A neonatal intensive care unit (NICU) is an intensive care unit specializing in the care of ill or premature newborn infants.

The first official ICU for neonates was established in 1961 atVanderbilt University by Professor Mildred Stahlman, officially termed a NICU whenStahlman was the first to use a ventilator off-label to assist a baby with breathing difficulties. [1] A NICU is typically directed by one or more neonatologists and staffed by nurses, nurse practitioners, pharmacists, physician assistants, resident physicians, and respiratory therapists. Many other ancillary disciplines and specialists are available at larger [2] units. The term neonatal comes from neo, "new", and natal, "pertaining to birth or origin". Healthcare institutions have varying entry-level requirements for neonatal nurses. Neonatal nurses are Registered Nurses (RNs), and therefore must have an Associate of Science in Nursing (ASN) or Bachelor of Science in Nursing (BSN) [3] degree. Some countries or institutions may also require a midwifery qualification. Some institutions may accept newlygraduated RNs who have passed the NCLEX exam; others may require additional experience working in adult-health or [4] medical/surgical nursing. Some countries offer postgraduate degrees in neonatal nursing, such as the Master of Science in Nursing (MSN) and [3] various doctorates. A nurse practitioner may be required to hold a postgraduate degree. The National Association of Neonatal [4] Nurses recommends two years' experience working in a NICU before taking graduate classes. As with any registered nurse, local licensing or certifying bodies as well as employers may set requirements for continuing [4] education. There are no mandated requirements to becoming an RN in a NICU, although neonatal nurses must have certification as a Neonatal Resuscitation Provider. Some units prefer new graduates who do not have experience in other units, so they may be trained in the specialty exclusively, while others prefer nurses with more experience already under their belt. Intensive care nurses endure intensive didactic and clinical orientation, in addition to their general nursing knowledge, to provide highly specialized care for critical patients. Their competencies include the administration of high-risk medications, management of high-acuity patients requiring ventilator support, surgical care, resuscitation, advanced interventions such as extracorporeal membrane oxygenation or hypothermia therapy for neonatal encephalopathy procedures, as well as chronic-care management or lower acuity cares associated with premature infants such as feeding intolerance, phototherapy, or administering antibiotics. NICU RNs undergo annual skills tests and are subject to additional training to maintain contemporary practice.

Equipment
Incubator

An incubator (or isolette

[14]

) is an apparatus used to maintain

environmental conditions suitable for aneonate (newborn baby). It is used in preterm births or for some ill full-term babies. Possible functions of a neonatal incubator are: Oxygenation, through oxygen supplementation by head hood or nasal cannula, or evencontinuous positive airway pressure (CPAP) or mechanical ventilation. Infant respiratory distress syndrome is the leading cause of death in preterm [15] infants, and the main treatments are CPAP, in addition to administering surfactant and stabilizing the blood sugar, blood salts, andblood pressure. Observation: Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity. [16] Protection from cold temperature, infection, noise, drafts and excess handling: Incubators may be described as bassinets enclosed in plastic, with climate control equipment designed to keep them warm and limit their exposure to germs. Provision of nutrition, through intravenous catheter or NG tube. Administration of medications. Maintaining fluid balance by providing fluid and keeping a high air humidity to prevent too great a loss from skin and [17] respiratory evaporation. A transport incubator is an incubator in a transportable form, and is used when a sick or premature baby is moved, e.g., from one hospital to another, as from a community hospitalto a larger medical facility with a proper neonatal intensive care unit. It usually has a miniature ventilator, cardio-respiratory monitor, IV pump, pulse oximeter, and oxygen supply built into its frame.

The Ballard Maturational Assessment, Ballard Score, or Ballard Scale is a commonly used technique of gestational age assessment. It assigns a score to various criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria. This scoring allows for the estimation of age in the range of 26 weeks-44 weeks. The New Ballard Score is an extension of the above to include extremely pre-term babies i.e. up to 20 weeks. The scoring relies on the intra-uterine changes that the fetus undergoes during its maturation. Whereas the neurological criteria depend mainly upon muscle tone, the physical ones rely on anatomical changes. The neonate (less than 37 weeks of age) is in a state of physiological hypertonia. This tone increases throughout the fetal growth period, meaning a more premature baby would have lesser muscle tone.

The Physical criteria[edit source | editbeta]

These are: 1. Skin 2. Ear/Eye 3. Lanugo Hair 4. Plantar Surface 5. Breast bud 6. Genitals Physical Maturity of the Ballard Maturational Assessment of Gestational Age -1 0 gelatinous, red, translucent Sparse >50 mm no crease 1 2 3 4
[2]

Record Score Below:

Skin

sticky, friable, transparent

superficial cracking, parchment, leathery, smooth pink, peeling &/or pale areas, deep cracking, cracked, visible veins rash, few veins rare veins no vessels wrinkled Abundant Faint red marks Thinning Anterior transverse crease only Bald areas Mostly bald Sparse

Lanugo None Plantar surface Heel-toe 40-50 mm: -1 <40 mm: -2

Creases over Creases over anterior 2/3 entire sole of sole

Breast

Imperceptable

Barely perceptable Lids open pinna flat stays folded Scrotum empty, faint rugae

Flat areola no bud Sl. curved pinna soft; slow recoil Testes in upper canal, rare rugae

Raised Stippled areola Full areola areola 1-2 mm bud 5-10 mm bud 3-4 mm bud Well-curved pinna soft but ready recoil Testes descending, few rugae Formed & firm instant recoil Thick cartilage ear stiff

Lids fused Eye and Loosely: -1 Ear Tightly: -2 Genitals Scrotum flat, (Male) smooth Clitoris Genitals prominent & (Female) labia flat

Testes Testes down, pendulous, good rugae deep rugae Majora cover clitoris & minora

Prominent Prominent clitoris & clitoris & small enlarging labia minora minora

Majora Majora & large, minora equally minora prominent small

Scoring
Each of the above criteria are scored from 0 through 5, in the original Ballard Score. The scores were then ranged from 5 to 50, with the corresponding gestational ages being 26 weeks and 44 weeks. An increase in the score by 5, increases the age by 2 weeks. The New Ballard Score allows scores of -1 for the criteria, hence making negative scores possible. The possible scores

then range from -10 to 50, the gestational range extending up to 20 weeks. (A simple formula to come directly to the age from the Ballard Score is Age=(2*score+120) /5)
Jump up^ Ballard JL, Novak KK, Driver M (November 1979). "A simplified score for assessment of fetal maturation of newly born infants". J. Pediatr. 95 (5 Pt 1): 76974. doi:10.1016/S0022-3476(79)80734-9. PMID 490248. 1. Jump up^ Ballard, JL; Khoury, JC; Wedig, K; Wang, L; Eilers-Walsman, BL; Lipp, R (September 1991). "New Ballard Score, expanded to include extremely premature infants.". The Journal of Pediatrics 119 (3): 41723. PMID 1880657. Retrieved 13 August 2012.
[hide]

Medical records and physical exam

History CC HPI (OPQRST) ROS Allergies/Medications PMH/PSH/FH/SH (SAMPLE) Psychiatric history

