ESSENTIAL

INTRAPARTUM AND
NEWBORN CARE

ESSENTIAL INTRAPARTUM
AND NEWBORN CARE
- are set of practices that upon
recommendations of the DOH, Phil
Health, and the WHO.
- because of its evidence based
standards that reduce maternal and
newborn mortality rate.

These practices are totally different

from the traditional newborn care
some of its objectives are to provide
evidence-based practices to ensure
survival of the newborn from birth up
to the first 28 days of life.

It supports the national

commitment to the United
Nations Millenium
Development Goals (MDG) 4
and 5 by the year 2015.

Time to focus on more than 350,000 preterm

births in the Philippines every year

Statistics on Newborn Mortality in

among ASEAN members states
U5MR Rank

NMR

# of Neonatal

Deaths
(deaths per 1000 LB

1990 2011

(thousands)

1990

2011
Myanmar
47
42 30
44 25 Timor-Leste
51
48 24
2
1
Cambodia
62
37 19
15 6
Lao PDR
63
38 18
7
2
Indonesia
71
29 15
140
66
Philippines
83
22 12
45
29
Viet Nam
87
22 12
45
17 Thailand
128
18
8
20
6
Brunei Darussalam
151
7
4
0 0 Malaysia
151
9
3
4 2 Singapore
184

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PhP1,750
UNBUNDLEDPhP1000 PhP500 for
caregiver &PhP500 for facility4 EINC core
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AgendaPhP1,750

PhP200 : Newborn Hearing Screen

ScreenPhP550 : Newborn Metabolic
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Photos

Notes

Self-Instructional Module (SIM)

Self-Instructional Module (SIM)

Essential Newborn
Care: From Evidence
to Practice

<5 year old and Neonatal Mortality

1988-1998: 40%
1998-2008: 20%
Neonatal mortality hasnt improved

Major Causes of Under Five Deaths

Western Pacific Region - 2010

Causes of Neonatal Deaths, 2010

Prematurity 27%
Asphyxia 26%
Infection (Sepsis + Pneumonia) 10%
Congenital Anomalies 9%
Neonatal Tetanus 2%
Diarrhea 2%
Other Conditions

 Majority of newborns die due to

stressful events or conditions during
labor, delivery and the immediate
postpartum period
3 out of 4 newborn deaths occur in
the 1st week of life

What Can We Do to Save Newborn Lives?

Preventive Interventions

Breastfeeding
13%
Insecticide-treated materials
7%
Complementary Feeding
6%
Zinc
4%
Clean delivery
4%
Hib Vaccine
4%
Water sanitation, hygiene
3%
Antenatal Steroids
3%
Newborn temperature management 2%
Vitamin A
2%
Tetanus Toxoid
2%
Nevirapine and replacement feeding
2%
Antibiotics for premature rupture of membranes 1%
Measles vaccine
1%
Antimalarial intermittent preventive treatment in pregnancy

<1%

Large NCR
Hospital
partially closed
for cleanup
25 babies
reportedly died
due to
infection

This was considered and

handled as a hospital infection
control problem
Large NCR Hospital partially
closed for cleanup
25 babies reportedly died due
to infection
How much colostrum did the
cases receive?
Environmental cultures
positive

Not a
drop

 Delaying Initiation of
breastfeeding increases
risk of infection-related
death

Essential Newborn
Care Protocol was
developed to
address these
issues

What Immediate Newborn

Care Practices Save
Lives?

Every Newborn Has Needs

To breathe normally
To be warm
To be protected
To be fed

Providing Warmth: Check the Environment

Check temperature of the delivery room*

Ideal temp: 25 28C
Check for air drafts
Turn air conditioner off at time of delivery
*non-mercury thermometer

After a baby is born, what should be

the first action performed?
A

Clamp and cut the cord

Dry the baby

C
D

Suction the babys

mouth and nose
Do foot printing

After a baby is born, what should be

the first action performed?
A

Clamp and cut the cord

Dry the baby

Suction the babys

mouth and nose

Do foot printing

 Drying should
be the first action
IMMEDIATELY
for a full 30
seconds unless
the infant is both
floppy/limp
and apneic

