1. Providing care for the newborn at birth Name of presenter: Prevention of Postpartum Hemorrhage Initiative (POPPHI) Project BASICS

2. Objectives By the end of this session, participants will be able to: Describe components of essential newborn care at birth. Provide essential newborn care at birth using a practice checklist. 2

3. 3 Brainstorming What are the elements of care required by the baby at birth?

4. 4 Thermal protection or maintenance of the baby’s body temperature Clearing of the airways only if necessary, not as a routine Eye care Cord care Infant feeding within the first hour of birth Administration of vitamin K Recording of the weight Routing monitoring of the baby Additional care if the baby was exposed to HIV Key components of essential newborn care (ENC) at birth

5. 5 Care of the baby at birth: Thermal Protection 1.Receive the baby in a sterile or clean, dry cloth. 2.Wipe the face and eyes and dry the whole body well. Verify that the baby is breathing while drying, discard the wet cloth. 3.Place the baby on the mother’s abdomen and cover the baby, including the head, over the mother with a fresh dry cloth. 4.Announce the time of birth and the sex of the baby. Never hold the feet and hang the baby upside down.

6. Assess the baby’s breathing while drying the baby. –If the baby is not crying or breathing at least 30 times per minute within 30 seconds of birth, call for help and begin resuscitation –If the baby is breathing normally, continue with immediate care of the newborn. Care of the baby at birth: Initiate breathing Clear the airways (mouth and nose) only if necessary (not as a routine). 6

7. 7 Care of the baby at birth: Cord care (1) Wait to clamp and cut the cord until the cord ceases to pulsate or 2–3 minutes after the baby’s birth, whichever comes first. Apply a clamp about 5 cm from the baby’s abdomen. Gently milk the cord towards the woman’s perineum and place a second clamp on the cord approximately 1 cm from the first clamp. Never milk the cord, especially towards the baby. Cover the cord with a sterile gauze while cutting the cord between the clamps to avoid splashing blood. Do NOT use the same scissors used for episiotomy.

8. Apply a disposable clamp or sterile ligatures on the cord stump. Do not apply a bandage on the cord. Do not cover it with a napkin/diaper. Keep the cord clean and dry. Apply an antiseptic only if it is the recommendation of the Ministry of Health. Care of the baby at birth: Cord care (2) The cord should be tied only after AMTSL or urgent procedures such as resuscitation for birth asphyxia have been carried out. 8

9. Care of the baby at birth: Maintenance of temperature After cutting the cord: Place the newborn in skin-to-skin contact on the mother’s chest and cover the baby with a fresh dry cloth. The baby should be kept in skin-to-skin contact whether or not the woman has chosen to breastfeed. Take care to cover the head either with a bonnet, cap or with the cloth. Verify the axillary temperature of the baby at least once after birth and if the baby’s feet are cold (axillary temperature should be between 36.5 o C to 37.5 o C). Inform the mother that the bath will be delayed at least 6 hours in order to prevent chilling. 9

10. 10 Wipe the eyes and apply the eye drops or ointment (commonly tetracycline). If an ointment is used, apply a filament in the lower eyelid from the inner canthus to the outer edge. Make sure that the tip of the bottle or tube does not touch the eyes. Care of the baby at birth: Care of the eyes

11. Give vitamin K1 intramuscularly –1 mg for term infant –0.5 mg for the very low birth weight infant <1500 grams 11 Care of the baby at birth: Vitamin K1 Immediate newborn care can be provided while the infant is in skin-to-skin contact with the mother.

12. Help the woman initiate infant feeding during the first hour after birth and preferably before being transferred out of the delivery room. Explain that the baby should be fed on demand. Explain what is meant by exclusive breast or formula feeding. Explain the importance of exclusive breast or formula feeding during the first 6 months of the baby’s life. Explain the dangers of “mixed” infant feeding. Care of the baby at birth: Infant feeding 12

13. 13 Care of the baby at birth: Breastfeeding (1) Commence breastfeeding within one hour after birth. Assist the mother in initiating breastfeeding. This will be facilitated by the skin-to-skin contact on the mother’s chest. Allow sufficient time for breastfeeding.

14. Care of the baby at birth: Breastfeeding (2) Check attachment of the baby’s mouth at the breast: The chin touches or nearly touches the breast. The mouth is wide open. Nearly the whole of the areola is in the mouth and more is visible above than below the mouth. The lips, especially the lower one, are everted. The sucking is slow and deep, with audible swallowing. 14

15. Care of the baby at birth: Breastfeeding (3) OMS, 1993 15

16. Show the woman how to hold the baby sitting semi- upright on her lap Show the woman how to hold the cup of milk to the baby’s lips: rest cup lightly on lower lip touch edge of cup to outer part of upper lip tip cup so that milk just reaches the baby’s lips but do not pour the milk into the baby’s mouth. Care of the baby at birth: Formula feeding (1) (WHO/IMPAC, 2003) 16

17. Explain signs of good feeding including the following: baby becomes alert, opens mouth and eyes, and starts to feed. the baby will suck the milk, spilling some. small babies will start to take milk into their mouth using the tongue. baby swallows the milk. Care of the baby at birth: Formula feeding (2) 17

18. Care of the baby at birth: Recording weight Record the weight when the baby is stable and warm. 1.Place a clean, preferably sterile, linen or paper on the pan of the weighing scale. 2.Adjust the needle to zero on the scale with the linen/paper on the pan. 3.Place the naked baby on the paper/linen. If the linen is large, cover the baby with the cloth. 4.Note the weight of the baby when the scale stops moving. 5.Record the baby’s weight in partograph/maternal/ newborn charts and delivery room register and inform the mother. 18 Never leave the baby unattended on the scale.

