4 million neonatal deaths occur annually, mostly in the first week. Main causes are prematurity, birth asphyxia, sepsis and pneumonia. Essential newborn care includes care during pregnancy, delivery, immediate assessment and resuscitation if needed, thermal protection, cleanliness, breastfeeding and eye prophylaxis. Danger signs include not feeding, respiratory distress, fever, hypothermia and signs of infection. Conditions like sepsis, asphyxia and prematurity require treatment including antibiotics, anticonvulsants and careful feeding and temperature management with hospital referral when possible.

1. Normal Newborn
Care

2. International
 Introduction
• 4 million neonatal deaths per year
• 2/3 of neonatal deaths occur in 1st
week of life
• Must improve maternal education in basic newborn
care and recognition of danger signs
• Improve training in neonatal resuscitation and
recognition and management of sick neonates

3. International
Main Causes of Infant Mortality
7%
15%
9%
1%
29%
24%
10% 5%
Neonatal tetanus 7%
Pneumonia 15%
Sepsis/Meningitis 9%
Diarrhea 1%
Birth asphyxia and trauma 29%
Prematurity 24%
Congenital anomalies 10%
Others 5%
Main Causes of Mortality

4. International
 Essential Care for Newborn Health
• Care of future mothers
• Care during pregnancy
• Care at time of birth
• Care after birth

5. International
 Immediate Care of the Newborn
 At birth, ask yourself the four following questions. If any answer is NO, THE BABY REQUIRES
RESUSCITATION
•Breathing or
crying?
•Good muscle
tone?
•Color pink?
•Term gestation?
Routine care
-Warmth
- Dry
IF YES
IF NO
-Provide warmth
-Position; clear airway
-Dry, stimulate
Evaluate:
-Respirations
-Heart rate
-Color
RAPID INTERVENTION…for resuscitation

6. International
 Apgar Scores
• A tool used to document the clinical status
of the newborn
• NOT used to identify newborns that require
resuscitation
• A score of 0 to 10 is assigned at 1, 5, and 10
minutes

7. International
Sign Score
0 1 2
Heart rate Absent Slow (< 100
beats/minute)
=> 100 beats/min
Breathing Absent Slow, irregular Good, crying
Muscle Tone Limp Some flexion Active motion
Reflex
irritability
No response Grimace Cough, sneeze
Color Blue or pale Pink body with blue
extremities
Completely pink
Apgar ScoringApgar Scoring

8. International
 Cleanliness for the Newborn
• Clean hands, perineum and delivery surface
• Immediate tying and clean cutting of cord
• Clean cloth to wrap baby in after delivery
• Clean cord care
- nothing applied to cord stump
- cord stump to be left uncovered to dry

9. International
 Thermal Protection of the Newborn
• Warm delivery room
• Immediate drying
• Skin to skin contact
• Breastfeeding
• Delay weighing and bathing
• Appropriate clothing and bedding
• Keep mother and newborn together
• Warm transportation and resuscitation

10. Newborn ResuscitationNewborn Resuscitation

11. International
• Be prepared for resuscitation – 10% of
babies require resuscitation
• 30-40% of babies that require
resuscitation are a surprise

12. International
 What is Necessary to Prepare
for Resuscitation?
• Appropriate equipment
• Skill to use equipment
• Learn to recognize which baby needs
resuscitation

13. International
At birth, ask yourself the four following questions. If any answer is NO, THE BABY
REQUIRES RESUSCITATION
Breathing or
crying?
Good muscle
tone?
Color pink?
Term gestation?
- Provide warmth
- Position; clear
airway
- Dry, stimulate
Evaluate:
- Respirations
- Heart rate
- Color
Supportive
care
Provide breathing assistance
RAPID INTERVENTION…for resuscitation
HR > 100 &
pink
Abnormal respirations or HR < 100
Routine care
- Warmth
- Dry
IF NO
Normal breathing

14. International

Meconium
 Babies (10 – 12%) may be born through meconium stained
amniotic fluid

 Meconium can plug the airway

 A vigorous baby is:
 - breathing or crying
 - heart rate > 100 bpm
 - good tone
 If baby not vigorous then clearing the airway by intubating and
suctioning of the trachea may be life saving.

