension which is called "Sniffing Position". This can be achieved either manually or
by placing a roll of sheet beneath the shoulders Fig 1.2

Shoulder KOII

fI Fig. 1.2: Snifling Position

Clearing of the airway. Depends on whether the liquor is clear 01. is me conium
stained. If the liquor is clear, do the suction of Mouth first followed by Nose.
I
r Procedure o f orophryngeal suction

I Secretion may be removed from the airway by wiping the nose and clearing the
oropharynx by applying suction through a suction catheter (size 12-14 F).
The negative pressure for suction should be between 80- 100 Inn1 Hg, not exceeding
I00 mm Hg in any case.
The mouth is suctioned before the nose to ensure that there is nothing to aspirate if
the baby takes gasp while the nose is being suctioned. You can remember mouth
I before nose because "M" comes before "N" in alphabet.
Suction should be gentle and avoid stimulating posterior pharyngeal wall.
Caution: Vigorous suctioning may cause bradycardia and apnea due to vagus nerve
stimulation. If bradycardia occurs, stop suctioning and re-evaluate the heart rate.

Don't: Don't apply mouth for suctioning. It may infect you or you may infect the baby.

Dry the baby and discard wet linen

Provide tactile stimulation if not breathing after above steps: Should only be
I provided twice by tapping or flicking the soles or gently rubbing the back Fig 1.3
avoid certain hannful actions (Table]. I)

Fig. 1.3: Method o f tactile stimulation

Care of Newborn and Table 1.1 Certain Harmful Actions which should be abandoned
Young Infant
-
Harmful Actions Consequences
Slapping the back Bruising
Squeezing the rib cage Fracture, pneumothorax, respiratory distress, death
Forcing thighs on abdomen Liver or spleen rupture
Dilate anal sphincter Tearing of sphincter
Hot or cold compresses Hyperlhypothermia, bums
-
Shaking Brain damage

Reposition the baby

Make next assessment
Management of Meconium Stained Amniotic Fluid (MSAF)
Pacts:

1) The management of babies born through MSAF does not depend on consistency of
me conium i.e thick or thin or color of me conium i.e yellow or green

2) Routine lntrapartum suctioning of mouth and nose is not required in these babies.

3) The management of these babies is decided by the condition of the baby i.e. whether
the baby is VIGOROUS or not
VIGOROUS BABY is defined as the one who has:
I) Strong respiratory efforts

2) Heart rate > 100 bpm

3) Good muscle tone
Babies who are born through MSAF and are vigorous perform usual resuscitation as
described in initial steps.
Those babies who are NOT VlGOROUS i.e either have poor respiratory efforts or Heart
rate is less than 100 bpm or has a poor muscle tone need Endotracheal Suction before
proceeding with other steps in Initial Steps.
While performing Endotracheal Suctioning:
Administer free flow oxygen throughout
Clear mouth and posterior pharynx
Perform endotracheal suctioning using the endotracheal tube and not through
endotracheal tube
Insert endotracheal tube into the trachea
Attach the ET to suction source
Apply suction as ET is slowly withdrawn
Repeat as necessary until no meconium or heart rate indicates further resuscitation
After performing Initial Steps make assessment oT:
Respiration
Heart rate- Count the heart beat or palpate the umbilical pulsations for only six .
seconds and multiplies by ten. To obtain the heart rate per minute (e.g. a count of 12
in 6 seconds is a HR of 12011ninute).
Color: Look for cyanosis al lips/tongue.
 Essential Newborn Care
Remember assessment during neonatal resuscitation is always done in this
sequence of Respiration, Heart Rate and Color
Some babies have spontaneous respiration, but have central cyanosis, ensure that they are
warm and the sheet is dry. At this stage provide them with free flowing oxygen with face
mask or loosely cupped hand with a oxygen source at a flow rate of 5 literslminute Fig 1.4.

I
Fig 1.4: Technique of free flow Oxygen

Use 100%oxygen during neonatal resuscitation. However, if oxygen is not available

proceed with resuscitation with room air.

Remember administering free flow oxygen or continuing to provide tactile

stimulation to a non-breathing new born or to a new born whose heart rate is less
than 100 beats per min is of no value and only delays appropriate treatment.
If the baby is still apneic or gasping, immediately initiate positive pressure ventilation with
a bag and mask.

k 1.4.4 Positive Pressure Ventilation

t Indications
I

Apnealgasping respiration after 30 sec of initial steps.

1 Heart rate below 100 after initial steps and positive pressure ventilation for 30 sec.

t
Persistent central cyanosis.
Bag and Mask
Self inflating bag: The self-inflating bag is designed to inflate automatically as you release
your grip on the bag, It does not require a compressed gas source to fill. It has the
following parts: Air inlet, oxygen inlet, patient outlet, valve assembly, oxygen reservoir
i and pressure release valve. Fig 1.5
1 Air inlet (with oxygen 6 . Pressure-release
resewoir attached) (pop-off) valve

ve assembly

2. Oxygen Inlet
7. Pressure
manometer stte
3. Patient outlet
Fig. 1.5: Self Inllating Bag
Care of Newborn and Ensure that oxygen reservoir is attached to be resuscitation bag.
Young Infant
An oxygen reservoir is an appliance that can be placed over the bag's air inlet.
The advantage of reservoir is to get 90-1 00% oxygen at the patient outlet as compared
to only 40 % without reservoir with oxygen connected to oxygen inlet.
If no oxygen is attached to the bag, it provides only 2 1% i.e. Room air
A pressure release valve is also called a pop-off valve. If pressures greater than 30 to
40 crn H20 are generated as the bag is compressed the valve opens, limiting the
pressure being transmitted to the lungs of the infant.
The ideal size of the'bag for neonates is 240 to 500 ml capacity.
Select the appropriate sized mask. Mask should cover the mouth, nose and tip of the
chin but not the eyes Fig 1.6. It should be cushioned and round.

