Care after delivery observation of newborns in the first few hours of life
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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 Few Hours of LifeNewborns

  • 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…. Few Hours of Life

  • 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 Few Hours of Life

  • 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 Few Hours of LifeMaternal 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 Factors Few Hours of Life1

  • 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 Few Hours of Life

  • 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 Statistics Few Hours of Life1,2

  • 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? Few Hours of Life

  • 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 Few Hours of Life

  • 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


Care after delivery observation of newborns in the first few hours of life
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 Period: Consensus Statements Guiding Practice

  • 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 Period: Consensus Statements Guiding Practice

  • 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