Routine postnatal care for the newborn Name of presenter: Prevention of Postpartum Hemorrhage Initiative (POPPHI) Proj

1. Routine postnatal care for the newbornName of presenter: Prevention of Postpartum Hemorrhage Initiative (POPPHI) ProjectBASICS

2. By the end of this session, participants will be able to: Describe elements of examination and care of the newborn in the facility. Provide the mother/family counseling on: - preventive care - identifying danger signs - appropriate care seeking behavior. Objectives Note: Examination and care of the newborn are beyond the scope of this course. A brief review of components of the examination and care will be provided, but the emphasis in this course will be on recognizing danger signs and counseling the mother/parents about care for the newborn.

3. Integration of maternal and newborn care The mother and her newborn are inseparable; both should be evaluated and treated at the same time. This presentation concentrates on care of the newborn and complements the sessions on care of the postpartum woman.

4. 4 millions neonatal deaths: When? Up to 50% of neonatal deaths occur during the first 24 hours 75% of neonatal deaths occur during the first week –– 3 millions deaths Most babies die at a time when their health care quality is the lowest Risk of death/day (for 1.000 survivors) Age (days) 4 Lawn et al, Lancet, March 3, 2005

5. Working in pairs Work in pairs with a participant sitting next to you. Tasks: Read the following sections in Chapter 8 in the Reference Manual: Introduction, Newborn Care – Overview, and Components of postnatal care. After 15 minutes, be ready to actively participate in a question/answer session.

6. When should the newborn receive routine postnatal exams? At 1 hour and 6 hours after childbirth At least once a day when in the facility At discharge 2-3 days after birth 5-7 days after birth 4-6 weeks after birth Timing of visits / exams may be adjusted depending on the newborn’s health status or needs.

7. How will you prepare for the examination? (1) Prepare to maintain the baby’s temperature during the examination. Prevent heat loss/hypothermia. Select a draft-free area, keep the baby warm during examination with a heat source, or, if not available, keep the baby covered, close to the mother, and expose only the part(s) to be examined. Promote cleanliness of the site where the baby is examined. Arrange to have adequate light. 7

8. Wash hands with soap and water; if these are unavailable, use alcohol/glycerine hand rub. Greet the mother and her family/companion, install them comfortably in a draft-free area, and explain what you are going to do. How will you prepare for the examination? (2) 8

9. Review mother’s and baby’s cards/charts: Pregnancy: Note any care received by the mother and risk factors for infection. Delivery: Note: Where the baby was born, the condition at birth, when the baby cried after birth, if the cry was spontaneous; if not, what actions were taken to initiate the cry. Birth weight Care given at birth (eye and cord care, vitamin K1 injection) Immunizations (Some of the above apply only to facility births.) What information will you gather during the history? 9

10. Danger signs (the first five are the most important): Difficulty in sucking/poor sucking/inability to suck or not sucking Lethargy, diminished activity, moving only when stimulated Fever/body feeling too hot or hypothermia/body feeling too cold Rapid breathing/difficulty in breathing Convulsions What danger signs will you ask about / assess for? (1) 10

11. Danger signs (continued): Repeated vomiting or green vomitus/abdominal fullness or distension Signs related to severe umbilical infection (in 1st few days look for oozing of blood from the cord) Other problems Passage of urine and stools (passing urine 6 or more times a day indicates that the baby is receiving adequate breast milk) What danger signs will you ask about / assess for? (2) 11

12. Adaptations necessary during examination of the newborn Count the respiratory rate when the baby is quiet. If the baby cries, take advantage to examine the mouth to look for thrush or cleft lip/palate. If feeding is necessary to calm the baby, use the opportunity to observe attachment at the breast and quality and adequacy of the sucking. 12

13. Group Work Group 1 Poor sucking/not sucking Inactivity/lethargy Group 2 Fever/hypothermia Group 3 Respiratory difficulty Convulsions Group 4 Vomiting/abdominal distension Severe umbilical infection Describe how to identify danger signs in the newborn through history and examination. 13

14. Danger sign: Poor sucking/not sucking Ask if the baby: Sucks well. Has any feeding problems; complaints include that the baby is sucking less than usual, does not suck at all, does not open the mouth when offered feeds, does not demand feeds. Take a good history from the mother. 14

15. Danger sign: Inactivity/lethargy The mother may complain that baby is: not as active as usual, sleeping excessively, is difficult to arouse, not waking up for feeds, lying limp, “loose-limbed,” excessively quiet, or “too good.” Check level of alertness and activity: Except in deep sleep, babies have frequent spontaneous movements; arms and legs are in flexion. In lethargic babies, the extremities remain flaccid and extended. Movements are minimal or absent. Normal baby with arms in flexion Lethargic baby with flaccid, extended extremities 15

16. Danger sign: Fever/hypothermia Note axillary temperature (normal temperature ranges between 36.5 °C to 37.5 °C). In between, touch the abdomen, hands, and feet of the baby to make sure that these parts are warm. Fever: Body hot to touch, history of the mouth feeling hot during breastfeeding; temperature more than 37.5 0 C. Hypothermia: body colder than normal; temperature less than 36.5 0C. 16

17. Danger sign: Difficulty in breathing Respiratory rate (RR ranges 30-60/minute). Recount if > 60/minute. Nasal flaring Grunting Severe subcostal retractions Note: Breathing may be irregular, with short pauses. Respiratory pauses > 10 seconds may be abnormal (apneas), especially if associated with bradycardia. Tactile stimulation may restart breathing. Refer such babies to a higher center in skin-to skin contact (KMC), in which position apneas are less frequent. 17