Incorrect Correct
Incorrect
1:ig. 1.6: Face Mask Position

Procedure of PPV
Position yourself at the side or head of the baby to use the bag effectively and to view the
baby's chest for the rise or fall. Fig 1.7

Fig. 1.7: Bag and Mask ventilation i

Application: The mask should be applied with slight pressure to avoid the leakage
and should be held with the thumb, index and the middle finger of the left hand; while
supporting the chin with the ring and the little finger. 1
Technique: The bag is squeezed to cause a visible chest expansion. The best guide to
adequate pressure during bag & mask ventilation is an easy rise and fall of the chest
with each breath.
Rate of PPV should be 40-60 per min and while applying pressure say "squeeze, two
three ... squeeze, two, three ... squeeze, two, three". Release the pressure while
counting "...two, three". This sequence will give a rate of 40 to 60 breathdminute.
Effect: If there is no improvement in color, heart rate or breathing, it is possible that
the chest is not expanding adequately
i Airway Blocked

1
- -
Check list in case of non expansion of chest

Yes Orophryngeal suction

Essential Newborn Care

I O '
C

- -
1 Chek neck position
t

i
Leak in Mouth Seal Yes Reapply face mask with proper seal

1
No
Insufficient Inflation b
- Yes ----b Check leak in bag

1 Increase pressure applied

N0
Lung Pathology (Consider the need to intubate the patient)

The primary measure of improvement is increasing heart rate. If heart rate is not of
improving, assess chest movements and check breath sounds.

After 30 seconds of adequate PPV assess the child for heart rate and there would be three
situations that you may come across.

Respiration adequate, heart rate above 100 per min. Wean this child off PPV by
providing free flow oxygen and look for color. Soon the child will become pink.

Heart rate 'between" 60- 100 per min: Continue positive pressure ventilation and
recheck for chest movements.

Heart rate below 60 per min: Continue positive pressure ventilation and start chest
compression.

Bag and mask ventilation may cause abdominal distention and may compromise
ventilation. Therefore if bag and mask ventilation is required for more than 2 minutes,
an orogastric tube (Feeding Tube size 6-8 Fr) should be inserted and left open to
decompress the abdomen.

1.4.5 Chest Compression

If the heart is below 60 despite adequate PPV for 30 seconds, Chest compression should
be initiated to improve circulation and must always be accompanied by ventilation with
100% oxygen.

Indication: Heart rate below 60 beatslminute after 30 sec of effective PPV with 100%
oxygen. Once the heart rate is 60 or above 60 beats per minute, chest compressions should
i be discontinued.
Technique: For chest compressions two trained personnel are needed: one for assisted
L ventilation and other for cardiac compression.

There are two ways of chest compression: Thumb and finger technique, Thumb
technique is preferred than finger technique.
t
,
Thumbs of both hands are placed either side by side or one over the other with fingers
i encircling the rib cage Fig I .8.
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 Essential Newborn Car
Chest compression can cause trauma to the underlying vital organs. Avoid pressure over
the ribs and xyphoid.

1.4.6 Endotracheal Intubation

Most ofthe babies are managed by initial Steps and PPV. Only less than 1-1.5% of births
need chest compression or endotracheal Intubation. Intubation is a ~~elatively
difficult skill
to master and it requires frequent practice to master this skill.
Indications
Me conium stained liquor and child is limp andlor apneic.
Suspected congenital diaphragmatic hernia.
Non-response to bag and mask ventilation.
Prolonged positive pressure ventilation is required.
Equipment: Correct sized endotracheal tube and straight blade laryngoscope of size "0"
for Preterm and "1" for term neonate. The appropriate size of the tubes for different
babies is given In the chart.

Tube Size
Inner diameter (mm) Weight (g)

2.5 <I000

3.0 1000-2000

3.5 2000-3000
4.0 >3000
1

Technique: With the help of laryngoscope, introduce the ET Tube to a level so that the
vocal cord guide is placed at the level of the vocal cords. This usually positions the tip of
the tube above the bifurcation of the trachea.
Confirm the tube placement by ventilating the infant and checking for heart sounds on
both sides of chest and stomach. With correctly placed tube, air entry is heard on both
sides of chest and air is not heard entering the stomach.

The role of drugs is very limited. In few infants who fail to improve with ventilation and
chest compression, the medication becomes necessary. Only the following drugs are
required for neonatal resuscitation: -

Adrenaline
Naloxone
Volume expanders (Normal Saline)
Remember atropine, dexamethasone, calcium, dextrose etc. are not indicated for
resuscitation in the delivery room.

Adrenaline
- Indication: Heart rate is below 60 beats per min despite chest compression and
PPV for 30 sec.
- Dose and route: Through intravenous route in a dose of 0. I to 0.3 ml per kg of
1: 10,000 dilutions.
- Awaiting IV access, it may be given through endotracheal route in a dose which
is 10 times the intravenous dose.
- Dose can be repeated after 3-5 minutes if no response
Care of Newborn and Naloxone hydrochloride
Young lnfant
- Indication: A baby with poor respiratory effort but good heart rate (>I001
minute) and is pink despite adequate PPV and there is history of administration
of Morphine or Pethidine to the mother within past 4 hours
- Dose of 0. I mglkg. Naloxone is to be given IV and not to be given by ET route.
Volume Expanders are indicated if there is evidence of acute blood loss with signs of
hypovolemia. Give 10 ml/kg of Normal Saline over 10 minutes intravenously.
Sodium bicarbonate is better avoided in labor room: It is indicated whenever there
is metabolic acidosis. However, in the delivery room situation, a baby must be
considered to have metabolic acidosis if after 5 minutes of assisted ventilation,
cardiac compression and drugs, the newborn is apneic or gasping and has a heart rate
<IOO/min. Dose is 2 ml/kg of sodium bicarbonate diluted with equal amount of
distilled water. Route is slow intravenous over 2-3 minutes.

