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Care after delivery: Observation of newborns in the First Few Hours of Life. Alexandra Wallace On behalf of the Neonatal Encephalopathy Working Group June 2012. Background – Normal N ewborns. Most term newborns adapt rapidly to life ex utero and require no resuscitation

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care after delivery observation of newborns in the first few hours of life

Care after delivery: Observation of newborns in the First Few Hours of Life

Alexandra Wallace

On behalf of the

Neonatal Encephalopathy Working Group

June 2012

background normal n ewborns
Background – Normal Newborns
  • Most term newborns adapt rapidly to life ex utero and require no resuscitation
  • Early skin to skin contact and initiation of breastfeeding are integral to obstetric and neonatal best practice1
    • Step 4 in the 10 steps of the BFHI policy2,3
  • Moore, E. R. et al. Cochrane database of systematic reviews(2): CD003519. (2009)
  • World Health Organization/UNICEF: Ten Steps to Promote Successful Breastfeeding (1989).
  • Saadeh, R. and J. Akre (1996). Birth (1996).
background when things go wrong
Background – when things go wrong….
  • Some newborns require assistance to initiate or maintain normal cardiorespiratory function following delivery
    • Problems may be apparent immediately after delivery or develop in the first few hours of life
    • May be expected or unexpected
  • Therefore…..
    • Normal cardiorespiratory function cannot be assumed
    • All newborns require assessment:
      • at birth
      • intermittently over the first few hours of life
potential newborn problems
Potential Newborn Problems
  • Failure to adapt to ex utero environment
  • Birth asphyxia
  • Meconium aspiration
  • Birth trauma
  • Sepsis
  • Congenital heart disease
  • Other congenital anomalies
  • Newborn vulnerability
    • Thermoregulation
    • Glucose homeostasis
    • Immature respiratory control
potential m aternal f actors
Potential Maternal Factors
  • Fatigue
  • Pain +/- immobility
  • Ongoing interventions or management of obstetric problems
  • Effects of medication
  • Body habitus
example compounding maternal and newborn factors 1
Example: Compounding Maternal and Newborn Factors1
  • Primigravida, increased BMI
  • Long labour, normal delivery
  • Big baby but well, no resuscitation required
  • Skin to skin soon after delivery with attempts to latch
  • At 2 hours of age – Mum sleeping
    • Baby prone on Mum’s chest, apnoeic, blue, cold
    • Required resuscitation, ventilation, inotropic support
  • Developed severe hypoxic-ischaemic encephalopathy and died at 15 days of age
  • Andres et al. Pediatrics, 2011.
sudi vs supc vs suend
SUDI vs SUPC vs SUEND
  • SUDI: Sudden Unexpected Death in Infancy
    • Clinically unexpected deaths in infants less than 12 months of age
  • SUPC: Sudden Unexpected Postnatal Collapse
    • Clinically unexpected collapse in apparently healthy term infants in the first hours of life
  • SUEND: Sudden Unexpected Early Neonatal Death
    • Does not include babies who collapse but do not die
supc statistics 1 2
SUPC Statistics1,2
  • Incidence varies from 2.6 to 5 per 100,000 live births
    • Death results in up to 50% of cases
  • Over half of the events occur in 1st 2 hours of life
  • Identifiable cause found in up to 30% of cases
  • Remainder due to accidental airway obstruction
  • 3 commonly identified risk factors:
    • Primiparous mother
    • Skin-to-skin in prone position with mouth and nose occluded
    • Mother and baby unattended by clinical staff
  • Becher, J-C et al Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.
  • Fleming, PJ. Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.
what is required
What is Required?
  • Awareness of the issues
    • What can go wrong?
    • Newborn and maternal factors that increase risk
  • Development of recommendations for observation of the WELL newborn that:
    • Do NOT impinge on initiation of skin to skin contact and breastfeeding
    • DO keep babies safe by identifying unexpected problems
dhb survey
DHB Survey
  • 18 responses from 21 DHBs
  • Of the 18 that responded:
    • 2 have specific policy on observation of the newborn
    • Variety of other policies submitted including:
      • Examination of the newborn
      • Early discharge
      • Breastfeeding
      • Hypoglycaemia guidelines
      • Care of low birth weight babies
      • Treatment of narcotic depression
      • Safe sleeping/SUDI prevention
slide11
Mother and Baby Observations in the Immediate Postnatal Period: Consensus Statements Guiding Practice
  • Active assessment for ALL babies in the early postnatal period, regardless of birth context
  • Minimum assessment time of 1 hour
    • Longer if increased risk
  • Early skin-to-skin contact and breast feeding is facilitated and supervised
    • Monitoring of colour, tone, respiration ongoing
    • Ensure nose and mouth are not occluded
  • Family/Whanau may be involved in process
    • Must know what to check for and who to call for help
newborn observations
Newborn Observations
  • Colour
  • Heart rate
  • Respiratory rate
  • Temperature
  • Airway patency
  • Tone and activity
  • Ability to feed
  • Overall condition
  • Any concerns require referral for Paediatric review
summary
Summary
  • Well newborns usually remain well
  • A few newborns develop problems soon after birth
  • All apparently well newborns require observation in the 1st few hours of life
    • This can be done without compromising early initiation of skin to skin contact and breast feeding
  • Health care providers must:
      • Be aware of the problems a newborn may encounter
      • Understand the observations required
      • Know what to do if a newborn becomes unwell
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