General/IPPA Inspection Auscultation Palpation Percussion Vital signs T HR BP RR HEENT Oral mucosa TM Eyes (Ophthalmoscopy, Swinging-flashlight test) Hearing (Weber, Rinne) Lungs: Respiratory sounds Respiratory Other: Cyanosis Clubbing Heart: Precordium (Heart sounds, Apex beat) Cardiovascular Other: Jugular venous pressure Abdominojugular test Carotid bruit Peripheral vascular(Ankle brachial Admission PE (incl. intimate) Abdominal Urinary Murphy's punch sign Digestive Liver span Rectal Murphy's sign Bowel sounds pressure index)

Pelvis Cervical motion tenderness

Back (Straight leg raise) Knee (McMurray test) Hip Wrist (Tinel sign, Phalen Extremities/Joint maneuver) Shoulder(Adson's sign) GALS screen Neuro Mental state (MMSE) Cranial nerve examination Neonatal Apgar score Ballard Maturational Assessment

L/I Labs (Electrolytes, ABG, LFT) Medical imaging (EKG, CXR, CT, MRI) A/P Medical diagnosis Differential diagnosis

Progress

SOAP note

Common diagnosis and pathologies in the NICU include: Anemia Apnea Bradycardia Bronchopulmonary dysplasia (BPD) Hydrocephalus Intraventricular hemorrhage (IVH) Jaundice Necrotizing enterocolitis (NEC) Patent ductus arteriosus (PDA) Periventricular leukomalacia (PVL) Infant respiratory distress syndrome (RDS) Retinopathy of prematurity (ROP) Sepsis Transient tachypnea of the newborn (TTN)

Levels of care[edit source | editbeta]

The concept of designations for hospital facilities that care for newborn infants according to the level of complexity of care [18] provided was first proposed in the United States in 1976. Levels in the United States are designated by the guidelines [19] published by the American Academy of Pediatrics In Britain the guidelines are issued by The British Association of Perinatal Medicine (BAPM), and in Canada they are maintained by The Canadian Paediatric Society.

Canada[edit source | editbeta]

Level 1: Basic neonatal care[edit source | editbeta]
Level 1a: Evaluation and postnatal care of healthy newborn infants; and Phototherapy Level 1b: Care for infants with corrected gestational age greater than 34 weeks or weight greater than 1800 g who have mild illness expected to resolve quickly or who are convalescing after intensive care; Ability to initiate and maintain intravenous access and medications; Nasal oxygen with oxygen saturation monitoring (e.g., for infants with chronic lung disease needing long-term oxygen and monitoring).

Level 2: special care newborn nursery[edit source | editbeta]

Level 2a: Care of infants with a corrected gestational age of 32 weeks or greater or a weight of 1500 g or greater who are moderately ill with problems expected to resolve quickly or who are convalescing after intensive care Peripheral intravenous infusions and possibly parenteral nutrition for a limited duration Resuscitation and stabilization of ill infants before transfer to an appropriate care facility Nasal oxygen with oxygen saturation monitoring (e.g., for infants with chronic lung disease needing long-term oxygen and monitoring).

Level 2b: Mechanical ventilation for brief durations (less than 24 h) or continuous positive airway pressure. Intravenous infusion, total parenteral nutrition, and possibly the use of umbilical central lines and percutaneous intravenous central lines.

Level 3: Intensive neonatal care[edit source | editbeta]

US Navy 100204-N-6326B-008 Chief of Naval Operations Adm. Gary Roughead speaks with Capt. Douglas N. Carbine and Rear. Adm. Christine M. Bruzek-Kohler during a tour of the neonatal intensive care unit

Level 3a: Care of infants of all gestational ages and weights; Mechanical ventilation support, and possibly inhaled nitric oxide, for as long as required Immediate access to the full range of subspecialty consultants. Level 3b: Comprehensive on-site access to subspecialty consultants; Performance and interpretation of advanced imaging tests, including computed tomography, magnetic resonance imaging and cardiac echocardiography on an urgent basis Performance of major surgery on site but not extracorporeal membrane oxygenation, hemofiltration and hemodialysis, or surgical repair of serious congenital cardiac malformations that require cardiopulmonary bypass. Level 3c: Extracorporeal membrane oxygenation, hemofiltration and hemodialysis, or surgical repair of serious congenital cardiac malformations that require a cardiopulmonary bypass.

The Neonatal Intensive Care Unit (NICU)

The birth of a baby is a wonderful yet very complex process. Many physical and emotional changes occur for mother and baby. A baby must make many physical adjustments to life outside the mother's body. Leaving the uterus means that a baby can no longer depend on the mother's circulation and placenta for important physiologic functions. Before birth, breathing, eating, elimination of waste, and immunologic protection all came from the mother. When a baby enters the world, many body systems change dramatically from the way they functioned during fetal life:

The lungs must breathe air. The cardiac and pulmonary circulation changes. The digestive system must begin to process food and excrete waste. The kidneys must begin working to balance fluids and chemicals in the body and excrete waste. The liver and immunologic systems must begin functioning independently. Illustration demonstrating fetal circulation

Click Image to Enlarge Your baby's body systems must work together in a new way. Sometimes, a baby has difficulty making the transition to the world. Being born prematurely, having a difficult delivery, or birth defects can make these changes more challenging. Fortunately for these babies, special newborn care is available.

What is the neonatal intensive care unit?

Newborn babies who need intensive medical attention are often admitted into a special area of the hospital called the Neonatal Intensive Care Unit (NICU). The NICU combines advanced technology and trained healthcare professionals to provide specialized care for the tiniest patients. NICUs may also have intermediate or continuing care areas for babies who are not as sick but do need specialized nursing care. Some hospitals do not have the personnel or a NICU and babies must be transferred to another hospital.

Ten to 15 percent of all newborn babies require care in a NICU, and giving birth to a sick or premature baby can be quite unexpected for any parent. Unfamiliar sights, sounds, and equipment in the NICU can be overwhelming. This information is provided to help you understand some of the problems of sick and premature babies. You will also find out about some of the procedures that may be needed for the care of your baby.

Which babies need special care?

Most babies admitted to the NICU are premature (born before 37 weeks of pregnancy), have low birthweight (less than 5.5 pounds), or have a medical condition that requires special care. In the US, nearly 13 percent of babies are born preterm, and many of these babies also have low birthweights. Twins, triplets, and other multiples often are admitted to the NICU, as they tend to be born earlier and smaller than single birth babies. Babies with medical conditions such as heart problems, infections, or birth defects are also cared for in the NICU.

