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Normal Newborn Care
Advances in Maternal and Neonatal Health
2 Normal Newborn Care
Session Objective
Define essential elements of early newborn care
Discuss best practices and technologies for promoting newborn health
Use relevant data and information to develop appropriate essential newborn recommendations
3 Normal Newborn Care
Newborn Deaths
8.1 million infant deaths (1993)
3.9 million (48%) newborn deaths
2.8 million (67%) early newborn deaths
Major causes of newborn deaths
Birth asphyxia: 21% Infections: 42% (tetanus,
sepsis, meningitis, pneumonia, diarrhea)
4 Normal Newborn Care
Newborn Deaths (continued)
Birth process was the antecedent cause of 2/3 of deaths due to infections
Lack of hygiene at childbirth and during newborn period Home deliveries without skilled birth attendants
Birth asphyxia in developing countries
3% of newborns suffer mild to moderate birth asphyxia Prompt resuscitation is often not initiated or procedure is
inadequate or incorrect
5 Normal Newborn Care
Newborn Deaths (continued)
Hypothermia and newborn deaths
Significant contribution to deaths in low birth weight infants and preterm newborns
Social, cultural and health practices delaying care to the newborn
Countries with high STD prevalence and inconsistent prophylactic practices
Ophthalmia neonatorum is a common cause of blindness
6 Normal Newborn Care
Newborn Deaths (continued)
Low birth weight
An extremely important factor in newborn mortality Place of childbirth
At least 2 out 3 childbirths in developing countries occur at home
Only half are attended by skilled birth attendants Strategies for improving newborn health should target
– Birth attendant, families and communities– Healthcare providers within the formal health system
7 Normal Newborn Care
Essential Newborn Care Interventions
Clean childbirth and cord care
Prevent newborn infection Thermal protection
Prevent and manage newborn hypo/hyperthermia Early and exclusive breastfeeding
Started within 1 hour after childbirth Initiation of breathing and resuscitation
Early asphyxia identification and management
8 Normal Newborn Care
Essential Newborn Care Interventions (continued)
Eye care
Prevent and manage ophthalmia neonatorum Immunization
At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO)
Identification and management of sick newborn
Care of preterm and/or low birth weight newborn
9 Normal Newborn Care
Cleanliness to Prevent Infection
Principles of cleanliness essential in both home and health facilities childbirths
Principles of cleanliness at childbirth
Clean hands Clean perineum Nothing unclean introduced vaginally Clean delivery surface Cleanliness in cord clamping and cutting Cleanliness for cord care
Infection prevention/control measures at healthcare facilities
10 Normal Newborn Care
Thermal Protection
Newborn physiology
Normal temperature: 36.5–37.5°C Hypothermia: < 36.5°C Stabilization period: 1st 6–12 hours after birth
– Large surface area– Poor thermal insulation– Small body mass to produce and conserve heat– Inability to change posture or adjust clothing to
respond to thermal stress Increase hypothermia
Newborn left wet while waiting for delivery of placenta Early bathing of newborn (within 24 hours)
11 Normal Newborn Care
Hypothermia Prevention
Deliver in a warm room
Dry newborn thoroughly and wrap in dry, warm cloth
Keep out of draft and place on a warm surface
Give to mother as soon as possible
Skin-to-skin contact first few hours after childbirth Promotes bonding Enables early breastfeeding
Check warmth by feeling newborn’s feet every 15 minutes
Bathe when temperature is stable (after 24 hours)
12 Normal Newborn Care
Early and Exclusive Breastfeeding
Early contact between mother and newborn
Enables breastfeeding Rooming-in policies in health facilities prevents
nosocomial infection Best practices
No prelacteal feeds or other supplement Giving first breastfeed within one hour of birth Correct positioning to enable good attachment of the
newborn Breastfeeding on demand Psycho-social support to breastfeeding mother
WHO 1999.
13 Normal Newborn Care
Breathing Initiation and Resuscitation
Spontaneous breathing (> 30 breaths/min.) in most newborns
Gentle stimulation, if at all Effectiveness of routine oro-nasal suctioning is unknown
Biologically plausible advantages – clear airway Potentially real disadvantages – cardiac arrhythmia Bulb suctioning preferred
Newborn resuscitation may be needed
Fetal distress Thick meconium staining Vaginal breech deliveries Preterm
Hamilton 1999.