When to terminate resuscitation

Babies who show no sign o f l ~ f eat birth (on no heart rate or respiratory efort) after
10 minutes qfresuscitation (i.e Apgar score o f 0 at 1, 5, 10 minutes) have a high rate
of mortality or severe neuro derrelopment impairment. I f after 10 minutes of
continuous and adequate resuscitation, no sign oflife remains it may be just@able to
stop resuscitative efforts.
>

Resuscitation should not be started a t all in the following cases

1) Birth weight below 500 g

2) Anencephaly
3) Trisorny 13 and 18
Remember in all so-called 'stillbirths' the resuscitation efforts must be continued for 10-
15 min. The data suggests that in fresh stillbirths prognosis is not all that bad.
Approximately 60-65% term babies can be revived with good outcome in so called
stillbirths.

1.4.8 Role of Apgar Score

The Apgar score (Table 1.2) is the measure of the status of the new born immediately after
delivery. As scoring does not begin until one minute of age, it is not used to determine the
need for resuscitation. The Apgar when properly applied it can be used for ongoing
standardized assessment of resuscitative efforts.
Table 1.2: Scoring of Apgar score

Parameters 0 1 2

Respiratory effort Absept Gasping Good cry .

Heart rate Zero <I 00/min >1 00/min

Color (Cyanosis) Central Cyanosis Peripheral Pink

Cyanosis

Tone Flaccid Partial Flexion of Complete

extremities flexion

Reflex response to None Grimace Sneeze

nasal catheter
L I I

A low Apgar sc~oreby itself is not indicative of intrapartum hypoxia, nor does it predict
mortality or long term neurological abnormality. The factors that depress Apgar scores
include low gestational age, maternal medications, infection, neonatal respiratory disease,
and congenital neurologic/neuromuscular disease.
1.5 ESSENTIAL POSTNATAL CARE
The basic principles of essential and effective postnatal care include
Prevention and optimal management of hypothermia .

Prevention of neonatal infections

Promotion of breast feeding.
Early identification of dangers signs for systemic illness and its management.
Mother should be advised regarding the immunization schedule.
1.5.1 Identification of At Risk Neonates
An important task of the attending physician at the delivery room is the identification of
newborns at high risk for morbidity and mortality. Examine for birth defects, birth injuries
or any breathing difficulty. The newborns thus identified would need to be provided
special care, either at their place of birth (if facilities exist) or referred to a health center
with appropriate facilities for the care of these newborns.
The patency of esophagus should be checked by passing a stiff rubber catheter into
the stomach.
Also check for anal opening
Record weight, length and head circumference
1) Birth weight: Birth weight of a baby is one of the most important predictors of risk
for disease and death. All newborns must be weighed at birth on an infant weighing
scale. Newborns with birth weights < 2500 g are known as low birth weightS(LBW)
and are at special risk. However, most well babies with birth weights > 1800 g can be
managed at home. Those < I 800 g would need referral to a hospital with special
facilities. (Unit 2 in this block provides details of management of Low Birth Weight
Babies
 2) Preterm: Preterm newborn, especially those c36 weeks of gestation need special care Essential Newborn Care
and would also need referral. These babies can be identified from the dates calculated
from the mother's Last Menstrual Period (LMP). If that is not available, the same can
be identified by examination of the baby. (For details of gestational assessment refer
to Unit 2).

3) Major malformations: Newborns with major malformations such as

Meningomyelocele, Hydrocephalus, Anterior abdominal wall defects such as large
Omphalocele are easily identified on inspection of the baby. Serious defects like
Diaphragmatic Hernia may be suspected in a baby with respiratory distress with a
scaphoid abdomen. Suspected cases of esophageal artesia (those with excessive
salivation, inability to pass red rubber catheter into stomach) also need referral. All
these babies need prompt referral for surgery.

Fig. 1.10: (A) case of Meningomyelocele (B) Hydrocephalous

4) Birth asphyxia: Newborns who are asphyxiated (who required positive pressure
ventilation at birth) would need referral to a hospital equipped to provide post
resuscitation care for problems such as convulsions, hypoxia, hypoglycemia,
hypocalcaemia, shock, renal failure etc.

5) Respiratory distress: Newborns who have respiratory rate > 60lmin (on counting for
one full minute), those with chest retractions or cyanosis, would need referral to a
hospital with facilities to provide respiratory support. (Details of management of such
neonates are provided in Unit 5).

1.5.2 Maintenance of Body Temperature

k The newborn has limitations in body temperature regulation compared to the adult. These
handicaps predispose the infant to hypothermia with its attendant serious sequelae.

Heat Production

Heat is generated in an adult by physical activity. In the newborn, however, muscular

activity has no role in heat production. It relies on a chemical process for heat production.
The essential components for chemical thermogenesis or non shivering thermogenesis in
the newborn include:
t
i
1) Brown fat: These are specialized fat cells located in the axilla, paraspinal and
I restrosternal areas and perirenal region. They have a high metabolic activity due to
F presence of mitochondria and are the power houses where heat is produced. These are
deficient in Preterm and LBW babies placing them at increased risk for hypotherrnia.

