Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

1. Newborn
Care
A learning programme
for professionals
Developed by the
Perinatal Education Programme
www.ebwhealthcare.com

2. VERY IMPORTANT
We have taken every care to ensure that drug
dosages and related medical advice in this book
are accurate. However, drug dosages can change
and are updated often, so always double-check
dosages and procedures against a reliable,
up-to-date formulary and the given drug‘s
documentation before administering it.
Newborn Care:
A learning programme for professionals
Updated: 15 June 2010
First published by EBW Healthcare in 2009
Text © Perinatal Education Programme 2009
Cover photograph © Harris Steinman
Illustrations by Mary Hann and Anne Westoby
Getup © Electric Book Works 2009
ISBN (paperback): 978-1-920218-28-7
ISBN (PDF ebook): 978-1-920218-57-7
All text in this book excluding the tests and
answers is published under the Creative Commons
Attribution Non-Commercial No Derivatives
License. You can read up about this license at http://
creativecommons.org/licenses/by-nc-nd/3.0/.
The multiple-choice tests and answers in this
publication may not be reproduced, stored in a
retrieval system, or transmitted in any form or by
any means without the prior permission of Electric
Book Works, 87 Station Road, Observatory, Cape
Town, 7925.
Visit our websites at www.electricbookworks.com
and www.ebwhealthcare.com

3. Contents
Acknowledgements 7 Case study 3 51
Case study 4 52
Introduction 9 Case study 5 52
About the EBW Healthcare series 9 Skills workshop: Gestational age and
Why decentralised learning? 9 weight 53
Books in the EBW Healthcare series 9
Assessing the gestational age 53
Format of the courses 11
Measuring weight and head circumference
Contributors 12
57
Updating the course material 13
Plotting weight and head circumference 57
Contact information 13
References 60
1 Neonatal asphyxia and resuscitation 15
3 The routine care of normal infants 61
Assessing the infant at birth 15
Managing normal infants 61
Neonatal resuscitation 17
Common minor problems 66
Preventing meconium aspiration 23
Discharging a normal infant 68
Neonatal encephalopathy 24
Case study 1 68
Case study 1 26
Case study 2 69
Case study 2 27
Case study 3 70
Case study 3 28
Case study 4 70
Case study 4 28
Skills workshop: Clinical history and
Skills workshop: Neonatal resuscitation 31
examination 72
Assessing the Apgar score 31
Taking a perinatal history 72
Giving mask ventilation 33
The physical examination of a newborn
Tracheal intubation 34
infant 73
Chest compressions 40
The road-to-health card 81
2 Assessing gestational age and size at
4 Feeding normal infants 83
birth 43
Introduction to infant feeding 83
Assessing an infant’s gestational age at
The benefits of breastfeeding 84
birth 43
Promoting breastfeeding 85
Assessing an infant’s size at birth 45
Teaching mothers to breastfeed 86
Grouping infants by their weight for
Managing breastfeeding problems 89
gestational age 45
Formula-feeding newborn infants 91
Case study 1 50
The baby friendly initiative 93
Case study 2 51
Feeding the HIV-exposed infant 93

