Essentials care of new born

1. Essentials of New Born care
Presented by –
Standee, Rohit & Majed Hussain
MPH SEM III, ISHS-SPPU 2020.

2. Essential New Born care
Essential new-born care (ENC) is defined as a strategic approach planned to improve the
health of new-born through interventions before, during and after pregnancy, immediately
after birth and during the postnatal period.
The components of essential newborn care are: ensuring warmth, immediate skin-to-skin
care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and
immunization.
The Apgar score is one component of essential new born care that is done during the first 1
and 5 minutes of life. The heart rate, respiratory rate, muscle tone, reflex irritability, and the
color are evaluated in an infant. Apgar score is the baseline for all future observations. The
1st minute Apgar score predicts the immediate outcome of the baby while the 5 minute
Apgar score predicts the future outcome.

3. Apgar score
Indicator
0 1 2
A Activity Absent Flexed arms and legs Active
P Pulse Absent Below 100 bpm Over 100 bpm
G Grimace Floppy
Minimal response to
stimulation
Prompt response to
stimulation
A Appearance Blue; pale
Pink body, blue
extremities
Pink
R Respiration Absent Slow & irregular Vigorous cry
Apgar scoring
0-3 points: the baby is in
serious danger and need
immediate resuscitation.
4-6 points: the baby’s
condition is guarded and may
need more extensive clearing
of the airway and
supplementary oxygen.
7-10 points: are considered
good and in the best possible
health.
Each parameter can have the highest score of two and the lowest is 0.
The scores of the five parameters are added to determine the status of the infant.

4. Resuscitation
Neonatal resuscitation is the sum of steps for the asphyxiated baby just after birth. Newborn
resuscitation helps to establish breathing and circulation. It is very essential to prevent hypoxic
damage to various organs especially the brain.
Resuscitation include measures such as clearing the baby’s airways, warming the baby,
providing oxygen, intubating the baby, performing neonatal CPR, providing medication or any
combination of these procedures.
When to resuscitate
1. No Respiration
2. No Cry after birth
3. Gasping respirations with long pauses in between
4. Pale Whitish or blue color
5. Heart rate absent or < 100 beats/min
6. Flaccid or decreased muscle tone
7. Low APGAR score

5. Steps of newborn resuscitation
1. Initial stabilization
2. Airway, breathing, circulation
3. Chest compressions
4. Administration of epinephrine or volume expansion
Initial stabilization
• Dry the baby
• Warm the baby (increase the room temperature to achieve this)
• Keep the baby swaddled or under a warmer. Maintain skin-to-skin contact with the mother
while the infant is covered
Airway, Breathing, Circulation
• Keep the infant’s neck in neutral or a slightly extended position. This will allow the airway to
open. Place a towel under the infant’s shoulder to help with the extension of the neck and the
opening of the airway.
Suction out the nose and mouth with a bulb
Check the heart rate
• The umbilical cord will pulsate and is the easiest place to check the infant’s heart rate.

6. Cont'd.
Chest Compressions
With apnea or a heart rate below 100/min, administer positive pressure ventilation using a bag and mask.
Newborn chest compression can be done by these techniques:
Bag-mask ventilation
• Stand at the head of the infant, with his or her airway open
• Suction the nose and mouth to remove any blockage or mucus
• Seal the mask and the mouth
• Apply the required 30 to 40 cm water to inflate the lungs for initial breaths
Thumb technique
• Place both hands around the infant’s chest
• Place your thumbs on the sternum
• Apply downward pressure
Two-finger technique
• Place tips of the first two fingers over the sternum
• Do not place too much pressure directly over the xiphoid process, as that can fracture and cause liver
injury
• Re-assess after 30 seconds of chest compression

7. Cont’d
Administration of epinephrine or volume expansion
• Drugs should not be routinely used and are considered a last resort. If, however, the
heart rate remains below 60/min after consistent attempts at resuscitation, medication may
be needed.
• Treat with epinephrine if the heart rate continues to be below 60/min. The easiest access
route in an emergency situation is via the umbilical vein.
High- risk new born
A high risk neonate can be defined as a newborn, regardless of gestational age or birth weight,
who has a greater-than-average chance of morbidity or mortality because of conditions or
circumstances associated with birth and the adjustment to extra uterine existence.
The high risk period encompasses human growth and development from the time of viability
(the gestational age at which survival outside the uterus is believed to be possible, or as early
as 23 weeks of gestation) up to 28 days after birth; thus it includes threats to life and health
that occur during the prenatal, perinatal, and postnatal periods.