- Glucose: Glucose is the principal metabolite which is broken down to generate heat.
2)
This is made available from the glycogen stores in the liver and carbohydrates from
feeding. Preterm and LBW have low glycogen stores and are at increased risk of
i hypoglycemia and hypothennia.
Care of Newborn and In responses to fall in temperature, the brown fat is stimulated to generate heat to keep the
Young Infant body warm and glucose is utilized in the process.

Heat Loss
Heat loss occurs by one of four mechanisms:

1) Radiatioh: Heat loss to environment surrounding the baby. If the environment is

lower than 30C, the baby is likely to loose more heat from its body. In Preterm and
LBW babies, decreased insulation due to decreased subcutaneous fat increases the
radiant heat loss.

Fig.l.11: Four ways a newborn may lose heat to the environment

2) Conduction: This is the heat lost by contact with cold objects like cold tables,
mattresses, weighing scale etc.

3) Convection: This is the heat lost to surrounding air that is moving around the baby.

4) Evaporation: This is the heat lost from the wet surface of the skin. This is mechanism
of heat loss is most evident at birth when a baby is born wet.

Temperature Recording

Normal temperature in a newborn is 36.5 - 37SC. Hypothermia occurs when the body
temperature drops below 36.5OC. Preferably low reading thermometer recording
temperature as low as 30C should be used in the newborn to record temperature (records
between 30% - 40C).

a) Axillary Temperature is as good as rectal and probably safer (less risk of injury or
infection). It is recorded by placing the bulb of thermometer against the roof of dry
axilla, free from moisture. Baby'sprm is held close to the baby to keep thermometer
in place. The temperature is read after five minutes.

b) Rectal Temperature Do not use this method for routine monitoring. However, it is
the best guide for core temperature in cold sick neonates. It is recorded by inserting
the bulb of the rectal thermometer backwards and downwards to a depth of 3cm in a
term baby (2cm in a Preterm baby). Keep thermometer in place at least for 2 minutes.

Assessment of Temperature by Touch

Baby's temperature can be assessed with reasonable precision by touching with dorsum of
hands. When feet are cold and abdomen is warm, it indicates that the baby is in cold stress
(temp 36 - 36SC). In hypotherrnia (temp below 36OC), both feet and abdomen are cold to
touch.
 Prevention of Hypothermia Essential Newborn C a r e

Baby must be kept warm at the place of birth (home or hospital), during transportation for
special care from home to hospital or within the hospital. Satisfactory control demands
both prevention of heat loss and promotion of heat.gain. The 'warm chain' is a set of
interlinked procedures carried out at birth and later, which will minimize the likelihood of
hypothermia in all newborns.

Steps to prevent heat loss in labor room

Immediate drying, remove wet towel, wrap the baby in another dry towel.
Warm delivery room (26OC)
Skin to skin contact between' mother and baby.
Steps to prevent heat loss in postnatal ward
a . Breast feeding
Appropriate clothing, cover head
Keep mother and baby together
Warm room
a Postpone bathing
Bathing of newborn - it is best to postpone bathing of newly born infants. However, if
cultural practices demand bathing or if the baby is soiled with blood or meconium,
washing 2-6 hrs after birth is permissible as long as baby's temperature is normal. When
bath is given caregiver should:
Warm a small area or corner of the room
Use warm water checked with her elbow, and undresses the infant on her lap.
Bathe the infant quickly and gently
Immediately wrap the infant in a warm towel and dried thoroughly from head to toes.
Quickly dress and wrap the infant, remembering to place a cap on baby's head.
Place the infant close to mother and allow breast-feeding.
1.5.3 Promotion of Breastfeeding
It is important both for the mother and her infant that breast feeding should be initiated
within an hour of birth. The delivery room staff must ensure that the mc her puts the baby
to breast as soon after delivery as possible. The advantages for the mother are that it aids
uterine involution and decreases the risk of post-partum hemorrhage (by release of
oxytocin secondary to the suckling reflex). The baby is benefited by the provision of
nutrition and immunity from breast milk and increased maternal-infant bonding. (You will
learn more about management of IactationIBreastfeeding in UniL 17, Block 4 of this
Course.

1.5.4 Prevention of Infection

Neonatal sepsis is the single most important cause of neonatal deaths in the community,
accounting for over half of them. For prevention of infection in neonate, appropriate care
of umbilicus, skin and eyes is very important.
C

A) Care of the Umbilical Cord Stump

The cord stump remains common site of entry for infections after birth.
Keep the cord dry and clean

Do not apply anything like oil or other substances on the cord and it must be left open
without any dressing.

The stump will dry and fall after 5 to 10 days of life.

Care of Newborn and Avoid soiling with urine. If soiled, the cord can be cleaned with clean water and dried
Young Infant with clean gauge. No antiseptics are needed for cleaning.

If the umbilical stump is draining pus or skin around it is becoming red, these are
signs of an umbilical infection requiring treatment with local antibktics. ,

Along with this, if the baby is lethargic or stops sucking, these are signs of serious
infection requiring parenteral antibiotics.

B) Care of the Eyes

Routine cleaning of eyes is not recommended.

Do not applying kajal or surnia in the eyes

In a baby with purulent eye discharge, clean eyes with sterile water and instill
antibiotic eye drops.

Babies with persistent eye discharge require massage of lachrymal sac at the outer
side of the nose adjacent to the medial cantus. This may be done 6 to 8 times or each
time before she feeds the baby.

C) Skin Care

Clean the baby off blood, mucus and meconium with clean water and dry it
adequately.