19. Care of the baby at birth: Miscellaneous Place preferably two identification bands on the wrist and ankle with the name of the mother and father (if available), date and time of birth, and the sex. Do not separate the mother and the baby unless it is unavoidable for special care. Do not leave the mother and baby unattended on the delivery table soon after delivery. Do not transfer the woman and baby out of the delivery room until at least one hour after childbirth. 19

20. Counsel the mother / family about care for the newborn: Thermal protection Cord care Infant feeding Eye care Counsel the mother / family about care for the baby 20

21. Demonstration of essential newborn care at birth 21 Refer to the Practice Checklist.

22. Return demonstration of essential newborn care at birth

23. 23 Additional care of the baby exposed to HIV (1) Clean the vagina with chlorhexidine before delivery if recommended by the MOH Do not suction the mouth and nose unless absolutely necessary. Clamp the cord soon after birth. Administer ARV prophylaxis to the baby. Ensure informed choice for infant feeding. The actual type of feeding will depend on the mother’s choice.

24. If replacement feeding is risky, promote exclusive breastfeeding for the first six months, followed by replacement and complementary feeding. –Highlight the risk of mixed feeding. –Provide guidance to avoid sore nipples, engorgement, and mastitis. When replacement feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS), avoidance of all breastfeeding by HIV-infected women is recommended (WHO). –Highlight the risk of mixed feeding. –Provide guidance on breast care. Additional care of the baby exposed to HIV (2) 24

25. 25 Integrating maternal and newborn care at birth

26. 1) Keep all required items for the mother and baby handy/close by, load oxytocin in syringe. 2) Inform the mother ahead of time what is being planned in a way she can understand. Receive and dry the baby, discard wet linen. Baby cries well Place the baby on mother’s abdomen. Cover with dry cloth. Inform the mother about the baby. Administer uterotonic after ruling out a second baby. Clamp and cut the cord when pulsations cease/2-3 minutes after the birth. Apply controlled cord traction with countertraction to the uterus. Massage the uterus after delivery of the placenta. Eye prophylaxis; tie the cord; warmth (skin-to-skin); initiate breastfeeding. Monitoring + rest of routine care for the woman and baby. 26

27. 1) Keep all required items for the mother and baby handy and close by. 2) Inform the mother ahead of time what is being planned in a way she can understand. Receive and dry the baby, discard wet linen. Cry not heard Wrap in fresh dry linen exposing chest. Keep warm. Assess breathing. Not breathing / gasping/breathing very slowly Cut cord. Begin newborn resuscitation. Give uterotonic (oxytocin/ misoprostol) after ruling out a second baby. Deliver placenta with CCT and massage the uterus with assistance. If no assistance, allow physiological 3 rd stage. Eye prophylaxis; tie the cord; warmth (skin-to-skin); initiate breastfeeding. Monitoring + rest of routine care for the woman and baby. 27

28. 1) Keep all required items for the mother and baby handy and close by. 2) Inform the mother ahead of time what is being planned in a way she can understand. Receive and dry the baby, discard wet linen. Cry not heard Wrap in fresh dry linen exposing chest. Keep warm. Assess breathing. Eye prophylaxis; tie the cord; warmth (skin-to-skin); initiate breastfeeding. Monitoring + rest of routine care for the woman and baby. Breathing well Call for help to observe baby. Give uterotonic (oxytocin/misoprostol) after ruling out a second baby. Deliver placenta with CCT. Massage the uterus. 28

29. 1) Keep all required items for the mother and baby handy and close by. 2) Inform the mother ahead of time what is being planned in a way she can understand. Receive and dry the baby, discard wet linen. Cry not heard Wrap in fresh dry linen exposing chest. Keep warm. Assess breathing. Not breathing / gasping / breathing very slowly Cut cord. Begin newborn resuscitation. Give uterotonic (oxytocin/ misoprostol) after ruling out a second twin. Deliver placenta with CCT and massage the uterus with assistance. If no assistance, allow physiological 3 rd stage. Eye prophylaxis; tie the cord; warmth (skin-to-skin); initiate breastfeeding. Monitoring + rest of routine care for the woman and baby. Baby cries well Place baby on the mother’s abdomen. Cover with dry cloth. Inform the mother about the baby. Administer uterotonic after ruling out a second baby. Clamp and cut the cord when pulsations cease/2-3 minutes after the birth. Apply controlled cord traction with countertraction to the uterus. Massage the uterus after delivery of the placenta. Breathing well Call for help to observe baby. Give uterotonic (oxytocin/misoprostol) after ruling out a second twin. Deliver placenta with CCT. Massage the uterus. 29

30. Demonstration of AMTSL + essential newborn care at birth 30

31. 31 Return demonstration of AMTSL + essential newborn care at birth

32. 32 Review session objectives By the end of this session, participants will be able to: Describe components of essential newborn care at birth. Provide essential newborn care at birth using a practice checklist.

33. Please complete learning activities found in the Participant’s Notebook for Session 5. You may work individually or in groups on the learning activities during breaks, in the evening, or in the clinical area when there are no clients. You may correct your answers individually or with another participant or the facilitator. See a facilitator if you have questions. 33 Learning activities