8. Classification of high risk newborn
High risk newborn are classified according to:
Birthweight
Low birthweight(LBW) <2500g(2.5kg)
Very low birthweight(VLBW) <1500g(1.5kg)
Extreme low birthweight(ELBW) <1000g(1kg)
SGA-small-for-gestational age-BW falls below the 10th percentile
IUGR-intrauterine growth restriction(symmetric IUGR, asymmetric IUGR)
LGA-large-for-gestational age-BW falls above the 90th percentile on intrauterine growth
chart
Gestational age
Preterm/ premature infant 37weeks
Extreme preterm infant 28weeks
Post-term/ post-mature infant after 42 weeks
Predominant pathophysiological problems
hypoglycemia, hypocalcemia, hyperbilirubinemia, respiratory distress, hypothermia

9. Apnea
Apnea is cessation of inspiratory gas flow for 20 seconds, or for a shorter period of time if accompanied by
bradycardia (heart rate less than 100 beats per minute), cyanosis, or pallor.
Types of Apnea
Central Apnea
Both the inspiratory effort and airflow cease simultaneously in this type of apnea (Absence of chest wall
movement and airflow)
Obstructive Apnea:
This type is characterized by absence of airflow in the presence of inspiratory efforts (Presence of chest wall
movement but no airflow).
Mixed Apnea:
Central apnea is either preceded or followed by airway obstruction.
Trigging Factors of Apnea in newborn
Infection-sepsis
Temperature regulation- hypothermia, hyperthermia
Drugs- prenatal and postnatal like narcotic, beta blockers
Metabolic- hypercalcemia, hyperglycemia
Hematology- Anemia
Pulmonary- pneumonia

10. Meconium
Meconium is the earliest stool of an infant.
composed of materials ingested during the time the infant spends in the uterus-intestinal epithelial cells, lanugo,
mucus, amniotic fluid, bile and water.
Meconium, unlike later feces, is viscous and sticky like tar, its color usually being a very dark olive green; it is
almost odorless.
It should be completely passed by the end of the first few days after birth, with the stools progressing toward
yellow (digested milk).
Meconium is normally retained in the infant's bowel until after birth, but sometimes it is expelled into the
amniotic fluid (also called "amniotic liquor") prior to birth or during labor and delivery.
The failure to pass meconium is a symptom of several diseases including Hirschsprung's disease and cystic
fibrosis.

11. the major factors for MAS are fetal distress, non-reassuring FHR tracing, cesarean birth, IUGR, and post
maturity. Screening of such patients at an early stage may minimize morbidity and mortality related to
MAS.(Chand et al., 2019)
Meconium aspiration syndrome (MAS), a
common cause of respiratory failure in
neonates, is associated with high mortality
and morbidity(Natarajan et al., 2016)
Thick Meconium stained amniotic fluid
was associated with low APGAR score, high
rate of emergency cesarean section and
meconium aspiration syndrome. Anemia
during pregnancy, PIH and GDM were
important risk factor associated with
MAS(Mohammad et al., 2018)

12. RDS-respiratory distress syndrome
Acute respiratory distress syndrome (ARDS) is a common clinical critical disease and is one of the main
causes of death and disability in neonates. The etiology and pathogenesis of neonatal ARDS are complicated.
It is an acute pulmonary inflammatory disease caused by the lack of pulmonary surfactant (PS) related to
various pathological factors(Chi et al., 2018)
Newborns with respiratory distress commonly exhibit tachypnea with a respiratory rate of more than 60
respirations per minute. They may present with grunting, retractions, nasal flaring, and cyanosis.
Common causes include-
 transient tachypnea of the newborn,
 meconium aspiration syndrome,
 pneumonia, sepsis, pneumothorax,
 persistent pulmonary hypertension of the newborn, and delayed transition.
 Congenital heart defects, airway malformations, and inborn errors of metabolism are less common
etiologies(Hermansen & Mahajan, 2015)

13. Hypothermia
 Hypothermia is increasingly recognized as a major cause of neonatal morbidity and mortality in resource
poor settings
 High prevalence of hypothermia has been reported widely from warmer high mortality regions of Africa
and South Asia
 The World Health Organization recognizes newborn thermal care as a critical and essential component
of essential newborn care; however, hypothermia continues to remain under-documented, under-
recognized and under-managed.
 A combination of physiological, behavioral and environmental factors universally put all newborns,
irrespective of birth weight, at risk of hypothermia. The knowledge deficit along the continuum from
health providers to primary care givers has sustained the silent epidemic of hypothermia.(Kumar et al.,
2009)
 the first bath can be postponed to favor the adaptation of the neonate to the extrauterine environment,
preventing the occurrence of neonatal hypothermia.(Ruschel et al., 2018)