15. International
 How to Assess a Baby in a Health Care Facility
 Breathing or Crying :
 -Watch babies chest rise
 -Normal rate 40-60/bpm
 - A vigorous indicates breathing
 Abnormal breathing may be:
 - absence of breathing
 - shallow respirations, poor chest movement
 - gasping respirations – extreme effort to inhale
associated with a slow respiratory rate

16. International
 Muscle tone - healthy term babies have a flexed position
 Color – Normal is pink lips and mucous membranes.
A dusky blue hue of lips and mucous membranes indicates
central cyanosis.
 Term gestation – by history
 Heart rate – normal heart rate 120 – 160 bpm
determined by auscultation of the heart.
How to Assess a Baby in a Health Care Facility

17. International
 Heart rate
 Hold the base of the umbilical cord with your thumb and
 index finger. The cord pulsations felt are the heart rate of
the baby. The baby’s heart rate should be more than your own
heart rate.
 All other assessments are similar to health facility
How to Assess a Baby in the Community

18. International
 How to Provide Resuscitation in a Health Care
Facility
 Warmth
 - warmer
 - warm delivery room
 - temperature – 25o
C to 28o
C (77 – 82.4o
F)
 - no fans or draughts
 - warm linen including 2 blankets/sheets, cap and clothing for baby
 -Dry baby immediately and remove wet linen
 - kangaroo care: even premature babies can maintain temperature
with skin to skin contact

19. International
 How to Provide Resuscitation in a Health Care Facility
 Suction
 - suction mouth and nostrils before delivery of baby
 - suction mouth and nostrils after delivery of baby. Remember
mouth is to be suctioned before the nose
 Stimulate – If the baby is not breathing provide:
 - tactile stimulation by gently rubbing the back
 - stroking the feet
 - drying also provides tactile stimulation

20. International
 How to Provide Resuscitation in the
Community
 Warmth
 - deliver baby in a room that is warm and has no draughts - may need
heating.
 - dry baby immediately and remove wet linen
 - warm linen including 2 blankets/sheets, cap and clothing for baby
 - baby’s body can be wrapped in a towel and then covered by plastic.
Ensure baby’s head is not covered by plastic.
 - kangaroo care: even premature babies can maintain temperature
with skin to skin contact

21. International
 How to Provide Resuscitation in the
Community
 Suction
 if you do not have a suction catheter or bulb syringe then wipe the
mouth gently with a cloth
 - deep suctioning may cause bradycardia
 Stimulate - If the baby is not breathing provide:
 - tactile stimulation by gently rubbing the back
 - stroking the feet
 - drying also provides tactile stimulation

22. International
 Breathing Assistance in a Health
Care Facility
 Bag and Mask Ventilation
 Indication:
 - not breathing
 - heart rate < 100 bpm
 Equipment:
 - self inflating bag with oxygen reservoir
 - infant mask

23. International
 Breathing Assistance in a Health Care Facility
Technique:
 - connect O2
to reservoir
 - cover mouth and nostrils with mask
 - squeeze bag 40-60 times/minute
 WATCH for chest movement. If no movement:
 - check for seal
 - reapply mask
 -reposition head
 - check for blocked airway
 and continue bag and mask ventilation

24. International
 Breathing Assistance in the
Community
 - If you have a self inflating bag and mask, follow
instructions in health care facility section.
 - You may use a tube and mask:
• - get a good seal covering the mouth and nostrils
• - breathe 40 times/minute into the tube by blowing into the
tube - make sure the chest rises

25. International
 When does the baby require continuing
observation and additional attention?
 Danger signs:
 - ineffective breathing/labored respiration – respiration rate > 60/min
 - heart rate < 100 bpm
 - cyanosis
 - pale, mottled or gray
 - abnormal tone
 - jitteriness
 - seizures
 - cool/warm baby
 - not feeding
 - at risk for infection

26. International
 Successful Resuscitation
 BABY SHOULD BE:
• WARM
• PINK
• BREATHING COMFORTABLY

27. Preventative Care
for the Newborn

28. International
 Breastfeeding
• Within one hour of birth
• Feed on demand to stimulate milk production
• 8 to 12 feeds in 24 hours
• Feeding is appropriate if: 6-8 wet diapers per day, frequent bowel
movements and weight gain
• No supplements needed
• Empty breast completely to use hind milk
• Mother must increase caloric and fluid intake

29. International
Proper LatchProper Latch

30. International
 Eye Care
• Helps prevent infectious conjunctivitis in 85 to
90% of newborns
• Clean eyes in all newborns within 1 hour of birth
• Prophylactic agents:
• Silver nitrate 1% solution (2 drops per eye)
• Tetracycline ointment 1%
• Erythromycin ointment 0.5%
• Provilodone solution – iodized 2.5%

31. International
 Other Measures
 Vitamin K
• 1 mg IM to prevent haemorrhagic disease
 Cord Care
• Keep stump clean and uncovered
• No traditional medicines, herbs, etc
 Immunizations
• BCG if at risk of TB
• One dose of oral polio vaccine (OPV) <2 wks after birth
• Hepatitis B if available

32. International
Recognition and ManagementRecognition and Management
of Problems Followingof Problems Following
Resuscitation or PresentingResuscitation or Presenting
During the First Week of LifeDuring the First Week of Life

33. International
 IMPORTANT PRINCIPLES
• Training
• neonatal resuscitation
• post resuscitation management
• prompt recognition of danger signs
• prompt management of danger signs
• Maternal education
• Urgency of assessment and management of a
sick newborn

34. International
 DANGER SIGNS
• A danger sign is a sign or a symptom identified
from history (mother, pregnancy, delivery, baby) as
well as physical exam of the baby, which indicates
that he/she is at risk for, or is in trouble and needs
urgent evaluation.
• Signs and symptoms are non-specific in the
neonatal period.