Immediate Thorough Drying

Dry the newborn thoroughly for at
least 30 seconds
Do a quick check of breathing while
drying
>95% of newborns breathe normally
after birth
Follow an organized sequence
Wipe gently, do not wipe off the vernix
Remove the wet cloth, replace with a dry
one

Immediate Thorough Drying

If baby not breathing,
STIMULATE by DRYING!
Do not slap, shake or rub
the baby
Do not ventilate unless the
baby is floppy/limp and not
breathing
Do not suction unless the
mouth/nose are blocked
by secretions

Immediate Thorough Drying

Immediate drying:
Stimulates Breathing
Prevents hypothermia
Hypothermia can lead to
Infection
Coagulation defects
Acidosis
Delayed fetal to newborn circulatory adjustment
Hyaline membrane disease

During drying and stimulation of the

baby, your rapid assessment shows
that the baby is crying. What is your next
action?
A

Suction the babys mouth and

nose

Clamp and cut the cord

Do skin-to-skin contact

Do early latching on

During drying and stimulation of the

baby, your rapid assessment shows
that the baby is crying. What is your
next action?
A

Suction the babys mouth and

nose

Clamp and cut the cord

Do skin-to-skin contact

Do early latching on

Early Skin-to-Skin Contact

If breathing or crying:
Position prone on the mothers
abdomen or chest
Cover the newborn
Dry linen for back
Bonnet for head
Temperature Check
Room: 25-28 C
Baby: 36.5 37.5 C

Skin-to-Skin Contact
General perception is purely for motherbaby bonding
Other benefits:
B breastfeeding success
L lymphoid tissue system stimulation
E exposure to maternal skin flora
S sugar (protection from hypoglycemia)
T - thermoregulation

When should the cord be clamped

after birth?
A

When the cord pulsations stop

Between 1 and 3 minutes

Not less than 1 minute in terms

and preterms not needing PPV
Suction the babys mouth and nose

All of the above are appropriate

When should the cord be clamped

after birth?
A
B
C
D

When the cord pulsations stop

Between 1 and 3 minutes
Not less than 1 minute in terms
and preterms not needing PPV
Suction the babys mouth and nose
All of the above are appropriate

Properly-Timed Cord Clamping

Prevents anemia in both term and preterm
babies
Prevents bleeding in the brain in premature
babies
When preparing for delivery, don 2 pairs of
gloves after thorough handwashing
Remove the first set of gloves
Palpate the umbilical cord
Wait 1-3 minutes or until cord pulsations have
stopped

Properly-Timed Cord Clamping

Clamp cord
using a sterile
plastic clamp or
tie at 2 cm from
the umbilical
base

Clamp
again at 5
cm from
the base

Cut the cord

close to the
plastic
clamp

Care of the Cord

Do not milk the cord towards the baby
Observe for the oozing of blood. If blood oozes,
place a second tie between the skin and the
clamp
DRY cord care is recommended
Do not apply any substance onto the cord
Do not use a binder or bigkis

Bathing the Baby in the

First 6 Hours is Protective.
FALSE

TRUE

Bathing the Baby in the

First 6 Hours is Protective.
FALSE

TRUE

Washing
Vernix - protective barrier to E.coli and Group B
Strep
Early washing
Hinders crawling reflex
Can lead to hypothermia
infection, coagulation defects, acidosis, delayed
fetal to newborn circulatory adjustment, hyaline
membrane disease, brain hemorrhage

What is the approximate capacity of

a newborns stomach?

How long after birth is a newborn

ready to breastfeed?
A
B
C
D

immediately
5-9 minutes
10-19 minutes
20-60 minutes

How long after birth is a newborn

ready to breastfeed?
A
B
C
D

immediately
5-9 minutes
10-19 minutes
20-60 minutes

Non-separation of Newborn from Mother

for Early Breastfeeding
Weighing, bathing, eye care, examinations, injections
should be done after the first full breastfeed is completed
Postpone bathing until at least 6 hours

Non-separation of Newborn from Mother

Never leave the mother and baby
unattended
Monitor mother and baby q15
minutes in the first 1-2 hrs. Assess
breathing and warmth.
Breathing: listen for grunting,
look for chest in-drawing and fast
breathing
Warmth: check to see if feet are
cold to touch if no thermometer