4. 4 NEWBORN CARE
Case study 1 94 Case study 1 137
Case study 2 95 Case study 2 138
Case study 3 95 Case study 3 138
Case study 4 96
Skills workshop: Temperature control and
5 Care of high-risk and sick infants 97 hypothermia 140
Classification of infants on the basis The telethermometer 140
of risk 97 The closed incubator 141
Managing a sick infant 99 The overhead radiant warmer 144
Monitoring a high-risk or sick infant 100
The management of shock 101 8 Glucose control and hypoglycaemia 147
The management of fits 102 Glucose control 147
The management of acidosis 103 Hypoglycaemia 150
Case study 1 105 Hyperglycaemia 153
Case study 2 105 Case study 1 153
Case study 3 106 Case study 2 154
Case study 4 106 Case study 3 154
Skills workshop: Clinical notes and Skills workshop: Glucose control and
observations 107 hypoglycaemia 156
Writing good clinical notes 107 Measuring the glucose concentration in
Recording routine observations 111 capillary blood with reagent strips 156
Recording fluid intake and output 111 Measuring the glucose concentration in
capillary blood with a glucose meter 158
6 Feeding sick or high-risk infants 115
Inserting an umbilical vein catheter 159
Fluid requirements 115
Intravenous fluids 117 9 Jaundice, anaemia and
Milk feeds for sick or high-risk infants 119 polycythaemia 163
Vomiting 121 Jaundice 163
Case study 1 122 Haemolytic disease 167
Case study 2 122 Phototherapy 170
Case study 3 123 Anaemia 173
Case study 4 123 Polycythaemia 174
Case study 1 175
Skills workshop: Feeding sick or high-risk
Case study 2 175
infants 125
Case study 3 176
Passing a nasogastric tube 125 Case study 4 176
Nasogastric feeding 126 Case study 5 177
Preparation of formula feeds 126
Starting a peripheral intravenous Skills workshop: Jaundice and
infusion 127 phototherapy 178
Using a fluid controller 129 Measuring the packed cell volume 178
Using a phototherapy unit 180
7 Temperature control and hypothermia 131
Measuring body temperature 131 10 Respiratory distress and apnoea 183
Heat production and loss 132 Respiratory distress 183
Hypothermia 133 Hyaline membrane disease 185
Pyrexia 137 Wet lung syndrome 187

5. CONTENTS 5
Meconium aspiration syndrome 188 Syphilis 235
Pneumonia 190 HIV infection 236
Pneumothorax 191 Case study 1 238
Heart failure and patent ductus Case study 2 239
arteriosus 191 Case study 3 239
Apnoea 193 Case study 4 239
Case study 1 194 Case study 5 240
Case study 2 195
Case study 3 196 13 Trauma and bleeding 241
Case study 4 196 Trauma 241
Bleeding 245
Skills workshop: Respiratory distress and
Case study 1 248
apnoea 198
Case study 2 249
Gastric aspirate shake test 198 Case study 3 249
Using an apnoea monitor 200 Case study 4 250
Transillumination of the chest 201
Emergency needling of a pneumothorax 14 Birth defects 251
201 Introduction to birth defects 251
Inserting a chest drain 202 Common birth defects 252
Serious birth defects 255
11 Oxygen therapy 205
Major neurological defects 257
Oxygen therapy 205 Important syndromes 257
Measuring the amount of oxygen 206 Managing parents of infants with a birth
The advantages and disadvantages of defect 259
extra oxygen 207 Case study 1 259
Administering oxygen safely 209 Case study 2 260
Providing continuous positive airways Case study 3 260
pressure (CPAP) 212
Case study 1 214 15 Communication 263
Case study 2 215 Communication with parents 263
Case study 3 215 Parental bonding 264
Case study 4 216 Managing the family of a sick or dying
infant 265
Skills workshop: Oxygen therapy 217
Bereavement 265
Using a flow meter with humidifier 217 Communicating with colleagues at other
Using a blender or venturi 218 hospitals and clinics 268
Using an oxygen monitor 218 Transferring newborn infants 270
Using a pulse oximeter (oxygen saturation Assessing the perinatal health-care status
monitor) 219 in your region 272
Providing nasal cannula oxygen 220 Case study 1 274
Providing nasal CPAP 220 Case study 2 275
Case study 3 276
12 Infection 223 Case study 4 276
Preventing infection 223
Tests 279
Minor infections 226
Major infections 230
Chorioamnionitis 233
Chronic intra-uterine infection 234

6. Acknowledgements
We acknowledge all the participants of Editor-in-Chief of the Perinatal Education
Newborn Care courses who have made Programme: Prof D L Woods
suggestions and offered constructive criticism.
Editor of Newborn Care: Prof D L Woods
It is only through constant feedback from
colleagues and participants that the content of Contributors to Newborn Care:
Perinatal Education Programme courses can Dr D H Greenfield, Prof G Theron,
be improved. Prof H de Groot, Ms H Louw, Dr N Rhoda,
Ms M Petersen, Prof P Henning, Prof C Pieper,
The production costs of this book were
Dr A Horn, Dr M Hann.
generously funded by Eduhealthcare, a non-
profit organisation dedicated to improving Cover photograph: Dr Harris Steinman
healthcare education.
Illustrations: Mary Hann and Anne Westoby