Bathing of babies soon after birth is not recommended. Postpone bath to preferably
next day and ensure that baby's temperature is normal before giving bath.

Do not apply any powder.

Look for any superficial infections like pustules or big boils. Treat as per IMNCl
guidelines:
- If less than 10, apply Gentian violet 0.5% (available solution of Gentian violet is
1% dilute this with equal volume of sterile water) and give oral amoxicillin / co-
trimoxazole for 5 days.
- If the number of pustules is more than 10, use systemic injectable ampicillin and
gentamicin for 5 - 7 days.

1.5.5 Danger Signs in a Newborn

The mortality among sick neonates is very high, it is therefore important that the mother
and family are explained about danger signs in a newborn for bringing the baby to a health
facility early.

Lethargy with poor suck

Hypothermia (Cold abdomen and feet)

Breathing d ificulty

Abdominal distention

Bleeding from any site

Jaundice: Yellow staining of palms/soles

1.5.6 Give Immunization advice after birth

At birth, BCG, OPV-0, and Hepatitis B vaccines are recommended. After this follow the
schedule of universal immunization programme.
 Essential Newborn Gal

A woman wishes to deliver her baby at home. Prepare a set of instructions for her which
will enable her to provide appropriate immediate care for her newborn infant at birth.

Visit a delivery room for a large hospital in your neighborhood or the district hospital and
then briefly write a plan of how you would organlze newborn care in the delivery room of
a peripheral hospital.

1.5.7 Weight Changes after Birth

Most healthy term babies lose weight during the first 2 to 3 days of life. The weight loss is
usually up to 5 to 7 per cent of birth weight. The weight remains stationary during next one
to two days and birth weight is regained by the end of I0 days. While Preterm babies
loose weight up to I0 per cent but regain birth weight by 14 days of age. Weight loss more
than 10 per cent over birth weight in a term baby and more than 1 5 per cent in Preterm
should be viewed with concern and one should attempt to seek the cause as early as
possible. The adequately fed baby passes urine at least 5 to 6 times in a day while many
babies may pass urine (even stools) after each feed during the first 3 inonths of life. The
average daily weight gain in term babies is around 30 g, 20 g and 10 g during the first,
second, third, fourth month's periods respectively during the first yea1 of life. Normally a
baby will gain 800 gm per month in first three months

1.6 COMMON NEONATAL PROBLEMS

Most mothers do observe their babies carefully and are often worried about minor physical
peculiarities and problems, which are of no serious consequence. She must be adequately
informed and appropriately advised regarding minor problems to prevent undue anxiety of
the mother.

A) Meconium passage- Most of the neonates (94%) pass meconium by 24 hours of age. If
meconium is not passed by 24 hrs and/or has associated vomiting andlor abdominal
distension, check for anal patency by passlng a nasogastric tube into the anal canal if not
done at birth. Investigate for anorectal anomalies and intestinal obstruction. It should be
remembered that some babies might have passed urine and/or stool In labour room
immediately after delivery but mother might not be aware. Also, delayed passage of
meconium may normally be seen in the Preterm babies due to functional Immaturity of the
bowel

B) Urine passage - Most of the newborns (93%) void by 24hrs of age and almost all
(98%) void by 48 hrs. The rate of urine fonnation varies from 0.5 to 5.0mllkgJhr at all
gestational ages. Common causes of delay in voiding are perinatal asphyxia. limited fluid
I intake due to poor feeding, increased fluid losses due to radiant warmers and increased
environmental temperature. If there is failure to pass urine for 48hrs. investigate for renal
function tests and abdominal sonography. Assess for presence and size of kidneys and to
rule out any genitourinary malformation.
C) Regurgitation of milk - Most of the neonates take out small amount of curdled milk
soon after feed. Child is usually active and vomitus is never yellow or green coloured and
baby looks healthy. To decrease the problem, mother should be advised regarding burping
after feed and reassured regarding benign nature of the problem. Vomiting is pathological
if it is;
a Persistent
Bile or Blood stained
Projectile
The presence of these signs may indicate intestinal obstruction
D) Transitional stools - It is the transition from meconium (sticky thick green or black
stools passed during first 2-3 days of life) to the yellow homogenous stool of a breast fed
baby and is physiological. It starts on the 3rd or 4th day of life, is yellowish green and
may be watery and contains some mucus. The frequency of stools is increased (up to 10 -
151day) and usually decreases by I0 days of life.
Transitionnl stools require no treatment except parental reassurnnce.
E) Erythema toxicum - The rash usually appears on the second or third day of life. It is a
scattering of erythematous macules, papules and even vesicles. It occurs commonly over
the trunk, face and extremities while palms and soles are spared. It is to be differentiated
from pyoderma in the vesicular stage. Microscopy reveals eosinophils in Erythema
toxicum and cultures of vesicular tluid are sterile. The rash disappears spontaneously in 1-
3 days. Reassurance of parents is all the treatment that is required.