Early and Appropriate Breastfeeding

Initiation
Leave the newborn between the mothers breasts in
continuous skin-to-skin contact
The baby may want to rest for 20-30 mins and even up
to 120 minutes before showing signs of readiness to
feed

Early and Appropriate Breastfeeding

Initiation
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 pacifiers
Do not throw away colostrum
Let the baby feed for as long as he/she wants on both
breasts

Early and Appropriate Breastfeeding

Initiation
Help the mother and baby into a comfortable position
Observe the newborn
Once the newborn shows feeding cues, ask the mother
to encourage her newborn to move toward the breast

Breastfeeding Cues
eye movement under closed lids
alertness, movements of arms
and legs
tossing, turning or wiggling
mouthing, licking, tonguing
movements
rooting
changes in facial expression
squeaking noises or light fussing
Crying is a late sign of hunger

Support Continued and Exclusive

Breastfeeding
After delivery, mother is moved
onto a stretcher with her baby
and transported to Recovery
Room, mother-baby ward or
private room
Breastfeeding support is
continued

Support Continued and Exclusive

Breastfeeding
Counsel on positioning
Newborns neck is not
flexed or twisted
Newborn is facing
the breast
Newborn is close to
mothers body
Newborns whole body is
supported

Support Continued and Exclusive

Breastfeeding
Counsel on attachment and suckling
Mouth wide open
Lower lip turned outwards
Babys chin touching
breast
Suckling is slow, deep
with some pauses

Proper Breastfeeding Hold

Look for a quiet place
Find a most relaxed position
for mother
Provide adequate back
support
Support feet
Do not hunch shoulders
Do not scissor the breast

Cradle Hold

Cross Cradle Hold

Underarm Hold
Underarm Hold
Football hold
Baby is held like a clutch
bag
Nose further away from the
breast
Babys trunk is secure
beside mothers trunk

Breastfeeding after Cesarean Delivery

Side-Lying Position

Essential Intra partum

Care
From evidence to practice

Objectives:
Discuss the problem of maternal mortality
rates and its impact on the attainment of
MDG 5
Discuss interventions that are
recommended and are not recommended
during:
o Antepartum
o Labor
o Delivery
o Immediate post-partum

Too many mothers and newborns are

dying every year
Global
560,000 Mothers

4,000,000 Newborns

Philippines
4,600 Mothers 33,620 Newborns

10%

15%
41%

22%

12%

WHO, 2010

Hemorrhage
Unsafe Abortion
Hypertension
Others
Infection

Antepartum Care
At least 4 antenatal visits with a skilled health
provider.
To detect diseases which may complicate
pregnancy.
To educate women on danger and
emergency signs and symptoms.
To prepare the woman and her family for
childbirth.

To detect diseases which may

complicate pregnancy.
Screen
Prevent
Anemia
- Ferrous and folic acid
Pre-eclampsia
Supplementation
Diabetes Milletus
- Tetanus toxoid
Syphillis
immunization
- Corticosteroid for
preterm labor

To detect diseases which may

complicate pregnancy.
Detect
Treat
PROM
- Ferrous sulfate for anemia
Pretem labor - Anti HPN meds and
MGSO4 for severe preeclampsia
- REFER

Antenatal steroids
Administer antenatal steroids to all
patients who are at risk for preterm
delivery.
- with preterm labor between 24-34
wks. AOG
- Or with any of the Following prior to term:
* Antepartal hemorrhage / bleeding
* Hypertension
* (preterm) Pre-labor rupture of
membranes

Antenatal Steroids

Antenatal steroids
Betamethasone 12 mg IM q 24 hours x 2 doses or
Dexamethasone 6mg IM q 12 x 4 doses

Overall reduction in neonatal death

Reduction RDS
Reduction in cerebro
ventricular hemorrhage
Reduction in sepsis in
the first 48 hours of life.

Educate women on DANGER

SIGNS AND SYMPTOMS

Vaginal bleeding
Headache
Blurring of vision
Abdominal pain
Severe difficulty of breathing
Fever (Temp>38, weak)
Burning sensation on urination

Prepare the woman

& her family for childbirth
Counsel on:

- Proper nutrition and self care during pregnancy

- Breastfeeding and family planning

Birth plan
-

Where she will deliver; transportation

Who will assist her delivery
What to expect during labor and delivery
Possible blood donors; where will she be
referred in case of emergency

Intra partum
Care

Recommended Practices during Labor:

1. Admission to labor when the parturient
is already in the active phase.
Active phase of labor:
- 2 to 3 contractions in 10 minutes
- cervix is 4 cm dilated.
*There is No difference in apgar score
* need for cesarian section by 82%
*No difference in need for labor
augmentation.