The following are some factors that can place a baby at high risk and increase the chances of being admitted to the NICU. However, each baby must be evaluated individually to determine the need for admission. High-risk factors include the following:

maternal factors: o age younger than 16 or older than 40 years o drug or alcohol exposure o diabetes o hypertension (high blood pressure) o bleeding o sexually transmitted diseases o multiple pregnancy (twins, triplets, or more) o too little or too much amniotic fluid o premature rupture of membranes (also called the amniotic sac or bag of waters) delivery factors: o fetal distress/birth asphyxia (changes in organ systems due to lack of oxygen) o breech delivery presentation (buttocks delivered first) or other abnormal presentation o meconium (the baby's first stool passed during pregnancy into the amniotic fluid) o nuchal cord (cord around the baby's neck) o forceps or cesarean delivery baby factors: o birth at gestational age less than 37 weeks or more than 42 weeks o birthweight less than 2,500 grams (5 pounds, 8 ounces) or over 4,000 grams (8 pounds, 13 ounces) o small for gestational age o medication or resuscitation in the delivery room o birth defects o respiratory distress including rapid breathing, grunting, or apnea (stopping breathing) o infection such as herpes, group B streptococcus, chlamydia o seizures o hypoglycemia (low blood sugar) o need for extra oxygen or monitoring, intravenous (IV) therapy, or medications o need for special treatment or procedures such as a blood transfusion

Who will care for your baby in the NICU?

The following are some of the specially trained healthcare professionals who will be involved in the care of your baby:

neonatologist - a pediatrician with additional training in the care of sick and premature babies. The neonatologist supervises pediatric fellows and residents, nurse practitioners, and nurses who care for babies in the NICU. respiratory therapists occupational therapists dietitians lactation consultants pharmacists social workers hospital chaplains The members of the NICU team work together with parents to develop a plan of care for high-risk newborns. Ask about the NICUs parent support groups and other programs designed to encourage parental involvement.

Topic Home Page | Return to Full List of Topics The information on this Web page is provided for educational purposes. You understand and agree that this information is not intended to be, and should not be used as, a substitute for medical treatment by a health care professional. You agree that Lucile Salter Packard Children's Hospital is not making a diagnosis of your condition or a recommendation about the course of treatment for your particular circumstances through the use of this Web page. You agree to be solely responsible for your use of this Web page and the information contained on this page. Lucile Salter Packard Children's Hospital, its officers, directors, employees, agents, and information providers shall not be liable for any damages you may suffer or cause through your use of this page even if advised of the possibility of such damages.

Abbreviations Commonly Used in the Nursery

Edward F. Bell, MD Peer Review Status: Internally Peer Reviewed 2/13/12

A/B apnea/bradycardia spell (episode of apnea and/or bradycardia) A/B/D apnea/bradycardia/oxygen desaturation spell (episode of apnea and/or bradycardia and/or decreased oxygen saturation) AGA appropriate for gestational age ARNP advanced registered nurse practitioner (PNP or NNP) ASD atrial septal defect BBT baby's blood type BM bowel movement BPD bronchopulmonary dysplasia CBG capillary blood gas CHD congenital heart defect or congenital heart disease CHF congestive heart failure CMV cytomegalovirus CNM certified nurse midwife CNS central nervous system CPAP continuous positive airway pressure C/S cesarean section CPT - chest physiotherapy CSF cerebrospinal fluid CVN central venous nutrition CXR chest x-ray DIC disseminated intravascular coagulation DR delivery room ECMO extracorporeal membrane oxygenation ELBW extremely low birth weight ETC emergency treatment center ETT endotracheal tube FOC fronto-occipital circumference FTP failure to progress G-P- - gravida ____para____ (pregnancies; pregnancies resulting in the livebirth of at least one child) GBS group B streptococcus HB, HGB, Hb, or Hgb hemoglobin HC head circumference HCT hematocrit HFJV high-frequency jet ventilation HFV high-frequency ventilation HFOV high-frequency oscillating ventilation HM human milk HMD hyaline membrane disease HMF human milk fortifier (makes breast milk 0.8 kcal/cc) HUS head ultrasound IAB or IAb induced abortion

IDM infant of diabetic mother IMV intermittent mandatory ventilation iNO inhaled nitric oxide IUFD intrauterine fetal demise IUGR intrauterine growth restriction IVF in-vitro fertilization IVH intraventricular hemorrhage L+D Labor and Delivery LGA large for gestational age LLSB lower left sternal border LMD local medical doctor (usage of primary care provider - PCP preferred) LSB left sternal border MAP mean airway pressure MAS meconium aspiration syndrome MBT mother's blood type MCL midclavicular line MGF maternal grandfather MGM maternal grandmother NAD - no apparent distress NAVA neurally adjusted ventilatory assistance NC nasal cannula NEC necrotizing enterocolitis NICU Neonatal Intensive Care Unit NNP neonatal nurse practitioner NNS neonatal screen (newborn metabolic screen) NO nitric oxide NPCPAP nasopharyngeal continuous positive airway pressure NPO nothing by mouth NSIMV nasopharyngeal synchronized intermittent mandatory ventilation NTD neural tube defect NVN neonatal venous nutrition (local term, not recommended for external communication) PC pressure control PCO2 partial pressure of carbon dioxide PCP primary care provider PDA patent ductus arteriosis PEEP peak and expiratory pressure PF premature infant formula PFC persistent fetal circulation PFO patent foramen ovale PGE1 prostaglandin E1 PGF paternal grandfather

PGM paternal grandmother PICC percutaneously inserted central catheter PIE pulmonary interstitial emphysema PIH pregnancy induced hypertension PIP peak inspiratory pressure PIV peripheral intravenous line PKU phenylketonuria, a disease detected on the NNS PMI point of maximum impulse PNP pediatric nurse practitioner PO2 partial pressure of oxygen PPH persistent pulmonary hypertension PPHN persistent pulmonary hypertension of the newborn PPROM preterm premature rupture of membranes PPS peripheral pulmonic stenosis PRBCs packed red blood cells (concentrated erythrocyte suspension for transfusion) PROM premature rupture of membranes (before the onset of labor) or prolonged rupture of membranes PS pressure support PTL preterm labor PVL periventricular leukomalacia PVN parenteral venous nutrition or peripheral venous nutrition RA room air (21% oxygen) RCM right costal margin RDS respiratory distress syndrome ROM rupture of membranes OR range of motion ROP retinopathy of prematurity RSV respiratory syncytial virus SAB or SAb spontaneous abortion SF stock formula or standard formula (iron-fortified term infant formula) SGA small for gestational age SIMV synchronized intermittent mandatory ventilation SO2 oxygen saturation TCM transcutaneous monitor (for PO2, PCO2) TG true glucose (more appropriately called blood glucose, there is no false glucose) TPN total parenteral nutrition TTN transient tachypnea of the newborn UAC umbilical arterial catheter UVC umbilical venous catheter VLBW very low birth weight baby VSD ventricular septal defect VS vital signs

premature baby: terminology in the NICU or SCN

It is very overwhelming for parents who find themselves in the Neonatal Intensive Care Unit (NICU) with their premature baby. Apart from learning to deal with the emotional aspect to having given birth to a premmie baby, they also have to learn very quickly all the terms used by the nursing staff in the NICU. Here is an overview of some of the terms that you may encounter.

Anemia
Too few red blood cells. Anemic babies may need blood transfusions

Apnoea
A short period of time when the baby does not take a breath.

