Postnatal care of the babyDr Utpal Sharma

Assistant ProfessorDept Of Community Medicine

Sikkim Manipal Institute of Medical Sciences

Introduction Infants (0-1year) constitutes about 2.92% of total population of

India

Of 136 million births every year 90% are in third world.

About 20-30% of the thee babies are underweight

About 40% of total infant mortality occurs in the 1st month of the life

During weaning period about 25% children doesn’t receive quality nutrition…

….making them susceptible to impaired health conditions later in life

Many low cost measures like immunization, breast feeding etc. are available to save these precious lives

Objectives of early neonatal care

Establish and maintenance of cardio-respiratory functions

Maintenance of body temperature

Avoidance of infection

Establishment of suitable feeding regimen

Early detection and treatment of congenital and acquired disorders

Immediate care

Clearing the airway

The airway should be cleared of mucus and other secretions

For newborns already subjected to hypoxia resuscitation requires more active measures

If the heart is not beating for 5 min, probably the baby dead

Apgar scoreTaken at 1min and again at 5min after birth

Requires immediate and careful observation ofHeart rate Respiration Muscle tone Reflex response Colour of the infant

Each sign is given a score of 0,1or 2Perfect score is 9-10, of a total score of 10 A score of 0-3 indicates baby is severly

depressed, 4-6 indicate moderate depression

Cont…

Score below demands prompt action

Low Apgar score at the end of 5 min is associated with….

….high risk of complication and …..death during neonatal period

Appearance

Pulse

Activity

Grimace

Respiration

Apgar score chart

Cont…

Care of cordCord should be cut only after cessation of pulsation

Stump should be kept dry with no application

Care of eyesShould be cleaned before opening with sterile swabs

from inner to outer side

Any discharge from eyes is pathological and demands immediate treatment

As a preventive measure maternal genital tract infections should be treated beforehand

Cont….

Care of skin First bath/sponging may be delayed for 24 hrs after birth Thereafter no need of bathing till discharged

Maintenance of body temperature Normal body temperature of a newborn is 36.5º to 37.5º C Most of the heat loss occurs trough evaporation of amniotic

fluid from the body of the wet child About 75% of heat loss occurs from the head It is important to dry the baby quickly with a clean

cloth and wrapped in warm clothing

A naked newborn exposed to an environmental temperature of 230C

suffers the same heat loss as a naked adult in 0 0 C

Do you know…..?????

Cont….

Breast feeding Initiated within 1/2 hour in case of a vaginal delivery

and within 4-6 hours in case of a C/S. (IYCF)

First milk called “colostrum” should be given to the baby

Exclusive breast feeding should be practiced for six months

Baby should be breastfed ON DEMAND i.e. whenever the baby cries for feeds.

Time interval between each feed is about 2 to 3 hours.

Frequency of feeds should be at least 8-10 times in 24 hours and compulsory night feeds

Warm chainAt delivery: Ensure the delivery room is warm (25° C), with no draughts. Dry the baby immediately; remove the wet cloth. Wrap the baby with clean dry cloth. Keep the baby close to the mother to stimulate early

breastfeeding. Postpone bathing/sponging for 24 hours.

After delivery: Keep the baby clothed and wrapped with the head covered. Minimize bathing especially in cool weather or for small

babies. Keep the baby close to the mother. Use kangaroo care for stable LBW babies and for re-warming

stable bigger babies

Low birth weight babies

Introduction Birth weight is the single most important determinant

of chances of child survival, healthy growth and development.

Low Birth Weight (LBW)babies are grouped as Preterm (short gestation) and… Small for Age/Date (SFA/D) term infants.

Countries with fewer incidence of LBW, preterm is the cause

In countries like India, where the proportion of LBW is high, majority of LBW is due to SFA.

Cont… By international agreement LBW is considered as

Low Birth Weight (LBW) : Any neonate weighing less than 2500 gm at birth

irrespective of gestational age.

Very Low Birth Weight baby (VLBW) : Any neonate weighing less than 1500 gm at birth

irrespective of gestational age.

Extremely Low Birth Weight baby (ELBW) : Any neonate weighing less than 1000 gm at birth

irrespective of gestational age.…when measured preferably within one hour of

life

Cont… Besides this babies are also classified according to the

gestational age

Pre-term Baby : Babies born before 37 completed weeks (<259 days) of

gestation irrespective of the birth weight.

Term baby : Babies born between 37 to 42 weeks of pregnancies

(259-294 days) irrespective of the birth weight.

Post-term baby Babies born at 42 completed week or thereafter (> 294

days of gestation)

Cont…

A LBW is any infant with birth weight <2.5 kg irrespective of gestation and includes….Extremely preterm (<28 weeks of gestation)Very preterm (28-32 weeks of gestation)Moderate to low preterm (32-37 weeks of gestation)

Even though born early their intrauterine growth may be normal according to the gestation

Given good care, these babies catch up good growth and by 2-3 years of age will be of normal size and performance.