2. Continuous Maternal support

One watcher one patient
Need for pain relief by 10%
Duration of labor shorter by
half an hour
Spontaneous vaginal delivery
by 8 %
instrumental vaginal delivery
10 %
5 minute apgar <7 by 30%

Having a LABOR COMPANION can result in:

Less use of pain relief drugs increased
alertness of baby
Baby less stresses, uses less energy
- Reduced risk of infant hypothermia
- Reduced risk of hypoglycemia
Early and frequent breastfeeding
Easier bonding with the baby

3. Upright position during first stage of labor

Freedom of movement - distract

mothers from the discomfort of labor,
release muscle tension, and give a
mother the sense of control over her
labor (Storton, 2007)

3. Upright position during first stage of labor

Freedom of movement distract mothers from the
discomfort of labor, release muscle tension, and
give a mother the sense of control over her labor
(storton, 2007)
First stage of labor shorter by about 1 hour
Need for epidural anesthesia by 17%
No difference in rates of SVD, CS, and Apgar
score <7 at 5 minutes

Restricting practices limit a mothers freedom

to move and/ or her position of choice.
1. IV lines
2. Fetal monitoring
3. Labor stimulating meds that require monitoring
of uterine activity.
4. Small labor rooms
5. Epidural placement
6. Absence of support persons to be with the
intra partum client.

4. Routine use of WHO partograph to monitor

progress of labor.

5. Limit total number of IE to 5 or less.

* No difference in endometritis
* UTI lower by 34%
* chorioamnionitis by 72%
* Neonatal sepsis by 61%

Interventions that are not recommended

during labor
No difference in rates of maternal fever,
1.perin
Routine
fever, perineal wound infection and
and
perineal wound dehiscence.
perineal

shaving on
No neonatal infection was
admission
observed
for labor
and
delivery

observed

Interventions that are not recommended

during labor
Fecal soiling during delivery
reduced by 64%
2. Routine
No difference in maternal
enema puerperal infection, episiotomy
during thedehiscence, neonatal infection,
first stageand neonatal pneumonia.

of labor.

Interventions that are not recommended

during labor
No difference in chorioamnionitis,
postpartum endometritis, perinatal
mortality, neonatal sepsis.

3. Routine
vaginal
No side effects reported.
douching

Interventions that are not recommended

during labor
Risk of dysfunctional labor by 25%
No difference in duration of labor,
4. RoutineCS rate, cord prolapse, maternal
infection and
infection and apgar score < 7 at 5
amniotomy
to shortenminutes.

spontaneous
labor

Oxytocin augmentation
Should only be used to augment labor in
facilities where there is immediate access
to caesarian section should the need arise.
Use of IM oxytocin before birth of the infant
is generally regarded as dangerous
because the dosage cannot be adapted to
the level of uterine activity.

Routine IVF
Advantage
Ready access for
emergency meds
To maintain maternal
hydration

Disadvantage
Interferes with the
natural birthing
process
Restricts womans
freedom to move
IVF not as effective
as allowing food and
fluids in labor to treat/
prevent DHN,
electrolyte imbalance.

Routine IVF
No study found showing that having an IV
in place improves outcome.
Even the prophylactic insertion of an IV
line should be considered unnecessary
intervention.

Routine NPO During Labor

Possible risk of aspirating gastric contents
with the administration of anesthesia.
One study evaluated the probable risk of
maternal aspiration mortality, which is
approximately 7 in 10 million births.
No evidence of improved outcomes for
mother or newborn.

Routine NPO During Labor

For the normal, low risk birth, there is no
need for restriction of food except where
intervention is anticipated.
A diet of easy to digest foods and fluids
during labor is recommended.

Care during Labor

Recommended

Not Recommended

Admission to labor when

in the active phase.
Comparison of choice to
provide continuous
maternal support.
Mobility and upright
position.
Allow food and drink.
Use of WHO partograph.
Limit IE to 5 or less.

X Routine perineal shaving.

