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Essential Newborn Care:The DOH/WHO ProtocolEssential Newborn Care:The DOH/WHO ProtocolMaria Asuncion Silvestre, FAAPConsultant, Essential Newborn Care
4 March 2010
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OUTLINE OUTLINE Why do we need this Protocol? What are the four core, time-bound stepsof Essential Newborn Care?
How are these steps performed? What can I do to implement the Protocolin my area of practice?
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<5 year old and Neonatal Mortality, 1988 to 2008 <5 year old and Neonatal Mortality, 1988 to 2008 <5 Yr Old mortality decreased 40% (1988-1998) Past 10 years, declined by 20% Slow decline since neonatal mortality hasnt improved
806070Under FiveMortality Rate0102030405060
1988 1993 1998 2003 2008NeonatalMRDHS 88, 93,98, 03, 08
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82,000 Filipino children die annually,most could have been prevented
Source: CHERG estimates of under-five deaths, 2000-03
The Philippines is one of the 42 countries thataccount for 90% of global under-five mortality
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Majority of newborns die due to stressful events orconditions during labor, delivery and the immediate
postpartum period.3outof4newborndeathsoccurintheweekoflifeofdeathsDayofLifeNumbero
NDHS 2003, special tabulations
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WhatImmediate Newborn CarePractices will save lives?
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Time Band: At perineal bulgingPrepare for the DeliveryTime Band: At perineal bulgingPrepare for the Delivery Check temperature of the delivery room 25-28 oC
Free of air drafts Notify appropriate staff Arrange needed supplies in linear fashion Check resuscitation equipment Wash hands with clean water and soap Double glove just before delivery
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Four Core Steps ofEssential Newborn CareFour Core Steps ofEssential Newborn Care Immediate and thorough drying Early skin-to-skin contact
Properly timed cord clamping Non-separation of the newborn andmother for early initiation ofbreastfeeding
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Time Band: Within 1st 30 secsImmediate Thorough DryingTime Band: Within 1st 30 secsImmediate Thorough Drying Call out the time of birth Dry the newborn thoroughly for at least 30
secondsseconds
Wipe the eyes, face, head, front and back, armsand legs Remove the wet cloth
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Time Band: Within 1st 30 secsImmediate and Thorough DryingTime Band: Within 1st 30 secsImmediate and Thorough Drying Do a quick check of breathing while drying Notes:
During the 1st secs:D t til t l th bbi Do not ventilate unless the baby isfloppy/limp and not breathing Do not suction unless the mouth/nose areblocked with secretions or other material
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Time Band 0 -3 mins:Immediate, Thorough DryingTime Band 0 -3 mins:Immediate, Thorough Drying Notes: Do not wipe off vernix
Do not bathe the newbornDo not bathe the newborn
Do not do footprinting No slapping No hanging upside -down No squeezing of chest
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Time Band: After 30 secs of dryingEarly Skin-to-Skin ContactTime Band: After 30 secs of dryingEarly Skin-to-Skin Contact If newborn is breathing or crying: Position the newborn prone on the mothers
abdomen or chest Cover the newborns back with a dry blanket Cover the newborns head with a bonnet
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Time Band: After 30 secs of dryingEarly Skin-to-Skin ContactTime Band: After 30 secs of dryingEarly Skin-to-Skin Contact Notes: Avoid any manipulation, e.g. routine
suctioning that may cause trauma or infectiongy
Place identification band on ankle (not wrist) Skin to skin contact is doable even forcesarean section newborns
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Time Band: 1 -3 minsProperly -timed cord clampingTime Band: 1 -3 minsProperly -timed cord clamping Remove the first set of gloves After the umbilical pulsations have
stopped, clamp the cord using a sterilestopped, clamp the cord using a sterileplastic clamp or tie at 2 cm from theumbilical base
Clamp again at 5 cm from the base Cut the cord close to the plastic clamp
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Time Band: 1 -3 minsProperly -timed cord clampingTime Band: 1 -3 minsProperly -timed cord clamping Notes: Do not milk the cord towards the baby
After the 1st clamp, you may strip the cordAfter the 1st clamp, you may strip the cordof blood before applying the 2nd clamp
Cut the cord close to the plastic clamp so thatthere is no need for a 2nd trim Do not apply any substance onto the cord
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Time Band: Within 90 minsNon-separation of Newbornfrom Mother forEarly BreastfeedingTime Band: Within 90 minsNon-separation of Newborn
from Mother forEarly Breastfeeding Leave the newborn in skin-to-skin contact Observe for feeding cues, including tonguing,licking, rooting Point these out to the mother and encourageher to nudge the newborn towards the breast
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Time Band: Within 90 minsNon-separation of Newbornfrom Mother forEarly BreastfeedingTime Band: Within 90 minsNon-separation of Newborn
from Mother forEarly Breastfeeding Counsel on positioning
