CARE AFTER DELIVERY: OBSERVATION OF NEWBORNS IN THE FIRST FEW HOURS OF LIFE
Alexandra Wallace
On behalf of theNeonatal Encephalopathy Working Group June 2012
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
1. Moore, E. R. et al. Cochrane database of systematic reviews(2): CD003519. (2009)
2. World Health Organization/UNICEF: Ten Steps to Promote Successful Breastfeeding (1989).
3. Saadeh, R. and J. Akre (1996). Birth (1996).
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 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 Maternal Factors Fatigue Pain +/- immobility Ongoing interventions or management
of obstetric problems Effects of medication Body habitus
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
1. Andres et al. Pediatrics, 2011.
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 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
1. Becher, J-C et al Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.
2. Fleming, PJ. Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.
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 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
Mother and Baby Observations in the Immediate Postnatal Period: Consensus Statements Guiding Practice
1. Active assessment for ALL babies in the early postnatal period, regardless of birth context
2. Minimum assessment time of 1 hour Longer if increased risk
3. 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
4. Family/Whanau may be involved in process Must know what to check for and who to call for
help
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 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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