Aspiration
The drawing in of foreign matter or other material in the upper respiratory tract into the lungs. Aspiration also refers to a medical procedure in which fluids are sucked out of the lungs, nose, or mouth using a suction device.

Bagging
Helping the baby to breathe by connecting a special rubber bag either to a mask over the mouth or to a tube in the trachea and lung.

Bilirubin
A chemical created by the breakdown of the red blood cells. A large amount of this bilirubin in the body causes yellow coloring of the skin and eyes (jaundice). Nearly all babies have some jaundice, including healthy full-term babies.

Bilirubin lights (bili lights)

Fluorescent lights that reduce jaundice; help break down the bilirubin in the skin. Baby is undressed to expose as much skin surface as possible; the babys eyes are covered with patches or a mask. Also called phototherapy.

Blood gas
A test using a small amount of blood to measure levels of oxygen and carbon dioxide in the blood.

Bradycardia
A slower than normal heartbeat; often occurs with apnoea.

Catheter
A tube which puts fluids into the body or drains fluids out.

Chest tube
A tube inserted through the chest wall; used to suction air and/or fluids from the chest.

Continuous Positive Airway Pressure (CPAP)

A continuous amount of air, sometimes with added oxygen, is delivered through tubes in the babys nose to keep the airways of the lungs open as baby breathes.

Culture
Taking a sample of blood or body fluids to test for germs which may cause an infection.

Cyanosis
A bluish colouring of the skin and lips caused by a low level of oxygen in the blood.

Edema
The collection of extra fluid in body tissues, causing swelling or puffiness of skin.

Electrode
A sensor which sends heartbeat and breathing information to the monitor. They can be placed on the chest, arms, or legs. Also called leads.

Electrolytes
Sodium, potassium, and chloride levels in the blood. Correct levels of these chemicals must be present so that the body organs can function properly.

Endotracheal tube (ET tube)

A plastic tube inserted through the nose or mouth into the trachea (windpipe) to help breathing; usually connected to a breathing machine (ventilator).

Extubation
The process of removing an endotracheal tube.

Nasogastric tube (NG tube)

A tube inserted through the nose or mouth (orogastric or OG) and into the stomach. The tube delivers nutrients and medications, and removes undigested food and fluids from the stomach.

Gavage feeding
Feeding a baby through a gastric tube inserted into the stomach.

Gestational age
The length of time from conception to birth (how long the baby stays in the womb). Full-term gestation is between 38 and 42 weeks.

High frequency ventilation (HFV)

A type of ventilator which gives very small breathes at a very fast rate; the babys chest will actually vibrate. HFVworks differently from conventional ventilation to treat specific breathing or lung problems.

Hyaline membrane disease (HMD)

A breathing problem that causes the tiny air sacs in the lungs to collapse; usually due to lung immaturity and lack of a natural lung chemical (surfactant). Also called respiratory distress syndrome ( RDS).

Hydrocephalus
Excess spinal fluid causing enlargement of the ventricles in the brain.

Hypoxia
A low level of oxygen in the body tissue. If very low, tissue damage can occur.

Incubator / isolette / humidicrib

A small, heated bed enclosed in clear plastic. Keeps the baby warm, while allowing caregivers see the baby.

Intraventricular haemorrhage (IVH)

Bleeding within the brains ventricles (spaces in the brain which contain spinal fluid). Also called intracranial haemorrhage (bleeding in or around the brain).

Intravenous line (IV)

A hollow needle or plastic tube inserted into a vein; used to give fluids, blood, and or medications.

Intubation
Placing a tube through the nose or mouth into the trachea (windpipe).

Jaundice
The yellow discoloration of a babys skin and eyes caused by too much bilirubin in the blood.

Kangaroo Care
Skin-to-skin contact where baby is positioned on mum or dads bare chest to promote bonding and healing.

Meconium
The first bowel movement/stool passed by a newborn, usually dark green and sticky.

Meconium aspiration syndrome

A type of pneumonia caused by stool being passed by the baby while still in the womb. The stool can be inhaled into the baby s lungs and can partially or completely block the babys air passage. This makes it difficult for the baby to b reathe.

Nasal Canula
A small plastic tube placed under the nose to provide oxygen.

Necrotizing Enterocolitis (NEC)

A bowel condition caused by lack of blood supply. A section of the bowel may become severely inflamed or infected.

NICU
Neonatal Intensive Care Unit

Neonate
A newborn infant, less than 30 days old.

Neonatologist
A physician who specializes in the care of critically ill newborn infants.

Oscillator
A type of high frequency ventilator.

Oxygen saturation
The level of oxygen in a babys blood. Oxygen level is measured by a small probe on the babys hand or foot, also by blood samples. This level tells at-a-glance how well oxygen is being carried through the body.

Patent Ductus Arteriosus (PDA)

A small vessel (ductus) between the major arteries of the heart and the lungs. Before birth, this vessel is open and allows blood to bypass the lungs (not yet in use). When this opening fails to close after birth, it can cause problems with oxygen rich blood getting to the body.

Peripherally Inserted Central Catheter (PICC)

A flexible, thin IV tube put into a vein in the arm, foot, or leg and then routed up into, or near, the heart.

Persistent Pulmonary Hypertension of Newborns (PPHN)

A serious condition that causes the baby to return to its prebirth route of blood circulation. The babys blood is only partially oxygenated through the lungs. This results in very low oxygen levels, plus a higher blood pressure in the arteries of the lungs. Treatment includes, oxygen, ventilator therapy, medications and/or ECMO. Also called persistent fetal circulation (PFC).

Phototherapy
See bilirubin lights.

Pneumothorax (pneumo)
Air escapes from the lung into the chest cavity, creating a pocket of air in the wrong place. This pocket of air then presses on the lungs or heart. A chest tube or catheter can be inserted to remove the pocket of air, which lets the lungs re-expand.

Pulse oximeter
An electronic monitor that detects oxygen saturation in the blood using a light sensor probe.

Respiratory Distress Syndrome (RDS)

See hyaline membrane.

Retinopathy Of Prematurity (ROP)

An eye disorder, involving the retina that can occur in premature infants.

Room air
The ordinary air we breathe which contains 21% oxygen. Oxygen therapy can deliver from 22 100% oxygen.

SCN
Special Care Nursery

Sepsis
An infection caused by bacteria.

Spinal tap
The removal of a small amount of fluid from the spinal canal. The fluid is then analyzed for infection, bleeding, and other disorders.

Surfactant
A substance in the lungs that helps keep the tiny air sacs from collapsing and sticking together. A lack of this substance contributes to Respiratory Distress Syndrome (RDS).

Transient Tachypnea of the Newborn (TTN)

A condition when a baby breathes with quick, shallow breathes (usually over 80 breaths per minute). It is often caused by fluid in the lungs and will improve as this fluid is absorbed. Some babies need oxygen as this resolves. TTN is often associated with cesarean delivery.

Umbilical Catheter, Arterial or Venous (UAC, UVC)

A tube inserted through the belly button (umbilical cord) into the arterial or venous blood vessels. Either tube is used to give the baby fluids and to draw blood samples. The UAC is used to monitor the babys blood pressure. If the baby requires oxygen therapy, the UAC will be used to draw blood gases and blood samples.