14. Risk factors for hypothermia
 Physiological risks-- Low birth weight (LBW) and preterm,
 Environmental and behavioral risks-- Delivery room is not warmed, Newborn is not dried or wrapped
immediately, Newborn is bathed soon after birth, Oil massage, Transport, delayed breastfeeding
significantly reduces skin contact with the mother and further increases the risk of hypothermia.
 Postpartum confinement As observed in Bangladesh, mothers and their newborn sleep for several days
(for example, 7–9 days in Bangladesh) in the place of birth as opposed to the bedroom or family bed,
potentially exposing the newborn to cold
 Care in health facilities- Studies on the knowledge and practices of health professionals in low resource
settings regarding thermal control of newborns revealed widespread prevalence of several high-risk
practices in health facilities: inadequate warmth in delivery rooms, improper or delayed drying and
wrapping of the newborn, bathing immediately after birth, reduced and delayed contact with the mother
and delayed initiation of breastfeeding

15. Prevention and management of hypothermia
 Warm chain The ‘warm chain’ is a set of 10 interlinked procedures to be taken at birth and during the
following few hours and days to prevent hypothermia by minimizing heat loss in all newborns(Kumar
et al., 2009)
 The 10 steps of the ‘warm chain’ are as follows:
(1) warm delivery room, (2) immediate drying, (3) skin-to-skin contact, (4) breastfeeding, (5) bathing
and weighing postponed, (6) appropriate clothing/ bedding, (7) mother and baby together, (8) warm
transportation, (9) warm resuscitation and (10) training and awareness raising.
 Synthetic external insulation- c wraps, bags, boxes and covers have been found to prevent heat loss in
the newborn, and are particularly effective when used immediately after delivery
 Topical agents and oil massage The application of topical agents, including paraffin39,69 petrolatum,
mineral oil and lanolin, or corn, sunflower, sesame or safflower oil, have been shown to reduce trans
epidermal water loss and as well as loss of heat.

16. Prematurity
- World Prematurity Day - 17 November, Most pregnancies last 40 weeks. A baby born before the 37th
week is known as a premature or pre-term baby. Every year 15 million babies are born prematurely. This
is more than one in ten of all babies.
Depending on how early a baby is born, he or she may be:
 Late preterm, born between 34 and 36 completed weeks of pregnancy
 Moderately preterm, born between 32 and 34 weeks of pregnancy
 Very preterm, born at less than 32 weeks of pregnancy
 Extremely preterm, born at or before 25 weeks of pregnancy
Some signs of prematurity include the following:
 Small size, with a disproportionately large head
 Sharper looking, less rounded features than a full-term baby's features, due to a lack of fat stores
 Fine hair (lanugo) covering much of the body
 Low body temperature, especially immediately after birth in the delivery room, due to a lack of stored
body fat
 Labored breathing or respiratory distress, Lack of reflexes for sucking and swallowing, leading to feeding
difficulties

17. risk factors for preterm birth –
 Having a previous premature birth
 Pregnancy with twins, triplets or other multiples, An interval of less than six months between
pregnancies
 Problems with the uterus, cervix or placenta
 Smoking cigarettes or using illicit drugs
 Some infections, particularly of the amniotic fluid and lower genital tract
 Some chronic conditions, such as high blood pressure and diabetes
 Being underweight or overweight before pregnancy
 Stressful life events, such as the death of a loved one or domestic violence
 Multiple miscarriages or abortions, Physical injury or trauma
Prevention of premature birth
 Progesterone supplements. Women who have a history of preterm birth, a short cervix or both
factors may be able to reduce the risk of preterm birth with progesterone supplementation.
 Cervical cerclage. This is a surgical procedure performed during pregnancy in women with a short
cervix, or a history of cervical shortening that resulted in a preterm birth.