8. Introduction
ABOUT THE EBW WHY DECENTRALISED
HEALTHCARE SERIES LEARNING?
EBW Healthcare publishes an innovative Continuing education for healthcare workers
series of distance-learning books for traditionally consists of courses and workshops
healthcare professionals, developed by the run by formal trainers at large central hospitals.
Perinatal Education Trust, Eduhealthcare, These teaching courses are expensive to attend,
the Desmond Tutu HIV Foundation and the often far away from the healthcare workers’
Desmond Tutu TB Centre, with contributions families and places of work, and the content
from numerous experts. frequently fails to address the real healthcare
requirements of the poor, rural communities
Our aim is to provide appropriate, affordable
who face the biggest healthcare challenges.
and up-to-date learning material for
healthcare workers in under-resourced areas, To help solve these many problems, a self-
so that they can manage their own continuing help decentralised learning method has been
education courses which will enable them to developed which addresses the needs of
learn, practise and deliver skillful, efficient professional healthcare workers, especially
patient care. those in poor, rural communities.
The EBW Healthcare series is built on
the experience of the Perinatal Education
Programme (PEP), which has provided BOOKS IN THE EBW
learning opportunities to over 60 000 nurses HEALTHCARE SERIES
and doctors in South Africa since 1992. Many
of the educational methods developed by PEP
are now being adopted by the World Health Maternal Care addresses all the common
Organisation (WHO). and important problems that occur
during pregnancy, labour, delivery and the
puerperium. It covers the antenatal and
postnatal care of healthy women with normal
pregnancies, monitoring and managing

9. 10 NEWBORN CARE
the progress of labour, specific medical glucose concentration, insertion of an umbilical
problems during pregnancy, labour and the vein catheter, phototherapy, apnoea monitors
puerperium, family planning and regionalised and oxygen therapy.
perinatal care. Skills workshops teach clinical
examination in pregnancy and labour, routine Primary Newborn Care was written
screening tests, the use of an antenatal card specifically for nurses and doctors who
and partogram, measuring blood pressure, provide primary care for newborn infants in
detecting proteinuria and performing and level 1 clinics and hospitals. Primary Newborn
repairing an episiotomy. Care addresses the care of infants at birth, care
of normal infants, care of low-birth-weight
Maternal Care is aimed at healthcare workers
infants, neonatal emergencies, and common
in level 1 hospitals or clinics.
minor problems in newborn infants.
Primary Maternal Care addresses the
Mother and Baby Friendly Care describes
needs of healthcare workers who provide
gentler, kinder, evidence-based ways of caring
antenatal and postnatal care, but do not
for women during pregnancy, labour and
conduct deliveries. It is adapted from theory
delivery. It also presents improved methods
chapters and skills workshops from Maternal
of providing infant care with an emphasis
Care. This book is ideal for midwives and
on kangaroo mother care and exclusive
doctors providing primary maternal care
breastfeeding.
in level 1 district hospitals and clinics,
and complements the national protocol of
Saving Mothers and Babies was developed in
antenatal care in South Africa.
response to the high maternal and perinatal
mortality rates found in most developing
Intrapartum Care was developed for doctors
countries. Learning material used in this book
and advanced midwives who care for women
is based on the results of the annual confidential
who deliver in district hospitals. It contains
enquiries into maternal deaths and the Saving
theory chapters and skills workshops adapted
Mothers and Saving Babies reports published in
from the labour chapters of Maternal Care.
South Africa. It addresses the basic principles
Particular attention is given to the care
of mortality audit, maternal mortality,
of the mother, the management of labour
perinatal mortality, managing mortality
and monitoring the wellbeing of the fetus.
meetings and ways of reducing maternal and
Intrapartum Care was written to support
perinatal mortality rates. This book should
and complement the national protocol of
be used together with the Perinatal Problem
intrapartum care in South Africa.
Identification Programme (PPIP).
Newborn Care was written for healthcare
Birth Defects was written for healthcare
workers providing special care for newborn
workers who look after individuals with birth
infants in regional hospitals. It covers
defects, their families, and women who are at
resuscitation at birth, assessing infant size and
increased risk of giving birth to an infant with a
gestational age, routine care and feeding of both
birth defect. Special attention is given to modes
normal and high-risk infants, the prevention,
of inheritance, medical genetic counselling,
diagnosis and management of hypothermia,
and birth defects due to chromosomal
hypoglycaemia, jaundice, respiratory distress,
abnormalities, single gene defects, teratogens
infection, trauma, bleeding and congenital
and multifactorial inheritance. This book
abnormalities, as well as communication with
is being used in the Genetics Education
parents. Skills workshops address resuscitation,
Programme which trains healthcare workers in
size measurement, history, examination and
genetic counselling in South Africa.
clinical notes, nasogastric feeds, intravenous
infusions, use of incubators, measuring blood