X Routine enema
X Routine NPO
X Routine IVF
X Routine vaginal douching
X Routine oxytocin
augmentation.

Practices Recommended
during delivery

Diagnosis of the 2nd stage of Labor

Traditional
Defined by a fully dilated
cervix
Coached to push through
out-of-phase with her own
sensation.

Non traditional
Redefined as complete
cervical dilatation +
spontaneous expulsive
efforts (Simkin 1991)
Perineal phase of active
pushing.

Upright Position during

delivery

Upright Position during delivery

More efficient uterine contractions
Improved fetal alignment.
Larger anterior-posterior and transverse
diameters of pelvic outlet enhances fetal
movement through the maternal pelvis in
descent for birth.
Faster delivery
Leads to less interventions: less episiotomies

Interventions that are recommended during

delivery
1. Upright position during delivery
2. Selective (non-routine) episiotomy
3. Use of prophylactic oxytocin for management of third
stage of labor.
4. Delayed cord clamping.
5. Controlled cord traction with counter traction to deliver
the placenta
6. Uterine massage after placental delivery

Interventions that are

recommended during
delivery

2. Selective (nonroutine
episiotomy

Perineal Support and

Controlled Delivery of
the Head
During delivery of the head,
encourage woman to stop
pushing and breathe rapidly
mouth open.
Keep one hand on the
head as it advances
during contractions
while the other hand
supports the perineum.

with

Non Routine Episiotomy

Anterior perineal trauma by 84%

Posterior perineal trauma by 12%
2nd 4th degree tears by 33%
need for suturing by 29%
No difference in infection rate

Prophylactic OXYTOCIN for the 3rd stage of

Labor
Oxytocin 10u IM
abdomen to rule out a second
3. Use Palpate
of
baby
prophylactic
q
Postpartum
blood loss > 500 ml
oxytocin
for
reduced by 39%
management
Need for additional uterotonic reduced
of 3rd stage
of labor.by 47%
No difference in need for maternal
blood transfusion, need for manual
removal of placenta, and duration of
third stage

Prophylactic OXYTOCIN for the 3rd stage of

Labor
3. Use of
prophylactic
oxytocin for
management
of 3rd stage
of labor.

OXYTOCIN 10 U
intramuscular

Early clamping : < 1 min after birth

Delayed ( properly timed) 1-4 minutes
After birth or when Pulsation stop

4. Delayed
cord
clamping

PROPERLY TIMED CORD CLAMPING

Lower infant hgb at birth and at 24 hrs
after birth prevented.
Fewer infants requiring phototherapy for
jaundice
No difference in rates of polycythemia,
need for neonatal resuscitation, and
NICU admission.

Controlled Cord Traction

Postpartum blood loss > 500 ml by 7 %
Postpartum blood loss > 100ml by 24%
No difference in rates of maternal
Mortality or serious morbidity
And need for additional uterotonics.

5. Controlled
cord Traction

6. Uterine
massage
after placental
delivery

Lower blood loss

Less for uterotonics

Active management of
the third stage (AMTSL)
1. Administration of uterotonic within one minute of
delivery of the baby .
2. Controlled cord traction with countertraction on the
uterus.
3. Uterine massage.

Interventions not
recommended during delivery
1. Perineal massage in the 2nd stage of labor
-commonly noted complications in practice (perineal
edema, perineal wound infection, and perineal wound
dehiscence) were not evaluated.
2. Fundal pressure during the 2nd stage of labor
- 2nd stage longer by 29 mins.
- increased 3rd and 4th degree perieneal tears.
- Uterine rupture evaluated.

Care during Delivery

RECOMMENDED

NOT RECOMMENDED

Upright position during

delivery
Selective episiotomy
Use of prophylactic oxytoxin
for mgt of 3rd stage of labor
Delayed cord clamping
Controlled cord traction with
counter traction to deliver
placenta
Uterine massage

o Coaching the mother to

push
o Perineal massage in the 2nd
stage of labor
o Fundal pressure during the
2nd stage of labor

Postpartum care
RECOMMENDED

NOT RECOMMENDED

Routinely inspect the birth

canal for lacerations
Inspect the placenta and
membranes for completeness
Early resumption of feeding
(<6 hrs after delivery)
Massage the uterus- ensure
uterus is well contracted
Prophylactic antibiotics for
women with a 3rd or 4th degree
perineal tear
Early postpartum discharge

X Manual exploration of the

uterus
X Routine use of icepacks
over the hypogastrium
X Routine oral
methylergometrine

Let us put it into practice!