F) Mongolian spots - They are pigmented lesions found at birth in more than 50% of
black native American or Asian infants and occasionally in white ones. The area most
commonly involved is the lumbosacral region but occasionally in the upper back,
shoulders, arms, buttock and legs {naybe involved. The lesions may be small or large,
grayish blue or bluish black in colour, irregularly shaped and always macular. The lesions
need no treatment except reassurance to parents as they tend to disappear within first year
of life.
G) Vaginal discharge and bleeding - White, glary vaginal discharge on second or third
day of life and disappearing by two weeks of life is physiological occurs in 25% of female
babies. It is a form of witlldrawal bleeding due to the removal of maternal estrogen
influence. It needs no treatment other that parental reassurance as it is self limiting in 4-5
days.
H) Breast engorgement - Full term babies of both sexes may develop engorgement of
breasts on the third or fourth day of life. A white or creamy white liquid may also'ooze
from the nipples. It is attributed to transplacentally acquire maternal hormones. It
normally lasts less than a week, although at times it can last several weeks. Advise mother
not to compress or manipulate breasts, since they won't reduce the swelling but can cause
infection.
-
..
1) Neonatal Jaundice Jaundice is a common physical finding (Manifesting as
yellowness of the skin of the face when the serum bilirubin level exceeds Smg/dL) during
first week of life. e

Common causes of neonatal jaundice are depicted following:

Physiological
a Blood group incompatibility
G6PD deficiency
Bruising and cephelhamatoma
lntrauterine and postnatal 'infections
Breast milk jaundice.
As the degree of jaundice increases, there is a cephalocaudal progression of jaundice.
Yellow coloration of trunk indicates the serum bilirubin to be in range between 10-12
mg/dl, whereas staining of palms and soles is ominous as it indicates a serum bilirubin
of more than I Smg/dL.
a In more than 90% of all neonatal jaundice it is physiological and does not need any
specific therapy. It is recognized by its characteristic timetable: jaundice appears
between 24 and 72 hours of age, its maximum intensity (peak serum bilirubin always
below 15mgldL) is seen on the 4th to 5th day of life and usually disappears before 14
days of life.
About 5-1 0% of newborn babies develop pathological jaundice or
hyperbilirubinemia. It should be considered a medical emergency as it may cause
bilirubin encephalopathy or kernicterus when unconjugated bilirubin exceeds 20mg/
 dL (term baby) or at lower levels in (Preterm). Pathological jaundice is recognized by Essential Newborn Car:
any of these features: Jaundice appearing within 24 hours of age. serum bilirubin
levels exceeding 15mg/dL, direct component of serum bilirubin more than 2mgidL
and persistence of jaundice beyond two weeks of age.
J) Perianal Rashes - Due to contact with the wet napkins soaked in urine, an
erythematous rash may develop in the diaper or buttock area. This is due to the
chemical irritant effect of ammonia in the urine. The treatment is to keep the buttock
region dry and well exposed to the atmosphere. In severe cases an ointment
containing zinc oxide can be applied locally to help the dermatitis to heal. In resistant
cases, infection of the skin by Candida albicans should be ruled out and appropriately
managed with a topical lotion.

K) Caput and Cephelhematoma - Soon after birth most babies have a boggy swelling
over the scalp, which is the caput succedaneum. This is because of pressure over the
presenting part. This has to be sometimes differentiated from cephelhematoma, which
is a subperiosteal collection of blood. It is characterized by a fluctuant swelling which
is limited by suture lines. The cephelhematoma usually appears after 2-3 days when
the caput is disappearing.

W i l e the caput is benign, a cephelhematoma can be associated with anemia (due to loss of
blood into the subperiosteal space) or jaundice (due to hemolysis of blood collected in the
subperiosteal space).

1.7 SPECIAL NEONATAL SITUATIONS

If a baby is born to a mother with one or more of the problems i.e hepatitis B,
Tuberculosis, syphilis or HIV there is a higher probability that the baby will develop a
problem at some time after birth, even if the baby appears entirely normal at birth. All such
cases need thorough evaluation of signs and symptoms and need management even if these
babies are clinically asymptomatic

1.7.1 HEPATITIS B
Mothers who had acute hepatitis during pregnancy or who are carriers of the hepatitis B
virus, as demonstrated by a positive serologic test for the hepatitis B surface antigen
(HbsAg), may transmit the hepatitis B virus to their babies.

Give the first dose of hepatitis B vaccine (HBV) 0.5 ml IM in the upper thigh as soon
after birth as possible (preferably within 12 hours of birth).
If available. give hepatitis immune globulin 200 units IM in the other thigh within 24
hours of birth, or within 48 hours of birth at the latest.
Reassure the mother that it is safe for her to breastfeed her baby.
1.7.2 TUBERCULOSIS
If the mother has active lung tuberculosis and was treated for less than two months
before birth or was diagnosed with tuberculosis after birth:
- Do not give the tuberculosis vaccine (BCG) at birth;
- Give prophylactic ionized 5 mglkg body weight by mouth once daily;

I - At the age of six weeks, re-evaluate the baby, noting weight gain and taking an
X- ray of the chest, if possible:

!
- If there are any findings suggestive of active disease, start full anti
tuberculosis treatment;
- If the baby is doing well and tests are negative, continue prophylactic
I
I
isoniazid to complete six months of treatment. ,

) Delay BCG vaccine unt; two weeks after treatment is completed. If BCG was already
I
e
given, repeat BCG two weeks after the end of the isoniazid treatment.
Care of Newborn and Reassure the mother that it is safe for her to breastfeed her baby.
Young Infant
Follow u p in two weeks to assess weight gain.

a If the mother tested positive for syphilis and was treated adequately (2.4 million
units of penicillin) and the treatment started at least 30 days before birth, no
treatment is necessary.
If the mother was not treated for syphilis, she was treated inadequately, o r her
treatment status is unknown o r uncertain and the baby has no signs of syphilis.
- Give the baby procaine benzyl penicillin (or benzathine benzyl penicillin) JM.
- Give the mother and her partner(s) benzathine benzyl penicillin 1.8 g 1M as two
injections at separate sites;
- Refer the mother and her partner(s) for follow-up to a clinic that offers services
for sexually transmitted infections.
Follow up in four weeks to examine the baby for growth and signs of congenital
syphilis.