Ventilator
A machine which fills the babys lungs with air and helps the baby breathe. Also called a respirator.

Ventricles of the brain

Spaces in the brain that contain spinal fluid to bathe and cushion the brain. References Laws PJ, Grayson N & Sullivan EA 2006. Australias mothers and babies 2004. Perinatal statistics series no. 18. AIHW cat. no. PER 34. Sydney: AIHW National Perinatal Statistics Unit. Dyer KA. 2007. For Those Who Hold The Littlest Hands. [Brochure] Retrieved October 6, 2007. Lui K, Bajuk B, Foster K, et al. Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop. Med J Aust 2006; 185: 495-500. Presbyterian Hospital of Dallas. Special Beginnings: A Parents Guide to the NICU. [Brochure] Retrieved 2006. Meriter Health Services. Preemie Health. Retrieved September 7, 2007. Lifes Little Treasures. Parents Information Guide. 2007 Powell K.(2001). Ambiguous Loss Experiencing Joy and Grief after the Birth of a Premature Child. Retrieved September 17, 2007. American Pregnancy Association. Premature Birth Complications. Retrieved September 20, 2007. The Regional Neonatal Center Maria Fareri Childrens Hospital at Westchester Medical Center Neonatology. Retrieved 2006. The Birth Trauma Association. Post Natal Post Traumatic Stress Disorder. Retrieved October 11, 2007. Information on this page has been kindly provided by representatives of the National Premmie Foundation. All material here is for informational purposes only and should in no way replace or be used as a substitute for, professional medical advice. the First Week of Life I. Immediate Newborn Care (The First 90 minutes) TIME BAND: At perineal bulging, with presenting part visible (2nd stage of labor) INTERVENTION: Prepare for the delivery ACTION: Ensure that delivery area is draft-free and between

25-28o C using a room thermometer. Wash hands with clean water and soap. (See page 33) Double glove just before delivery. TIME BAND: Within the 1st 30 secs Call out the time of birth INTERVENTION: Dry and provide warmth. ACTION: Use a clean, dry cloth to thoroughly dry the baby by wiping the eyes, face, head, front and back, arms and legs. Remove the wet cloth. Do a quick check of newborns breathing while drying. (See fold-out on Immediate Care of the Newborn.) Note: During the rst 30 seconds: Do not ventilate unless the baby is oppy/limp and not breathing. Do not suction unless the mouth/nose are blocked with secretions or other material. D10 D11 IMMEDIATE NEWBORN CARE2 Clinical Practice Pocket Guide TIME BAND: If after 30 secs of thorough drying, newborn is not breathing or is gasping INTERVENTION: Re-position, suction and ventilate ACTION: Clamp and cut the cord immediately. Call for help. Transfer to a warm, rm surface. Inform the mother that the newborn has dif culty breathing and that you will help the baby to breathe. Start resuscitation protocol. (See page 21) Notes: If the baby is non-vigorous (limp/ oppy and not breathing) and meconium-stained, and; a) Health worker not skilled at advanced resuscitation (or skilled but not equipped with intubation needs): Clear the mouth Start bag/mask ventilation Refer and transport b) Health worker with advanced skills at resuscitation: Intubate the baby and provide positive-pressure ventilation Refer and transport as necessary When appropriate, and when personnel skilled in advanced resuscitation (intubation, cardiac massage) are available, refer to appropriate guidelines. TIME BAND: If after 30 secs of thorough drying, newborn is breathing or crying INTERVENTION: Do skin-to-skin contact ACTION: If a baby is crying and breathing normally, avoid any manipulation, such as routine suctioning, that may cause trauma or introduce infection. K11 IMMEDIATE NEWBORN CARENewborn Care until the First Week of Life 3 Place the newborn prone on the mothers abdomen or chest skin-to-skin. Cover newborns back with a blanket and head with a bonnet. Place identi cation band on ankle. Notes: Do not separate the newborn from mother, as long as the newborn does not exhibit severe chest in-drawing, gasping or apnea and the mother does not need urgent medical stabilization e.g. emergent hysterectomy. Do not put the newborn on a cold or wet surface.

 Do not wipe off vernix if present. Do not bathe the newborn earlier than 6 hours of life. Do not do footprinting. If the newborn must be separated from his/her mother, put him/her on a warm surface, in a safe place close to the mother. INTERVENTION: Palpate the mothers abdomen. Exclude a second baby. If there is a 2nd baby, get help. Deliver the second newborn. Manage as in Multi-fetal pregnancy ACTION: If a baby is crying and breathing normally, avoid any manipulation, such as routine suctioning, that may cause trauma or introduce infection. TIME BAND: 1 - 3 minutes INTERVENTION: Do delayed or non-immediate cord clamping ACTION: Remove the rst set of gloves immediately prior to cord clamping. D11 D18 D18 D11 IMMEDIATE NEWBORN CARE4 Clinical Practice Pocket Guide Clamp and cut the cord after cord pulsations have stopped (typically at 1 to 3 minutes) Put ties tightly around the cord at 2 cm and 5 cm from the newborns abdomen. Cut between ties with sterile instrument. Observe for oozing blood. Note: Do not milk the cord towards the newborn. After cord clamping, ensure 10 IU IM is given to the mother. Follow other protocols per PCPNC TIME BAND: WITHIN 90 min of age INTERVENTION: Provide support for initiation of breastfeeding ACTION: Remove the rst set of gloves immediately prior to cord clamping. Leave the newborn on mothers chest in skin-to-skin contact. Observe the newborn. Only when the newborn shows feeding cues (e.g. opening of mouth, tonguing, licking, rooting), make verbal suggestions to the mother to encourage her newborn to move toward the breast e.g. nudging. Counsel on positioning and attachment. When the baby is ready, advise the mother to: Make sure the newborns neck is not exed nor twisted. Make sure the newborn is facing the breast, with the newborns nose opposite her nipple and chin touching the breast. Hold the newborns body close to her body. Support the newborns whole body, not just the neck and shoulders. D12 K2 IMMEDIATE NEWBORN CARENewborn Care until the First Week of Life 5 Wait until her newborns mouth is opened wide. Move her newborn onto her breast, aiming the infants lower lip well below the nipple Look for signs of good attachment and suckling: Mouth wide open Lower lip turned outwards Babys chin touching breast Suckling is slow, deep with some pauses