10. INTRODUCTION 11
Perinatal HIV enables midwives, nurses doctors and nurses with wide experience in
and doctors to care for pregnant women and the care of adults with HIV, under the auspices
their infants in communities where HIV of the Desmond Tutu HIV Foundation at the
infection is common. Special emphasis has University of Cape Town.
been placed on the prevention of mother-to-
infant transmission of HIV. It covers the basics
of HIV infection and screening, antenatal FORMAT OF THE COURSES
and intrapartum care of women with HIV
infection, care of HIV-exposed newborn
infants, and parent counselling. 1. Objectives
The learning objectives are clearly stated at the
Childhood HIV enables nurses and doctors
start of each chapter. They help the participant
to care for children with HIV infection. It
to identify and understand the important
addresses an introduction to HIV in children,
lessons to be learned.
the clinical and immunological diagnosis
of HIV infection, management of children
with and without antiretroviral treatment, 2. Pre- and post-tests
antiretroviral drugs, opportunistic infections There is a multiple-choice test of 20 questions
and end-of-life care. for each chapter at the end of the book.
Participants are encouraged to take a pre-test
Childhood TB was written to enable before starting each chapter, to benchmark
healthcare workers to learn about the primary their current knowledge, and a post-test after
care of children with tuberculosis. The book each chapter, to assess what they have learned.
covers an introduction to TB infection,
and the clinical presentation, diagnosis, Self-assessment allows participants to monitor
management and prevention of tuberculosis their own progress through the course.
in children and HIV/TB co-infection.
Childhood TB was developed by paediatricians 3. Question-and-answer format
with wide experience in the care of children Theoretical knowledge is presented in a
with tuberculosis, under the auspices of the question-and-answer format, which encourages
Desmond Tutu Tuberculosis Centre at the the learner to actively participate in the
University of Stellenbosch. learning process. In this way, the participant
is led step by step through the definitions,
Child Healthcare addresses all the common
causes, diagnosis, prevention, dangers and
and important clinical problems in children,
management of a particular problem.
including immunisation, history and
examination, growth and nutrition, acute and Participants should cover the answer for a few
chronic infections, parasites, skin conditions, minutes with a piece of paper while thinking
and difficulties in the home and society. Child about the correct reply to each question. This
Healthcare was developed for use in primary method helps learning.
care settings. Simplified flow diagrams are also used, where
necessary, to indicate the correct approach to
Adult HIV covers an introduction to HIV
diagnosing or managing a particular problem.
infection, management of HIV-infected adults
at primary-care clinics, preparing patients for
antiretroviral (ARV) treatment, ARV drugs, Each question is written in bold, like this,
starting and maintaining patients on ARV and is identified with the number of the
treatment and an approach to opportunistic chapter, followed by the number of the
infections. Adult HIV was developed by question, e.g. 5-23.