1.7.4 Mother with HIV

There are no specific signs or features diagnostic of HIV at birth; clinical signs of HIV
may begin appearing around six weeks of life, but the baby's HIV status cannot be verified
by antibody testing until 15 to 18 months of age.
Management
A) General measures
When caring for a baby of an HIV-positive mother, always;
- Respect the confidentiality of the mother and family;
- Care for the baby as for any other baby, paying particular attention to infection
prevention procedures;
- Give the baby all routine immunizations

Emphasize to the mother the importance of condom use to prevent infection of her
partner(s) and transmission of other sexually transmitted infections.
Provide emotional support.
B) Antiretroviral Therapy
Without antiretroviral therapy, 15% to 30% of babies born to known HIV positive mothers
will be infected during pregnancy and birth, and 5% to 20% may be infected by
breastfeeding.
Determine if the mother is receiving or has received antiretroviral treatment for HIV
to prevent mother-to-child transmission.
Treat the baby according to the protocol used for the mother as per national policy.
For example:
- If zidovudine (AZT) was given to the mother for four weeks before birth,
continue to give AZT to the baby for six weeks after birth (2 mgkg body weight
by mouth every six hours);
- If the mother received a single dose of nevirapine during labour and the baby is
less than three days old, immediately give the baby nevirapine in
suspension 2 mgkg body weight by mouth;
- Schedule a follow-up examination in 10 days to assess feeding and growth.
 Essential Newborn Care

Advise the mother regarding her feeding options, and respect and support the mother's
choice. Allow the mother to make an informed choice about the best feeding option for her
baby. Explain to the mother that breastfeeding carries an increased risk of transmitting HIV
to the baby after birth.

Inform the mother about her options for feeding, the advantages, and the risks. The
mother can choose to:
- Give replacement feeding if this is acceptable, affordable, feasible, sustainable,
and safe. Explain to the mother that replacement feeding often carries a higher
risk of infant mortality than breastfeeding, especially if it cannot be prepared
safely, is not continuously available and affordable to the family.
- Exclusively breastfeed until replacement feeding is feasible. It is important that
the mother stops breastfeeding once replacement feeding is introduced;
- Exclusively breastfeed for six months, then continue breastfeeding while starting
complementary feeding (e.g. mashed solid foods) after six months of age.

Help the mother to assess her situation. Help her decide whether to breastfeed (below)
or give replacement feeding

Mother Chooses to Breastfeed

Support the mother's choice.
Advise the mother against mixed feeding (i.e. feeding anything other than breast milk,
such as commercial breast-milk substitute, animal milks, local porridges, tea, water,
etc.). Mixed feeding may increase the risk of both HIV transmission and illness or
death from diarrhea or other illnesses.
Ensure correct positioning and attachment to prevent mastitis and damage to the
mother's nipples.
Arrange for further counselling to prepare the mother for the possibility of stopping
breastfeeding early.

Mother Chooses Replacement Feeding

Support the mother's choice.
Ensure that the mother understands that if she chooses replacement feeding, she
should begin complementary feeding at six months of age while continuing to
provide milk.

Review the guidelines for preparing and feeding breast-milk substitutes

Allow the mother to begin preparing the replacement feed as soon as she is able to
and teach her how to feed the baby using a cup, cup and spoon. or other device (e.g.
paladai).
Encourage the mother to feed the baby at least eight times daily. Teach her to be
flexible and respond to the baby's demands.
Give the mother written instructions on safe preparation of the replacement feed.
Explain the risks of replacement feeding and how to avoid them:
- The baby may get diarrhea if the mother's hands, water, or i~tensilsare not clean,
or if the milk stands too long before being used;
- The baby may not grow well if:

- too little substitute is given at each feed;

- too few feeds are given;

Care of Newborn and - the substitute contains too much water;
Young Infant
- the baby has diarrhea.
Advise the mother to seek care if the baby has any problems, such as:
- Feeding less than six times daily or taking smaller quantities;
- Diarrhea:
- Poor weight gain.

If there are no other problems requiring hospitalization, discharge the baby;

Ensure a follow-up visit during the first week after discharge to assess how the mother
is coping with replacement feeding and ensure that she ,receives support to provide
safe replacement feeding.
Ensure that the baby receives regular follow-up visits with an appropriate child care
provider.
 Essential Newborn Care
1.8 LET US SUM UP
In this unit you. have learnt about the care of newborn at birth.

Immediate care at birth includes helping the baby clear its airway, preventing heat loss and
providing warmth, and care of the cord, skin and eyes.

Birth asphyxia is an important emergency in the delivery room. The asphyxiated newborn
has no or poor respiratory effort at birth. The assessment of these babies for resuscitation
needs is based on observation of respiratory effort, heart rate and colour assisted
ventilation with a bag and mask is provided for babies who have no spontaneous breathing
or those with spontaneous breathing effort with a heart rate below 100Imin. Babies with
heart rate below 601min require chest compressions. This unit also provides information on
the use of drugs-adrenaline, naloxone, sodium bicarbonate - in the delivery room.

High risk infants in the delivery room include LBW babies (especially those weight below
1800 g), with major congenital malformations, birth asphyxia, respiratory distress and
those who are preterm.

Breast feeding should be initiated in the delivery room within an hour of birth of the
newborn.

In addition you have learnt of some normal phenomena after birth. You have learnt the
normal breathing and heart rate pattern in the newborn. An important point to remember is
that the respiratory rate in the newborn must be counted for at least I minute and
alternative to blood pressure measurement is estimating the capillary filling time to assess
perfusion in the newborn.