18. Complication of premature birth
Some problems may be apparent at birth, while others may not develop until later
Short-term complications Long-term complications
 immature respiratory system. baby's lungs lack
surfactant
 patent ductus arteriosus (PDA) and low blood
pressure (hypotension)
 intraventricular hemorrhage
 Hypothermia
 immature gastrointestinal systems, resulting in
complications such as necrotizing enterocolitis
(NEC)
 anemia and newborn jaundice
 Hypoglycemia
 higher risk of infection
 Cerebral palsy
 Impaired learning
 retinopathy of prematurity
 at increased risk of some degree of hearing loss.
 delayed tooth eruption, tooth discoloration and
improperly aligned teeth
 Behavioral and psychological problems
 Premature babies are more likely to have chronic
health issues

19. Low birth weight
LBW contributes to 60% to 80% of all neonatal deaths. The global prevalence of LBW is 15.5%, which
amounts to about 20 million LBW infants born each year, 96.5% of them in developing countries
Birth weight may be classified as
 Normal weight (term delivery): 2,500–4,200 g (5 lb 8 oz–9 lb 4 oz)
 Low birth weight: less than 2,500 g (5 lb 8 oz)
 Very low birth weight: less than 1,500 g (3 lb 5 oz)
 Extremely low birth weight: less than 1,000 g (2 lb 3 oz)
LBW infants are forty times more likely to die within their first four weeks of life than normal birth weight
infants. LBW infants are also three times more likely than normal birth weight infants to have
neurodevelopmental complications and congenital abnormalities. Patients with poor socio-economic status
are more prone to develop LBW babies. Most common complications are bad obstetric history, anemia, pre-
eclampsia, preterm delivery, PROM and malpresentation(Mishra & Joshi, 2017)

20. Low birth weight…
Any baby born prematurely is more likely to be small. However, there are other factors that can also
contribute to the risk of low birthweight.
These include:
 Race - African-American babies are twice as likely as Caucasian babies to have low birthweight.
 Mother's age - Teen mothers (especially those younger than 15) have a much higher risk of having a
baby with low birthweight.
 Multiple birth - Multiple birth babies are at increased risk of low birthweight because they often are
premature.
 Mother's health - Babies of mothers who are exposed to illicit drugs, alcohol and cigarettes are more
likely to have low birthweight. Mothers of lower socioeconomic status are also more likely to have
poorer pregnancy nutrition, inadequate prenatal care, and pregnancy complications — all factors that
can contribute to low birthweight.

21. Complications of low birth weight
 Low oxygen levels at birth
 Trouble staying warm
 Trouble feeding and gaining weight
 Infection
 Breathing problems and immature lungs (infant respiratory distress syndrome)
 Nervous system problems, such as bleeding inside the brain (intraventricular hemorrhage)
 Digestive problems, such as serious inflammation of the intestines (necrotizing enterocolitis)
 Sudden infant death syndrome (SIDS)
Babies with very low birth weight are at risk for long-term complications and disability.
Long-term complications may include:
 Cerebral palsy
 Blindness
 Deafness
 Developmental delay

22. Facility based sick newborn care
1. Facility Based Newborn Care is one of the key
components to improve the status of newborn
health.
2. The various components of FBNC are: Newborn
Care Corners (NBCCs) are established at delivery
points to provide essential newborn care at birth
soon after delivery.
3. This are dedicated space within the delivery room
where essential care as well as life saving care
including resuscitation is provided to the newborn.

23. New born care corner

24. Special Newborn Care Units (SNCUs)
1. is a neonatal unit in the vicinity of the labor room to provide special
care (all care except assisted ventilation and major surgery) to the
sick newborns.
2. SNCU Online Reporting Network is established in the State since
August 2015-16 with 13 SNCUs generating real time data.

25. The SNCU at the district hospital is expected to provide
the following services:
1. Care at birth
2. Resuscitation of asphyxiated newborns
3. Managing sick newborns (except those requiring mechanical
ventilation and major surgical interventions)
4. Kangaroo mother care
5. Post natal care
6. Follow-up of high risk newborns
7. Referral services
8. Immunization services

26. Newborn Stabilization Units (NBSUs)
1. facility located within or in close proximity to the
maternity ward where sick and low birth weight
newborns are cared for short periods.

27. Home based newborn care (HBNC)
1. Exclusive breast feeding
2. Cord care
3. Maintenance of temperature
4. Early detection of pneumonia and sepsis at first level care
5. Promoting hygiene practices
6. Grater care and support of high risk baby

28. Objectives (HBNC)
1. The provision of essential newborn care to all newborns and
preventions of complications .
2. Early detection of special care of preterm and low birth weight
newborn .
3. Early identification of illness in the newborn and provision of
appropriate care and referral.
4. Support the family for adaption of healthy practices and build the
confidence and skills to the mother safeguard her health and that
of the newborn