Counsel on positioning
Newborns neck is not flexed nor twisted Newborn is facing the breast Newborns body is close to mothers body Newborns whole body is supported
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Time Band: Within 90 minsNon-separation of Newbornfrom Mother forEarly BreastfeedingTime Band: Within 90 minsNon-separation of Newborn
from Mother forEarly Breastfeeding Counsel on attachment and suckling
Counsel on attachment and suckling
Mouth wide open Lower lip turned outwards Babys chin touching breast Suckling is slow, deep with some pauses
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Time Band: Within 90 minutesNon-separation of Newbornfrom Mother forEarly BreastfeedingTime Band: Within 90 minutesNon-separation of Newborn
from Mother forEarly Breastfeeding Weighing, bathing, eye care, examinations,ij ti (h titi BBCG) h ldbinjections (hepatitis B, BCG) should be doneafter the first full breastfeed is completed
Postpone washing until at least 6 hours
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Time Band: Within 90 minutesNon-separation of Newbornfrom Mother forEarly BreastfeedingTime Band: Within 90 minutesNon-separation of Newborn
from Mother forEarly Breastfeeding Weighing, bathing, eye care, examinations,ij ti h ldb d ft th fi tfinjections should be done after the first full llbreastfeed is completed
Postpone washing until at least 6 hours
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The evidence is solid:
The following NewbornCare Practices will save
lives:
Immediate and
Thorough Drying
Thorough Drying
Early Skin-to-SkinContact
Properly Timed Cord
Clamping
Non-separation ofNewborn from Motherfor Early Breastfeeding
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Delaying Initiation of breastfeedingincreases risk of infection-related death,
RR
Nepal 2008, 22,838 breastfed babies
8101214Mullany LC, et al. J Nutr, 2008;138(3):599-603.0246
8<1 1-24 24-48 48-72 >72Hours after Birth
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Delaying Initiation of breastfeeding increasesrisk of infection-related death,Ghana 2004, 10,947 breastfed infants
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ENC Time-Bound Interventions
Within 30SecondsObjective:
To stimulatebreathing,providewarmthAfter thoroughdryingObjective:To provide warmth,bonding, preventinfection &hypoglycemiaUp to 3 minutes
Post-deliveryObjective:To reduceanemia in term &preterm;IVH & transfusionsWithin 90 minutesOf ageObjective:To facilitate initiationof breastfeedingthrough sustainedcontact warmth hypoglycemia
-Put on doublegloves-Dry thoroughly-Remove wet cloth-Quick check ofNBs breathing-Suction only ifneeded-Put prone on chest/abdomen skin to skin-Cover w/ blanket,bonnet-Place identificationon ankle-Do not remove vernixIVH & transfusionsin preterm-Remove 1st set ofgloves-Clamp and cut cordafter cord pulsationsstop (1-3 mins)-Do not milk cord-Give oxytocin 10mgIM to mother
contact-Uninterrupted skin toskin contact
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-Observe NB forfeeding cues-Counsel onpositioning &attachment-Do eye care, injectionsetc after 1st breastfeed
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Training Video
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Current State ofNewborn Care PracticesNewborn Care Practicesin Philippine HospitalsCurrent State ofNewborn Care PracticesNewborn Care Practicesin Philippine Hospitals
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Variation in Sequence of Interventions
Sobel, Silvestre, Mantaring, Oliveros, 2009
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EssentialNewborn CareProtocol wasguidelinedeveloped toaddress these
issues
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Next Steps
Dissemination DOH Administrative Order2009-0025 on ENC signed2009 0025 on ENC signed
Unang Yakap campaignlaunched Dec 9, 2009 Implementation Monitoring
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Scope of Application
Whole hierarchy of the DOH and itsattached agencies Public and private providers
Development partners involved in theMNCHN strategy All health practitioners involved in maternaland newborn care
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ENC Implementation ENC Implementation The current state of maternal and newborn careneeds urgent action Evidence-based interventions are not practicedsufficiently.
ENC Protocol provides an evidence-based, lowstl tch l cka fi t ti thcost, low technology package of interventions that twill save tens of thousandsof lives.
Each of us, as individuals and as organizations, haveto look inward to find ways to implement ENC Join us to bring Unang Yakap to your membershipand every person they can influence.
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How can I contribute toimplementing ENC?
Organize a multidisciplinary ENC Working Group
MDs: Obs, Pediatricians, Anesthesiologists Nurses, nursing assistants Midwives Administrators Infection control committeeInfection control committee
Conduct a situational analysis of your facility Revise hospital policies and standard operatingprocedures, forms, order sheets etc
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How can I contribute toimplementing ENC?
Enable the environment for ENC
Disable the environment that hinders ENC Join us to bring Unang Yakap to yourmembership and every mother, fatherthat they can influence.
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