You also learnt that most newborns would pass meconium by 24 hours and urine by 48
hours of age. During initial days there is loss of weight which is regained by end of 10
days in a term and 14 days in a preterm baby.

1.15 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) Keeping the baby on mothers chest skin to skin contact after cleaning and
drying.Cover with dry linen.Wipe secretions if necessary no need of routine suction.

2) The steps taken to minimize heat loss from new born are:

a) Receive baby in warm, dry linen and discard wet linen after use. Rewrap the
baby in warm, dry linen.

b) Place the baby under a source of warmth e.g. lamplwarmer or in skin to skin
contact with the mother.

c) Ensure that fans are shut, open windows are closed in the delivery room area
where the baby is to be delivered and observed.

3) Components for essential postnatal care are:

- Nurse in thermal comfo'rt (baby should be warm to touch, at abdomen and feet
pink soles)

- Check umbilicus, skin, eyes

. - Good suckling at breast
- Screen for danger signals

- Advice on immunization
Care of Newborn and 4) The definitions for birth asphyxia can be (a) Apgar at 1 min < 7 or (b) an infant who
Young lnfant at birth is not breathing or gasping

5) Indications for assisted ventillation in an asphyxiated newborn are:

a) Apneic or gasping respiration in spite of oral suction and tactile stimulation

b) In a spontaneously breathing baby, a .heart rate < 1 OOlmin.

6) Indicators of good response to assisted ventilation are:

a) Appearance of spontaneous breathing efforts by the baby.

b) Heart rate > 100lmin

c) Pink colour

7) The equipment for newborn care in the delivery room include:

a) Warming facilities : Lamp, or overhead radiant warmer

b) Suction devices : Disposable mucus traps, foot operated suction pumps, or

electric suction devices.

c) Infant resuscitation bags (capacity 300-750 ml) with appropriate size 0 and I
face mask.

d) Laryngoscope and endotracheal tubes sizes 2.5, 3.0, 3.5 mm (internal diameter)

e) Drugs : Adrenaline (1 : 1 OOO), Sodium bicarbonate (7.5%)

f) Fluids : Normal saline. 10% dextrose in water, Ringer's lactate.

g) Syringes (2, 10 ml), intravenous needles and cannula (No. 22, 24).

8) Since the baby is still gasping, assisted ventilation has to be continued. The heart rate
is 4 beats is 6 seconds i.e. 4 x I0 = 40 bpm. This is an indication to initiate cardiac
massage. This activity would need the services of two trained personnel- one to
provide assisted ventilation and the other to cany out cardiac massage. The baby must
be reevaluated after 30 seconds of assisted ventilation and cardiac massage.

9) Adrenaline is the drug to be administered. The dose is 0.1-0.3 mllkg diluted I: I0

times and administered intra-cardiac or intravenously.

10) Sodium bicarbonate is indicated if after 5 minutes of assisted ventilation, cardiac

compression and drugs, the newborn is apneic or gasping and has a heart rate < 1001
min. Dose is 2 ml k g of sodium bicarbonate diluted with equal amount of distilled
water. Route is slow intravenous over 2-3 minutes.
Check Your Progress 2.

1) The rate must be counted for at least 1 minute.

2) The criteria to label the respiration in the newborn as abnormal are:

a) RR >60/minute

b) There is severe chest indrawing

c) Associated with apnea (HR < 100 bpm or cyanosis)

3) Transitional stools are different from diarrhoea because:

- Diarrhoea may have associated blood~mucousin the stools.

- Diarrhoea is associated with clinical dehydration.

- The newborn may appear sick with diarrhoea.

 4) Nan-passage of meconium within 24 hours and urine within 48 llours are abnormal Essential Newborn Care

5) Characteristics of physiological jaundice are:

- First appears between 24-72 hours of age
- Maximum intensity seen on 4-5th day in term and 7th day in preterm neonates
- Does not exceed 15 mgldl

- Clinically undetectable after 14 days

- No treatment is required but baby should be observed closely for signs of
worsening jaundice.
Weight loss Maximum weight loss Regains birth
(%) (%) weight by (days)
Term baby 5-7 10 10
Preterm baby 10 15 14

7) Differentiating features of caput succedaneum and cephalhematoma are:

Caput succedaneum Cephalhematorna

Present at birth Appears on day 2-3
Crosses midline (sutures) Limited by sutures dues not cross midline

Boggy swelling Fluctuant swelling

Disappears over 48 hours Persists for weeks

Benign condition May result in anemia and jaundice

Activity 1
The instruction's needed to be given to a mother planning to deliver at home are:
- Linen used for receiving the baby must be washed and sundried.

- There must be facilities to warm the room e.g. room heater if electricity available,
anghiti, or other locally available devices.
- There must be utensils for boiling water.

- Soap for hand washing.

- Boiled cord ties.
I
- Safe delivery kit from the local health centre.

Activity 3
t
The essential elements of pIanning newborn care in the delivery room include:

1) Warming facilities: Lamp, or overhead radiant warmer

2) Suction devices: Disposable mucus traps, foot operated suction pumps, or electric
suction devices

3) Infant resuscitation bags (~apacity250-750 ml) with appropriate size 0 and 1 face
mask

4) Laryngoscope and endotracheal tube sizes 2.5,3.0, 3.5 mm (internal diameter)

5) Drugs: Adrenaline ( I :1 OOO), Sodium bicarbonate (7.5%)

6) Fluids: Norma saline, 10% dextrose in water, Ringer's lactate.

7) Syringes (2, 10 ml), intravenous n,eedles and cannulas (No. 22.24)