If the attachment or suckling is not good, try again and reassess. Notes: Health workers should not touch the newborn unless there is a medical indication. Do not give sugar water, formula or other prelacteals. Do not give bottles or paci ers. Do not throw away colostrum. If the mother is HIV-positive, see of PCPNC for special counseling. Diagrams of infants mouth showing good and poor attachment to the breast. G7 Good Attachment Good Attachment Poor Attachment Poor Attachment (Outside appearance) Fr. WHO. Department of Child and Adolescent Health and Development. Relactation: A review of experience and recommendations for practice. Geneva, 1998 IMMEDIATE NEWBORN CARE6 Clinical Practice Pocket Guide INTERVENTION: Provide additional care for a small baby or twin Please see Kangaroo Mother Care ACTION: For a visibly small newborn or a newborn born >1 month early: Encourage the mother to keep the small newborn in skin-to-skin contact with her as much as possible. Provide extra blankets to keep the baby warm If mother cannot keep the baby skin-to-skin because of complications, wrap the baby in a clean, dry, warm cloth and place in a cot. Cover with a blanket. Use a radiant warmer if room not warm or baby small. Do not bathe the small baby. Ensure hygiene by wiping with a damp cloth but only after 6 hours. Prepare a very small baby (<1.5 kg) or a baby born >2 months early for referral. INTERVENTION: Do eye care ACTION: Administer erythromycin or tetracycline ointment or 2.5% povidone-iodine drops to both eyes after newborn has located breast. Do not wash away the eye antimicrobial. J11 K9 IMMEDIATE NEWBORN CARENewborn Care until the First Week of Life 7 II. Essential Newborn Care from 90 min to 6 hours TIME BAND: From 90 Min - 6 Hrs INTERVENTION: Give Vitamin K prophylaxis ACTION: Wash hands. (See page 33) Inject a single dose of Vitamin K 1 mg IM. (If parents decline intramuscular injections, offer oral vitamin K as a 2nd line). INTERVENTION: Inject hepatitis B and BCG vaccinations at birth ACTION: Inject hepatitis B vaccine intramuscularly and BCG intradermally. Record. INTERVENTION: Examine the baby ACTION: Thoroughly examine the baby. Weigh the baby and record. INTERVENTION: Check for birth injuries, malformations or defects. ACTION: Look for possible birth injury:

 Bumps on one or both sides of the head, bruises, swelling on buttocks, abnormal position of legs (after breech presentation) or asymmetrical arm movement, or arm that does not move. K9 J2 J8 ESSENTIAL NEWBORN CARE 8 Clinical Practice Pocket Guide If present: Explain to parents that this does not hurt the newborn, is likely to disappear in a week or two and does not need special treatment. Gently handle the limb that is not moving. Do not force legs into a different position. Look for malformations: Cleft palate or lip Club foot Odd looking, unusual appearance Open tissue on head, abdomen or back If present: Cover any open tissue with sterile gauze before referral and keep warm. Refer for special treatment and/or evaluation if available. Help mother to breastfeed. If not successful teach her alternative feeding methods INTERVENTION: Cord care ACTION: Wash hands. (See page 33) Put nothing on the stump. Fold diaper below stump. Keep cord stump loosely covered with clean clothes. If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth. Explain to the mother that she should seek care if the umbilicus is red or draining pus. Teach the mother to treat local umbilical infection three times a day. Wash hands with clean water and soap. Gently wash off pus and crusts with boiled and cooled water and soap. Dry the area with clean cloth. Paint with gentian violet. K5 K6 K10 K10 K13 ESSENTIAL NEWBORN CARE Newborn Care until the First Week of Life 9 K9 Wash hands. If pus or redness worsens or does not improve in 2 days, refer urgently to the hospital Notes: Do not bandage the stump or abdomen. Do not apply any substances or medicine on the stump. Avoid touching the stump unnecessarily. INTERVENTION: Provide additional care for a small baby or twin ACTION: If the newborn is delivered 2 months earlier or weighs < 1500 g, refer to specialized hospital. If the newborn is delivered 1-2 months earlier or weighs 1500 - 2500 g (or visibly small where scale not available), see Additional care for small newborns (See pages 24) Notes: Encourage the mother to keep her small baby in skin-to-skin contact. If mother cannot keep the baby in skin-to-skin contact because of complications, wrap the baby

in a clean, dry, warm cloth and place in a cot. Cover with a blanket. Use a radiant warmer if the room is not warm or the baby small. Do not bathe the small baby. Keep the baby clean by wiping with a damp cloth but only after 6 hours. J6 J11 K9 ESSENTIAL NEWBORN CARE ESSENTIAL NEWBORN CARE Newborn Care until the First Week of Life 11 III. Care Prior to Discharge (but after the rst 90 minutes) TIME BAND: After the 90 minutes of age, but prior to discharge INTERVENTION: Support unrestricted, per demand breastfeeding, day and night ACTION: Keep the newborn in the room with his/her mother, in her bed or within easy reach. Do not separate them (rooming-in). Support exclusive breastfeeding on demand day and night. Assess breastfeeding in every baby before planning for discharge. Ask the mother to alert you if with dif culty breastfeeding. Praise any mother who is breastfeeding and encourage her to continue exclusively breastfeeding. Explain that exclusive breastfeeding is the only feeding that protects her baby against serious illness. De ne that exclusive breastfeeding means no other food or water except for breast milk. Notes: Do not discharge if baby is not feeding well. Do not give sugar water, formula or other prelacteals. Do not give bottles or paci ers. INTERVENTION: Ensure warmth of the baby ACTION: Ensure the room is warm (> 25o C and draft -free). Explain to the mother that keeping baby warm is important for the baby to remain healthy. J10 K9 CARE PRIOR TO DISCHARGE12 Clinical Practice Pocket Guide TIME BAND Keep the baby in skin-to-skin contact with the mother as much as possible. Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap for the rst few days, especially if baby is small. INTERVENTION: Washing and bathing (Hygiene) ACTION: Wash your hands. (See page 33) Wipe the face, neck and underarms with a damp cloth daily. Wash the buttocks when soiled. Dry thoroughly. Bathe when necessary, ensuring that the room is warm and draft-free, using warm water for bathing and thoroughly drying the baby, then dressing and covering after the bath. If the baby is small, ensure that the room is warmer when changing, wiping or bathing INTERVENTION: Sleeping ACTION: Let the baby sleep on his/her back or side. Keep the baby away from smoke or from people smoking. Ensure mother and baby are sleeping under impregnated bed net if there is malaria in the area. INTERVENTION: Look for danger signs

ACTION: Look for signs of serious illness : Fast breathing (>60 breaths per min) Slow breathing (<30 breaths per min) Severe chest in-drawing K10 K10 K10 J6 J7 CARE PRIOR TO DISCHARGENewborn Care until the First Week of Life 13 Grunting Convulsions Floppy or stiff Fever (temperature >38o C) Temperature <35o C or not rising after re-warming Umbilicus draining pus More than 10 skin pustules or bullae, or swelling, or redness, or hardness of skin (sclerema) Bleeding from stump or cut Pallor If any of the above is present, consider possible serious illness. See IMPAC: Managing Newborn Problems. Start resuscitation, if necessary. (See page 21) Re-warm and keep warm during referral for additional care. Give rst dose of two IM antibiotics Stop bleeding. Give oxygen, if available. INTERVENTION: Look for signs of jaundice and local infection ACTION: Look at the skin. Is it yellow? Refer urgently, if jaundice present : on face of <24 hour old newborn on palms and soles of 24 hour old infant Encourage breastfeeding. If feeding dif culty, give expressed breast milk by cup. Look at the eyes: Are they swollen and draining pus? If present, consider gonococcal eye infection. Give single dose of appropriate antibiotic for eye infection. Teach mother to treat eyes. K9 K12 J6 K14 K12 K13 K6 CARE PRIOR TO DISCHARGE14 Clinical Practice Pocket Guide TIME BAND Follow-up in two days. If pus or swelling worsens or does not improve refer urgently. Assess and treat mother and her partner for possible gonorrhea. Look at the umbilicus: What has been applied to the umbilicus? Advise mother proper cord care (See page 8) If there is redness that extends to the skin, consider local umbilical infection. Teach mother to treat umbilical infection. If no improvement in 2 days, or if worse, refer urgently.