Scenario

In 2010, an estimated 15 million babies were born prematurely and about more than 1 million of these died globally.

Prematurity is now the leading cause of deaths amongst under-5 year children…..

..…and single most important cause of death in the first month of life.

The survivors may face a lifetime with significant disability

Causes of preterm birthPreterm births are classified into two groups

Spontaneous preterm birthProvider initiated preterm birth

Prematurity is an important risk factor for developing NCDs (HTN, DM) in later life for these babies

This creates a intergenerational cycle of risk

So the link between prematurity and NCDs adds a very important dimension in public health aspect…

…..when increasing trend of both are observed worldwide

Types of preterm births and risk factors involved

Spontaneous preterm births Provider initiated preterm births

Age at pregnancy and spacingMultiple pregnancyInfectionUnderlying chronic medical conditionLifecycle/ work relatedPsychological healthGenetic and other

Medical induction / Cesarean section for maternal or foetal indication

Other- Not medically indicated

Small for date babiesMay be born at term or preterm

Weighs less than 10th percentile for the gestational age

Results due to intrauterine growth retardation

These babies have high mortality rate not only in neonatal period but during infancy as well

Hence inflate the perinatal and infant mortality rates

They are frequent victims of PEM and infections

Cont…

In developing nations 3 determining factors are associated with adverse prenatal and postnatal development of the childMalnutrition Infections Unregulated pregnancy

LBW

Factors associated with IUGRMaternal factors Placental cause Foetal causesMalnutrition Severe anemiaHeavy physical work during pregnancyHypertensionMalaria Toxemia SmokingLow socio-economic statusShort maternal statureVery young ageHigh parity and close spacingLow educational status

Placental insufficiencyPlacental abnormalities

Foetal abnormalitiesIntrauterine infections Chromosomal abnormalities Multiple gestation

Importance High incidence

Association with mental retardation

High risk of perinatal and infant mortality

Human wastage and suffering

Very high cost of special care

Association with socioeconomic underdevelopment

Infant mortality is 20 times higher in LBW babies

Serves as an important guide for level of care to the children

Indicates the malnutrition and ill health of the mother

High percentage of LBW warrants need of improved care of newborn

What Problems Do Low Birth Weight Babies Have?

Breathing problems at birth and later.

Low body temperature because there is little fat on the body and the newborn’s temperature regulating system is immature.

Low blood sugar because there is very little stored energy.

Feeding problems because of their small size, lack of energy, small stomach and inability to suck.

Infections because the infection fighting system is not mature.

Jaundice (high bilirubin) because the liver is not mature.

Bleeding problems due to immature clotting ability at birth.

Other clinical Problems related to prematurity

ApneaIVHRDS/HMDNECOxygen toxicity

Prevention

Despite of all efforts rate of LBW can’t be lowered more than 10% around the world.

This is due to multiplicity of causes

Intervention have to be cause specific

Attention must be given to good prenatal care and intervention programme…….

…..rather than “treatment” of the LBW babies born later

Direct Interventions Identifying “at risk” pregnant ladies by using mother health

card….

…..primarily by the grass root level health care workers

A small increase in food intake, even in the last trimester results in considerable improvement in weight of the infant

Other interventions consists of supplementary nutrition, IFA tablets, food fortification etc.

Infections affecting foetal growth should be detected and treated early

Other medical disorders like HTN, toxemias and diabetes should be detected and treated early

Indirect interventions Family planning

Avoidance of excessive smoking

Improved sanitation measures

Measures to improve health and nutrition of young girls

In addition improved socioeconomic and environmental conditions with distribution of health and social services…..

….. guarantees long lasting effect

Government support in form of maternity leave and child benefits.

Treatment For treating LBW babies, the are classified

into 2 groups

Those under 2 kgs

Requires first class modern neonatal care in intensive care unit until gains weight >2.5 kg

Those between 2-2.5 kgsNeeds intensive care unit for a day or two

Cont…. Intensive care includes Incubatory care comprising adjustment of

temperature, humidity and oxygen supply

Feeding of baby with breast milk if possible by nasal catheter.

Prevention of infections

Leading causes of death in LBW babiesAtelectesisMalformationPulmonary haemorrhage Intracranial haemorrhage, secondary to trauma or

anoxiaPneumonia and other infections

Kangaroo mother care(KMC)

Introduced first in Colombia in 1979 by Dr. Hector Martinez and Dr Edzar Rey

Intervention to combat high infection and mortality rate owing to overcrowding in hospitals.

Now adopted across the developing world and considered as essential element in continuum in neonatal care

Cont… Four components of KMC are Skin to skin positioning of baby on mother’s

chest Adequate nutrition through breast-feeding Ambulatory care as a result of earlier discharge from

hospital Support for the mother and her family in caring for the

baby

For improved management of newborn in facilities, newer initiatives has been designed Newborn care corner Newborn stabilizing unit Special newborn care unit

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