35. International
 HISTORICAL DANGER SIGNS
 maternal history
• maternal fever
• incomplete maternal immunization status
• maternal HIV,TB, syphilis, malaria
 delivery history
• prolonged rupture of membranes
• prolonged labor
• unclean delivery
• bleeding, foul amniotic fluid
• need for neonatal resuscitation

36. International
DANGER
SIGNS
Not feeding well
(<6 feeds/day) Respiratory
Cardiac
Other
Neurologic
Skin
Risk of infection
General

37. International
 NEONATAL DANGER SIGNS
 Not feeding well
• After first day of life, a healthy baby should be feeding 8-12
times a day. He/she should wake up for feeding and show
interest in feeding.
 General appearance
• low birth weight <2500g
• premature <34 weeks
• twins or triplets
• dysmorphism
• temperature abnormalities
 hypothermia <35.5 °C axillary
 hyperthermia >37.5 °C axillary

38. International
 DANGER SIGNS
 Respiratory
• tachypnea RR>60, irregular breathing, apnea
• labored breathing, grunting, retractions
• cyanosis
• cough
• requiring bag and mask ventilation
 Cardiac
• tachycardia HR>200, bradycardia HR<100
• pale, mottled, capillary refill>3sec
• cyanosis

39. International
 DANGER SIGNS
 Neurologic
• seizures
• hypotonia
• hypertonia
• jitteriness, tremors
• irritability
• lethargy
• poor suck
• weak cry or high pitch cry
• bulging fontanel, depressed fontanel

40. International
 DANGER SIGNS
 Skin
• jaundice
• pustules
• pus from the umbilicus
• redness around the umbilicus
• purulent eye discharge
 Other
• abdominal distension, diarrhea
• vomiting
• bleeding

41. International
 CLINICAL SIGNS
 Not feeding well (with risk of hypoglycemia)
• irritability
• seizures
• jitteriness
• temperature instability
• respiratory distress
• poor colour
• jaundice

42. International
 CLINICAL SIGNS
 Sepsis /meningitis
• all the danger signs
 Pneumonia
• RR>60
• retractions, nasal flaring
• grunting
• cough

43. International
 CLINICAL SIGNS
 Asphyxia
• abnormality of muscle tone
• lethargy, poor activity, irritability
• seizures, jitteriness, tremors
• poor sucking reflex
• poor respiratory effort
• poor colour

44. International
 CLINICAL SIGNS
 LBW/prematurity
• BW<2500g
• physical immaturity
• risk of respiratory problems, especially the
premature infant
• difficult temperature control (risk of
hypothermia)
• poor feeding
• higher risk of infections
• higher risk of jaundice

45. International
 MANAGEMENT
 Not feeding well with no other danger signs
• evaluate
 milk production
 feeding technique
 sucking ability of the baby
• spoon feeding of extracted milk or formula
• treat oral thrush with gentian violet

46. International
 MANAGEMENT
 Severe infection (pneumonia, sepsis,
meningitis)
• antibiotics: Septra PO for 10 days, and Gentamicin
IM for 7 days
• temperature control
• nutrition
• transfer (with mother) to a hospital, if feasible

47. International
 MANAGEMENT
 Local infection
• Eyes: IM Cefotaxime or Ceftriaxone, 1dose, or
Penicillin for 7 days
• Umbilicus:
 if mild redness not extending: observation
 if redness extending or pus draining, or other
danger signs: see severe infection
• Skin:
 hygiene and oral cloxacillin
 if not improving with oral treatment, or other danger
signs present: see severe infection

48. International
 MANAGEMENT
 Asphyxia/seizures
• treat the seizures with phenobarbital
• antibiotics (see severe infection)
• nutrition/prevention of hypoglycemia
• temperature control
• transfer if possible

49. International
 MANAGEMENT
 LBW/Premature baby
• handle with care
• temperature control
• early and frequent feedings
• spoon feeding of expressed colostrum/breast
milk if unable to suck
• close observation for signs of infection
• check skin for jaundice