18. Danger sign: Convulsions Ask if the baby had convulsions. Convulsions may present in an atypical manner in the newborn: Fixed gaze Blinking of the eyes Chewing/chapping movements of the lips Tonic and/or clonic movements of the extremities 18

19. Danger sign: Vomiting/abdominal distention Repeated or persistent vomiting (occasional vomiting is normal); green-colored vomitus Abdominal distention 19

20. Danger sign:Major umbilical cord infection If the umbilical cord is intact, lift it to observe the base. Features include spreading redness or swelling around the umbilicus and/or foul smell with or without pus discharge. , 20

21. Urgent action for danger signs Note: In case of even one danger sign, refer the baby with the mother and follow the instructions for referral. 21

22. Early detection of problems Babies with danger signs may have to be taken long distances to the appropriate centers. Hence, ideally problems such as major infections need to be detected even earlier. Very early signs are vague and difficult to recognize. These include the baby “not looking well” or having a “facial grimace” or a look of “discomfort.” They require careful daily observation. Mothers/family members and health care providers should be encouraged to see the baby in adequate light at least once a day, especially in the first week or two when problems are more common. 22

23. Examination: Look for jaundice Check by pressing the tip of the nose and observing the yellowish color over the blanched skin. Check also the grooves at the base of the nose when the baby cries. Jaundice progresses from the face to the palms and soles. Jaundice in normal babies starts after 24 hours of birth, does not spread to palms and soles, and ends within 10 days. 23

24. Referral criteria for jaundice • Referral criteria for jaundice : • Starting early within 24 hours • Reaching the palms and soles • When associated with a danger sign • Occurring in a low birth weight baby • Persisting beyond the second week of life 24

25. Check for minor infections Conjunctivitis Pus discharge from the eyes, with or without redness or swelling. Thrush White patches on the tongue, inner cheeks, and palate. Different from normal smooth coating on center of tongue. Minor umbilical infection Pus discharge from umbilicus or base of cord. No surrounding redness, swelling, or foul smell. Pyoderma/pustules Pustules or peeling of skin with underlying redness. 25

26. Check infant feeding If breastfeeding, check for signs of a proper attachment. • If formula feeding, check for signs of good feeding. 26

27. Weigh the baby Compare the baby’s weight to previous weights Newborns normally lose 5% to 10% of their birth weight in the first few days of life, and then begin to gain weight. By the 14th day, a baby should have regained his birth weight. . 27

28. Evaluate findings from history and physical examination • Record all the key information in the mother/baby card/register. • Based on analysis of findings: • Identify problems and danger signs. • Decide where and by whom the newborn should receive care. Refer all newborns who need specialized care for any reason. • Make a plan of care with the mother/parents. • Make a plan for counseling the mother/parents on caring for the newborn and follow-up of any identified problems. 28

29. Make a plan of care • Give advice/prescription/medication for minor infections, if they are present. • Immunize with BCG, OPV, hepatitis B, as recommended if not given earlier or, if not feasible, make an appointment. • Counsel on key preventive care, danger signs, and care-seeking. 29

30. Care for newborn exposed to HIV (1) • Verify ARV regimen and counsel mother/parents on administering ARV drugs to the newborn. • Provide support for chosen the infant feeding choice. • Reinforce the importance of exclusive breast or formula feeding. • If breastfeeding: • Reinforce messages on care of the breast and prevention of problems. • Address any questions, concerns, and problems related to breastfeeding. 30

31. Care for newborn exposed to HIV (2) • Counsel the mother / parents on: • symptoms of opportunistic infections in the baby, such as fever, cough, night sweats, weight loss, and thrush. • symptoms of opportunistic infections in herself, such as fever, cough, night sweats, weight loss, diarrhea. • when to bring the child for HIV testing and cotrimoxazole prophylaxis. • If no clinical HIV services are immediately available for referral of mother and infant, counsel the mother about HIV in infants and the need to get testing and treatment as soon as possible. 31

32. Group work • Work in groups of 2-3 participants. • Tasks: • Read the section “Provide counseling for caring for the newborn” in Chapter 8 of the Reference Manual. • You have 5 minutes to prepare a short summary of counseling to provide to a mother/father on the following subjects: • Group 1: Preventing hypothermia / hyperthermia • Group 2: Sleep. • Group 3: Protection from Infection / Cord care • Group 4: Loving Care • Group 5: Immunization / Hygiene

33. Routine care for the postpartum woman: Develop a complication-readiness plan Recognize danger signs. Establish a financing plan/scheme. Develop a plan for decision-making. Arrange a system of transport.

34. Team work • Divide into groups of 3-4 participants. TASKS: • You have 5 minutes to develop a catchy way to help mothers/parents remember danger signs in the newborn. • Present your team work to all of the participants. 34

35. Postnatal visit: Closing (1) Ask the mother/parents if there are any further questions or concerns. Tell the mother/parents when to bring their newborn back for routine postnatal care. Reassure the mother/parents that the newborn can be brought to the facility at any time if there are questions or concerns.

36. Postnatal visit: Closing (2) Advise the mother/parents to go to the hospital/health center immediately, day or night, WITHOUT waiting if the newborn has even one danger sign. Thank the mother/parents for coming. Record the relevant details of care for the newborn.

37. 37

38. Review session objectives By the end of this session, participants will be able to: • Describe elements of examination and care of the newborn in the facility. • Provide the mother/family counseling on: - preventive care - identifying danger signs - appropriate care seeking behavior.

39. 39

40. 40