Kangaroo Mother
Care

Is care of preterm infants

carried skin-to-skin with the
mother
KANGAROO MOTHER CARE

Starting KMC in the First Week of Life

Reduction in neonatal mortality for <2000g
- 95%
Reduction in serious morbidity for babies
<2000 g -95%

Kangaroo Position (KP)

1.Stabilized LBW placed in
vertical position
2.Prone on the mothers chest
3.In-between her breasts
4.Skin-to-skin contact
5.Held together by an
expandable shirt or
clothing

KMC Method: Fulfilling the essential

needs of the LBW/Preterm Newborn

1.Warmth
2.Nutrition
3.Protection
4.Stimulation

KMC Intervention (KMCI)

1.

KMC Method
-Kangaroo Position
-Breastfeeding
2. Early Discharge
3. Ambulatory KMC

Kangaroo Mother Care Intervention

(KMCI)
Series of steps thoroughly
and systematically
following the kangaroo
mother care method
Includes a system of early
discharge and follow-up

KMCI: Benefits for the LBW & Family

Improved maternal/family and infant
bonding
Increased and sustained breastfeeding
success
Better weight gain
Decreased risk for infection
-Protection from breastfeeding
-Decreased risk of nosocomial infection
to early discharge

KMCI: Benefits for the LBW & Family

-Protective maternal flora acquired from
skin-to-skin contact
Maternal and family empowerment
Decreased cost of care (early discharge)
and health maintenance (breastfeeding)

KMCP: Benefits to the Families,

Communities and the Nation
Improved breastfeeding rates postdischarge
Appropriate catch-up growth rates and
neurodevelopment of the LBW
Decreased neonatal morbidity and mortality
and help achieve MDG 4
Decreased incidence of adult diseases
among LBW in KMC contributing to a
healthier and productive population.

Accredited KMCP in Philippine Hospitals

Dr. Jose Fabella Memorial Hospital
Marcos Memorial Hospital (Ilocos)
Southern Philippines Medical Center
(Davao)
Eastern Visayas Regional Medical Center
(EVRMC)
Gat Andres Bonifacio Memorial Medical
Center (Tondo)

KMC: The Essential Components

Kangaroo Position

Kangaroo Mother Care: A Practical Guide. WHO 2003

Learn more about KMC

Visit the WHO website
http://www.who.int/reproductivehealth/publ
ications/maternal_perinatal_health/924159
0351/en/index.html

CUP FEEDING

Notes about Cup Feeding

The safe alternative to bottle or teat
feeding
Use expressed breast milk
Does not result in nipple confusion
Associated with better breastfeeding
success.

For supplemental feeding, cup feeding

better than bottle feeding (those bottlefed
were more fretful in breastfeeding p<0.01
and bottlefeeding moms thought their
breastmilk was inadequate p<0.01a
AYa-Yi Huang, et. Al. Chang Gung Med J
2009; 32:423-31

Feeding Strategy (Breastfeeding)

Direct breastfeeding
-Football or clutch hold
-Cross-cradle hold
Expressing the hind milk
Feeding by cup or dropper
Tube feeding with non-nutritive sucking on
the breast
Storing breast milk

Whats stopping cup feeding?

How to Cup Feed?

Wash hands
Prepare Cup, no more than 30 mL
capacity, do not fill to brim
Support alert and awake infant upright,
sitting position, secure arms
Tilt the rim of the cup towards the lower lip
Milk must be at the rim

How to Cup Feed?

Do not pour milk into mouth
Maintain position until baby laps up milk
using the tongue and feeds/swallows
Remove cup when baby stops feeding
Return cup when with signs of readiness
to feed
Rinse cup in hot soapy water when
finished

When is there a need to cup feed?

Mother is unable to
breastfeed (eg. Returned
to work, baby in NICU)
Baby is unable to breastfeed,
needs supplementation
In times of emergencies with
above conditions

The Philippines promoting and protecting

breastfeeding: working with the LGUs to provide
breastfeeding support in the evacuation centers