 If the umbilicus is draining pus then consider possible serious illness Give rst dose of two IM antibiotics Refer baby urgently Look at the skin, especially around the neck, armpits, inguinal area: Are there pustules? If less than 10 pustules, consider local skin infection: Teach mother to treat skin infection. Follow-up in 2 days. If pustules worsen or do not improve in 2 days or more, refer urgently. If more than 10 pustules, refer for evaluation. INTERVENTION: Discharge Instructions Advise the mother to return or go to hospital immediately if baby has any of the following: Jaundice to the soles Dif culty feeding* Convulsions* Movement only when stimulated* Fast or slow or dif cult breathing (e.g., severe chest in-drawing)* Temperature > 37.5o C # or <35.5o C* * From Lancet 2008, new IMCI algorithm for Young Infant II Study # Cut-off of 38o C per local expert opinion during Panel Review E8 K13 K12 K14 K13 K14 CARE PRIOR TO DISCHARGENewborn Care until the First Week of Life 15 Schedule Routine Visits as follows: Postnatal visit 1: at 48 72 hours of life Postnatal visit 2: at 7 days of life Immunization visit 1: at 6 weeks of life Advise Newborn Screening test Schedule additional Follow up Visits depending on babys problems: After two days if with breastfeeding dif culty, Low Birth Weight in 1st week of life, red umbilicus, skin infection, eye infection, thrush or other problems. After seven days If Low Birth Weight discharged more than a week of age and gaining weight adequately. CARE PRIOR TO DISCHARGECARE PRIOR TO DISCHARGENewborn Care until the First Week of Life 17 TIME BAND: From discharge to 7 days INTERVENTION: Support unrestricted, per demand exclusive breastfeeding, day and night ACTION: Ask the mother exactly what the baby fed on in the past 24 hours before the visit. Ask about water, vitamins, local foods and liquids, formula and use of bottles and paci ers. Ask about stooling and wet diapers. Praise any mother who is breastfeeding and encourage her to continue exclusively breastfeed. (Re-) explain that exclusive breastfeeding is the only food that protects her baby against serious illness. De ne that exclusive breastfeeding means no other food or water except for breast milk. Reassure her that she has enough breast milk for her babys needs. Advise the mother to Keep the newborn in the room with her, in her bed

or within easy reach Exclusively breastfeed on demand day and night (8 times in 24 hours except in the rst day of life when newborn sleeps a lot). Observe a breastfeed, if possible. Ask the mother to alert you if she has breastfeeding dif culty, pain or fever. Observe, Treat and Advise: If nipple(s) is/are sore or ssured, and the baby is not well attached, in addition to the above; Reassess after 2 feeds (within the same day). IV. Care after Discharge to 7 days J9 J10 CARE AFTER DISCHARGE18 Clinical Practice Pocket Guide Advise the mother to smear hind milk over the sore nipple after a breastfeed. Check the babys mouth for candidal thrush and treat baby and mother. If not better, teach the mother how to express breast milk from the affected breast and feed baby by cup until breast(s) is/are better. If breasts are swollen but the milk is dripping Reassure the mother, that this is normal breast fullness and will improve with frequent breastfeeding in 36-72 hours If breasts are swollen, shiny and the milk is not dripping, mothers temperature is <38o C and the baby is not well attached, treat and advise for engorgement. In addition to the above: Breastfeed more frequently Reassess after 2 feeds (within the same day). If not better, teach and help the mother express enough breast milk to relieve the discomfort. If breast(s) is/are swollen, painful, there is patchy redness, and mothers temperature is > 38o C, treat and advise for mastitis. In addition to the above: Give Cloxacillin 500 mg q 6 hours for 10 days. If severe pain, give paracetamol. Reassess in 2 days. If no improvement or worse, refer to a hospital. Notes: Do not give sugar water, formula or other prelacteals. Do not give bottles or paci ers. INTERVENTION: Ensure warmth for your baby ACTION: Explain to the mother that babies need an additiolnal layer of clothing compared to older children or adults. Keep the room or part of the room warm, especially in a cold climate. K9 CARE AFTER DISCHARGENewborn Care until the First Week of Life 19 During the day, dress up or wrap the baby. At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding. Notes: Do not put the baby on any cold or wet surface. Do not swaddle/wrap too tightly. Do not leave the baby in direct sunlight. Ensure additional warmth for the small baby (or twin) INTERVENTION: Look for danger signs (From New IMCI data from Young Infant II study, Lancet 2008) ACTION: Look for signs of very severe disease

 Yellow skin to the soles History or dif culty feeding History of convulsions Movement only when stimulated Respiratory rate >60 per minute Severe chest in-drawing Temperature > 38.0o C (per local expert opinion) Temperature <35.5o C Refer baby urgently to hospital: After emergency treatment, explain the need for referral to the mother/father. Organize safe transportation. Always send the mother with the baby, if possible. Send referral note with the baby. Inform the referral center, if possible by radio or telephone. A. Newborn Resuscitation INTERVENTION: See Algorithm on Resuscitation (page 21). ACTION: Start resuscitation if the newborn is not breathing or is gasping after 30 seconds of drying or before 30 seconds of drying if the baby is completely oppy and not breathing. Clamp and cut the cord immediately, if necessary. Transfer the newborn to a dry, clean and warm surface. Keep the newborn wrapped or under a heat source if available. Inform the mother that the newborn needs help to breathe. INTERVENTION: Open airway ACTION: Position the head so it is slightly extended. Introduce the suction tube: First, into the newborns mouth 5 cm from the lips and suck while withdrawing. Second, 3 cm into each nostril and suck while withdrawing. Repeat once, if necessary taking no more than a total of 20 secs. Notes: - Do not suction mouth and nose prior to delivery of the shoulders of babies with meconium stained amniotic uid. K11 K11 ADDITIONAL CARENewborn Care until the First Week of Life 23 INTERVENTION: Ventilate, if still not breathing ACTION: Place mask to cover chin, mouth and nose to achieve a seal. Squeeze bag attached to the mask with 2 ngers or whole hand, according to bag size, 2 or 3 times. Observe rise of chest. If chest is not rising: First, reposition babys head If babys chest is still not rising Check for adequate mask seal If chest is still not rising, squeeze bag harder. If chest is rising, ventilate at 40 breaths per minute until newborn starts crying or breathing. Reassess at 30-second intervals. If baby still fails to improve, check the following: Failure To Improve Checklist Face-mask seal tight? Airway clear of secretions? Head positioned properly? Is contact with the soft tissue of the infants anterior neck being avoided?