11. 12 NEWBORN CARE
4. Important lessons Participants need to achieve at least 80%
in the examination in order to successfully
complete the course. Successful candidates
Important practical lessons are emphasised by will be emailed a certificate which states
placing them in a box like this. that they have successfully completed
that course. EBW Healthcare courses are
5. Notes not yet accredited for nurses, but South
African doctors can earn CPD points on the
NOTE Additional, non-essential information is
provided for interest and given in notes like this.
successful completion of an examination.
These facts are not used in the case studies or Please contact info@ebwhealthcare.com or
included in the multiple-choice questions. +27 021 44 88 336 when you are ready to take
the exam.
6. Case studies
Each chapter closes with a few case
studies which encourage the participant CONTRIBUTORS
to consolidate and apply what was learned
earlier in the chapter. These studies give the The developers of our learning materials are a
participant an opportunity to see the problem multi-disciplinary team of nurses, midwives,
as it usually presents itself in the clinic or obstetricians, neonatologists, and general
hospital. The participant should attempt to paediatricians. The development and review of
answer each question in the case study before all course material is overseen by the Editor-
reading the correct answer. in-Chief, emeritus Professor Dave Woods,
a previous head of neonatal medicine at the
7. Practical training University of Cape Town who now consults to
UNICEF and the WHO.
Certain chapters contain skills workshops,
which need to be practised by the participants
Perinatal Education Trust
(preferably in groups). The skills workshops,
which are often illustrated with line drawings, Books developed by the Perinatal Education
list essential equipment and present step-by- Programme are provided as cheaply as possible.
step instructions on how to perform each Writing and updating the programme is both
task. If participants aren’t familiar with a funded and managed on a non-profit basis by
practical skill, they are encouraged to ask an the Perinatal Education Trust.
appropriate medical or nursing colleague to
demonstrate the clinical skill to them. In this Eduhealthcare
way, senior personnel are encouraged to share
their skills with their colleagues. Eduhealthcare is a non-profit organisation
based in South Africa. It aims to improve health
and wellbeing, especially in poor communities,
8. Final examination
through affordable education for healthcare
On completion of each course, participants workers. To this end it provides financial
can take a 75-question multiple-choice support for the development and publishing of
examination on the EBW Healthcare website, the EBW Healthcare series.
when they are ready to.
All the exam questions will be taken from The Desmond Tutu HIV Foundation
the multiple-choice tests from the book. The The Desmond Tutu HIV Foundation at the
content of the skills workshops will not be University of Cape Town, South Africa,
included in the examination. is a centre of excellence in HIV medicine,

12. INTRODUCTION 13
building capacity through training and CONTACT INFORMATION
enhancing knowledge through research.
The Desmond Tutu Tuberculosis Centre EBW Healthcare
The Desmond Tutu Tuberculosis Centre at Website: www.ebwhealthcare.com
Stellenbosch University, South Africa, strives
Email: info@ebwhealthcare.com
to improve the health of vulnerable groups
through the education of healthcare workers Telephone: +27 021 44 88 336
and community members, and by influencing Fax: +27 088 021 44 88 336
policy based on research into the epidemiology
of childhood tuberculosis, multi-drug- Post: 87 Station Road, Observatory, 7925,
resistant tuberculosis, HIV/TB co-infection Cape Town, South Africa
and preventing the spread of TB and HIV in
southern Africa. Editor-in-Chief: Professor Dave Woods
Website: www.pepcourse.co.za
UPDATING THE COURSE Email: pepcourse@mweb.co.za
MATERIAL Telephone: +27 021 786 5369
Fax: +27 021 671 8030
EBW Healthcare learning materials
Post: Perinatal Education Programme,
are regularly updated to keep up with
PO Box 34502, Groote Schuur, Observatory,
developments and changes in healthcare
7937, South Africa
protocols. Course participants can make
important contributions to the continual
improvement of EBW Healthcare books
by reporting factual or language errors,
by identifying sections that are difficult to
understand, and by suggesting additions or
improvements to the contents. Details of
alternative or better forms of management
would be particularly appreciated. Please send
any comments or suggestions to the Editor-in-
Chief, Professor Dave Woods.