14 Normal Newborn Care
Eye Care To Prevent or Manage Ophthalmia Neonatorum
Ophthalmia neonatorum
Conjunctivitis with discharge during first 2 weeks of life Appears usually 2–5 days after birth Corneal damage if untreated Systemic progression if not managed
Etiology
N. gonorrhea
– More severe and rapid development of complications– 30–50% mother-newborn transmission rate
C. trachomatis
15 Normal Newborn Care
Eye Care To Prevent or Manage Ophthalmia Neonatorum (continued)
Prophylaxis
Clean eyes immediately 1% Silver nitrate solution
– Not effective for chlamydia 2.5% Povidone-iodine solution 1% Tetracycline ointment
– Not effective vs. some N. gonorrhea strains Common causes of prophylaxis failure
Giving prophylaxis after first hour Flushing of eyes after silver nitrate application Using old prophylactic solutions
16 Normal Newborn Care
Efficacy of Prophylaxis for Conjunctivitis in China
Objective: To assess etiology of newborn conjunctivitis and evaluate the efficacy of regimens in China
Design: November 1989 to October 1991 rotated regimens monthly: tetracycline, erythromycin, silver nitrate
302 (6.7%) infants developed conjunctivitis, most S. aureus (26.2%) and chlamydia (22.5%)
Silver nitrate, tetracycline: fewer cases than no prophylaxis (p < 0.05), erythromycin: not significant
Chen 1992.
17 Normal Newborn Care
Prophylaxis for Conjunctivitis: Objective and Design
Objective: To compare efficacy in prevention of nongonococcal conjunctivitis
Design: Randomized control trial to compare erythromycin, silver nitrate, no prophylaxis
Examined with test for leukocyte esterase and chlamydia trachomatis antibody probe 30–48 hours postpartum, 13–15 days later, and telephone contact up to 60 days of life
Main outcome measured: conjunctivitis within 60 days of life and nasolacrimal duct patency
Bell 1993.
18 Normal Newborn Care
Prophylaxis for Conjunctivitis: Results and Conclusion
Results: 630 infants
109 with conjunctivitis
Silver nitrate vs. no prophylaxis: Hazard ratio 0.61 (0.39-0.97)
– Chemical conjunctivitis with silver nitrate resolves within 48 hours
Erythromycin vs. no prophylaxis: Hazard ratio 0.69 (not significant)
Conclusion: Parental choice of prophylaxis, including no prophylaxis, is reasonable IF antenatal care and STD screening
Bell 1993.
19 Normal Newborn Care
Povidone-Iodine for Conjunctivitis: Objective and Design
Objective: To determine incidence and type of conjunctivitis after povidone-iodine in Kenya
Design: Rotate regimen weekly: erythromycin, silver nitrate, povidone iodine
Results:
Conjunctivitis:
– Chlamydia in 50.5%– S. aureus in 39.7%
More infections in silver nitrate than povidone-iodine, OR 1.76, p < 0.001
More infections in erythromycin OR 1.38, p=0.001
Isenberg, Apt and Wood 1995.
20 Normal Newborn Care
Povidone-Iodine for Conjunctivitis: Conclusion
Povidone-iodine:
Is good prophylaxis Has wider antibacterial spectrum Causes greater reduction in colony-forming units and
number of bacterial species Is active against viruses Is inexpensive
Isenberg, Apt and Wood 1995.
21 Normal Newborn Care
Immunization
BCG vaccinations in all population at high risk of tuberculosis infection
Single dose of OPV at birth or in the two weeks after birth
HBV vaccination as soon as possible where perinatal infections are common
22 Normal Newborn Care
Summary
The essential components of normal newborn care include:
Clean delivery and cord care
Thermal protection
Early and exclusive breastfeeding
Monitoring
Eye care
Immunization
23 Normal Newborn Care
References
Bell TA et al. 1993. Randomized trial of silver nitrate, erythromycin and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 92: 755–760.Chen J. 1992. Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin, and no prophylaxis. Pediatr Infect Dis J 11: 1026–1030.Child Health Research Project and Maternal and Neonatal Health Program. 1999. Reducing Perinatal and Neonatal Mortality. Report of a meeting in Baltimore, Maryland, 10–12 May, 1999.Hamilton P. 1999. Care of the newborn in the delivery room. Br Med J 318: 1403–1406. Isenberg SJ, L Apt and M Wood. 1995. A controlled trial of povidone-iodine as prophylaxis against ophthalmitis neonatorum. N Engl J Med 332: 562–566.World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. WHO: Geneva.