 Resuscitator working properly? Adequate pressure being used? Air distending the stomach? Air leak (pneumothorax)? If baby starts crying or breathing >30 per minute and has no chest-in-drawing, stop ventilating: Put the newborn in skin-to-skin contact on mothers chest and continue care while monitoring breathing and warmth. Explain the babys condition to the mother. K11 K11 K11 D19 ADDITIONAL CARE24 Clinical Practice Pocket Guide If after 30 sec of effective bag/mask ventilation, the newborn is gasping/ breathing <30 per min or > 30 per min but has severe chest in-drawing: Continue bag/mask ventilation Continue assessing at 30 sec intervals while transporting or Proceed to intubation per advanced resuscitation guidelines, if skilled personnel and equipment are available If after 20 minutes of effective ventilation, the newborn does not start to breathe or gasp at all, stop ventilating. Explain to the mother that the baby is dead, give supportive care and record the event. Notes: While ventilating, refer and explain to the mother what happened, what you are doing and why. Ventilate, if needed, during transport Record the event on the referral form and labor record. B. Additional Care of a Small Baby (or Twin): If newborn is preterm, 1-2 months early or weighing 1500 - 2499 g (or visibly small where scale not available) AREA OF CONCERN: Warmth ACTION: Ensure additional warmth for the small baby. Ensure the room is maintained 25-28o C. Teach the mother how to keep the small baby warm in skin-to-skin contact via Kangaroo Mother Care (See page 24). Provide extra blankets for mother and baby, plus bonnet, mittens and socks for baby. Notes: Do not bathe the small baby. Keep the baby clean by wiping with a damp cloth but only after 6 hours. D24 N7 N6 J11 K9 ADDITIONAL CARENewborn Care until the First Week of Life 25 AREA OF CONCERN: Feeding Support ACTION: Give special support for breastfeeding: Encourage the mother to breastfeed every 2-3 hours. Assess breastfeeding daily: positioning, attachment, suckling, duration and frequency of feeds, and baby satisfaction with the feed. Weigh baby daily. When mother and newborn are separated, or if the baby is not sucking effectively, use alternative feeding methods. Refer to Dealing with Feeding Problems (See page 27). AREA OF CONCERN: Kangaroo Mother Care (KMC)

(Adapted from WHO. ENCC Jan 2009) ACTION: Start kangaroo mother care when: The baby is able to breathe on its own (no apneic episodes). The baby is free of life-threatening disease or malformations. Notes: The ability to coordinate sucking and swallowing is not a pre-requisite to KMC. Other methods of feeding can be used until the baby can breastfeed. KMC can begin after birth, after initial assessment and basic resuscitation, provided the baby and mother is stable. If kangaroo mother care is not doable, wrap the baby in a clean, dry, warm cloth and place in a crib. Cover with a blanket. Use a radiant warmer if room is not warm or baby small. K4 K4 K9 ADDITIONAL CARE26 Clinical Practice Pocket Guide Explain KMC to the mother: continuous skin-to-skin contact positioning her baby attaching her baby for breastfeeding expressing her milk caring for her baby continuing her daily activities preparing a support binder Position the baby for KMC: Place the baby in upright position between the mothers breasts, chest to chest Position the babys hips in a frog-leg position with the arms also exed. Secure the baby in this position with the support binder Turn the babys head to one side, slightly extended Tie the cloth rmly Notes: - KMC should last for as long as possible each day. If the mother needs to interrupt KMC for a short period, the father, a relative or friend should take over. AREA OF CONCERN: Discharge Planning ACTION: Plan to discharge when: Breastfeeding well and gaining weight adequately for 3 consecutive days Fr. WHO Department of Reproductive Health and Research. Kangaroo mother care: A practical guide. Geneva 2003. ADDITIONAL CARENewborn Care until the First Week of Life 27 Body temperature between 36.5 and 37.5o C for 3 consecutive days Mother is able and con dent in caring for baby FOR THE MOTHER AREA OF CONCERN: Equipment _ Delivery bed that supports the woman in a semi-sitting position or lying in a lateral position, with removable stirrups (only for repairing the perineum or for instrumental delivery) _ Stethoscope _ Blood pressure apparatus _ Body thermometer Delivery Instruments _ Scissors _ Needle holder _ Artery forceps and clamp _ Dissecting forceps

_ Sponge forceps _ Vaginal speculum _ Clean (plastic) sheet to place under mother _ Sanitary padsNewborn Care until the First Week of Life 39 EQUIPMENT AND SUPPLIES MAINTENANCE CHECKLIST Drugs _ Oxytocin _ Methylergonovine maleate _ Magnesium sulfate _ Calcium gluconate _ Dexathasone or betametasone _ Diazepam _ Hydralazine _ Ampicillin _ Gentamicin _ Metronidazole _ Benzathine penicillin _ Lignocaine _ Epinephrine _ Ringers lactate _ Dextrose 10% _ Normal saline _ Sterile water for injection _ Isoniazid _ RPR testing kit _ HIV testing _ Hemoglobin testing kit _ Contraceptives _ Nevirapine (adult, infant) _ Zidovudine (AZT) (adult, infant) _ Lamivudine (3TC) Forms and records _ Birth certi cates _ PhilHealth forms _ Death certi cates _ Referral forms For CEmONC above plus _ Equipment for cesarean section _ Blood supply and needs for blood transfusion EQUIPMENT AND SUPPLIES MAINTENANCE CHECKLIST40 Clinical Practice Pocket Guide FOR THE NEWBORN AREA OF CONCERN: Equipment _ Fetal stethoscope _ Clean towels for drying and wrapping the baby _ Self-in ating bag and mask (term and preterm size) _ Suction tube with mucus trap _ Feeding tubes (Fr 5 and 8) _ Cord ties (sterile) or clamps _ Blankets _ Bonnets, mittens and socks Drugs _ Eye antimicrobial (2.5% povidone-iodine or erythromycin ointment or 1% silver nitrate) _ Vitamin K (phytomenadione) _ BCG vaccine _ Hepatitis B vaccine _ Ampicillin _ Gentamicin _ Penicillin G _ Plain Ringers lactate or normal saline _ Dextrose 10% _ Sterile water for injection Supplies _ 1 cc syringes _ 3 cc syringes _ Digital thermometers _ Baby weighing scale _ Feeding cups _ Support binders for KMC

_ Newborn screen lter cards _ Lancets Records and Forms _ Birth certi cates _ PhilHealth forms _ Death certi cates _ Referral forms EQUIPMENT AND SUPPLIES MAINTENANCE CHECKLISTNewborn Care until the First Week of Life 41 For CEmONCs - above plus: _ Laryngoscope with Miller 0 and 1 blades _ Epinephrine 1:10,000 _ Dopamine _ Oxygen source _ Suction machine or wall suction _ Radiant warmer or heat source _ Phototherapy units