CARE AFTER DELIVERY: OBSERVATION OF NEWBORNS IN THE FIRST FEW HOURS OF LIFE

Alexandra Wallace

On behalf of the

Neonatal Encephalopathy Working Group

June 2012

Background – Normal 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